Agenda

CONFERENCE DAY ONE
Monday 30 July 2012

DAY ONE | DAY TWO

8:30 Registration and coffee

9:00 Opening remarks from Chair

9:10 Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals

• Developing a new policy directive to standardising the transfer of care process in NSW public hospitals
• 'Discharge' versus 'transfer of care'
• Framework for managing and preparing a patient for transfer of care from the time of admission
• The five stages of the Care Coordination process which most admitted patients will transition through
• Supporting materials to assist hospitals with implementation

Daniel Comerford, Project Director - Patient Flow and Emergency Redesign, NSW Ministry of Health

9:50 What PCEHR Will and Won't do to Improve the Discharge Process

• The role of discharge summaries in the world of PCEHR
• An analysis of the beneficiaries of the new PCEHR processes
• An analysis of the things that will not change from a discharge perspective
• A proposed approach to ensuring change occurs in a sustainable and measurable manner
• Calvary Health care ACT's project approach to achieve the above

Barry Gernaat, Change Officer - Calvary eHealth, Calvary Health Care ACT

10:30 Morning tea

11:00 Discharge Planning at St Vincent's Private Hospital, Sydney

• Outline of the model of discharge planning used in a Magnet designated Private Hospital
• Multidisciplinary approach with daily meetings to identify patients early who require intervention
• Key initiatives of the department: The Extended Care Home Rehab Program and the Department of Veteran Affairs Better Discharge Planning Program
• Discharge planning training program

Thelma De Lisser-Howarth, Nurse Manager - Discharge Planning Team, St Vincent's Private Hospital, Sydney

11:40 Six Degrees of Separation: Ask me About 9 Years in a Biscuit Tin

• Human Capital - A staff journey
• Relationships - The move from Disciplinary to Multi-Disciplinary
• Integrated approach to Health Care - Interconnectedness of Allied Health Staff
• Culture Shift - What's mine is yours
• Habits and Habitats

Genevieve Juj, Director Allied Health, Royal Melbourne Hospital

12:20 Lunch

1:20 Western Health's Immediate Response Service

• The service model development and its differences from the previous model
• Workforce development
• Outreach and Inreach and the impact it has on the patients and the organisation
• Outcomes from both the patient perspective and the originations

Jenny Orr, Manager - Immediate Response Service, Western Health

2:00 The Role of a Pharmacist in a Multi-Disciplinary Team to Improve Medication Management

• Pharmacists within the Gold Coast Health Service District are members of a variety of multi-disciplinary teams
• District focus on process redesign, to improve discharge care and co-ordination
• Medicines are a significant cause of harm
• Pharmacist role expansion in the community setting

Trudy McGovern, Deputy Director of Pharmacy, Gold Coast Health Service District

2:40 Afternoon tea

3:10 Persistence, Patience and Perspiration: Case Study of a Frequent Presenter

• The very frequent presenter - 47 ED presentations in 12 months
• Engaging the client, reviewing medical records and information from 15 specialists, liaising with numerous departments
• Diagnosis, clinical summary developed and signed off by relevant consultants and Director of Medicine
• Development and implementation of ED Management Plan and Inpatient Management Plan
• What worked well and what went wrong?
• Key outcomes and learnings

Bill Faulkner, Team Leader/Care Coordinator, and
Pat Doughney, Care Coordinator, HARP Community Care Coordination, Rosebud Community Health, Peninsula Health

3:50 PANEL DISCUSSION: The Push to Reduce Length of Stay

With Activity Based Funding being implemented nationally this year there will be added incentive to reduce length of stay. What impact will this have on:

> Quality of care
> Ability to conduct thorough discharge planning
> Rates of readmission

Participants and delegates are invited to participate in an open and honest discussion on the above issues

Panelists to be advised

4:20 Closing remarks from Chair

4:30 IIR invites all speakers and delegates to an informal networking drinks reception

CONFERENCE DAY TWO
Tuesday 31 July 2012

DAY ONE | DAY TWO

8:30 Morning coffee

9:00 Opening remarks from Chair

9:10 Hospital Readmission after Stroke

Data from the New South Wales Stroke Audit Program analysed to describe:

• Readmission rates
• Patient profile
• Common reasons for readmission
• Factors (clinical, hospital or patient related) that contribute to hospital readmission
• Prevention strategies to avoid readmissions

Monique Kilkenny, Senior Research Officer, Monash University

9:50 Reducing Readmissions through Coordinated Care

• The SWSLHD Connecting Care program
• Algorithm used to identify frequent presenters with a chronic disease
• Identifying and addressing the issues
• Connecting and co-ordinating care: Enhancing communication between care providers including hospitals, GP's, Specialists and community service providers
• Results to date

Robyn Tumeth, Chronic Care Clinical Coordinator, South Western Sydney Local Health District (SWSLHD)

10:30 Morning tea

11:00 ALERT: An Integrated Team Approach to Reducing Presentations to St Vincent's Emergency Department

• Overview of ALERT model of care and service structure incorporating multiple program streams and partnerships
• Case studies and
• Future directions and challenges

Una McKeever, Manager - Assessment, Liaison and Early Referral Team (ALERT), St Vincent's Hospital Melbourne (Invited)

11:40 The Role of Medicare Locals
Aileen Colley, Executive Officer, Townsville - Mackay Medicare Local

12:20 Lunch

1:20 It's Not Just About the Number of Beds: The Development of a Model of Care That Seeks a Seamless Transition from Community to Hospital and Back Home Again (Mental Health)

• History/What was happening? Why change?
• Evolution and development of model
• Resistance and embedding the model into practice
• What has been achieved?
• Sustainability
• Case study

Barry Walls, Nurse Practitioner Mental Health (Acute), Austin Health

2:00 Mobile Rehabilitation Team: Providing an Alternative to In-Patient Rehab and Facilitating Early Discharge Planning in an Acute Setting

• Providing early multi-disciplinary rehabilitation care to patients in the acute setting, in parallel with their acute medical or surgical care
• Program aims: Improve function, prevent complications associated with prolonged bed rest, and achieve earlier discharge, reducing the need for inpatient rehabilitation admissions in some cases
• Patient outcomes
• The changing landscape of rehabilitation care

Shari Parker, Chair of Rehab Medicine, St Vincent's Private Hospital; Deputy Director of Rehabilitation Medicine, St Vincent's Public; Conjoint Lecturer, University of NSW; and Senior Conjoint Lecturer, University Notre Dame

2:40 The Role of Case Management in Hospital Discharge: What happens When They go Home?

• The importance of case management for a safe transition from hospital to home
• Patients with high and complex care needs
• Balancing dignity of risk and duty of care when working with a range of clients in differing situations and conditions
• How effective linkage and the establishment of strong community supports assists in preventing unnecessary hospital readmissions
• Examples of the diversity of clients and situations as supported through both the ComPacks (Community Packages) program (NSW Health) and the Transpac Northern Sydney program (NSW Transitional Aged Care Program)

Dani Bultitude, Manager Episodic Care, CCNB Community Care (Northern Beaches) Ltd

3:20 Closing remarks from Chair

3:30 Close of conference and afternoon tea

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