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Inter-agency care planning initiatives in Victoria

Examples of current projects are listed below.

The Alfred HIV Chronic and Complex Care Management
Model of Chronic and Complex Care Management developed by the Alfred Integrated Care Working Group to support people with HIV, indicating when care coordination and inter-agency care plans are required.

The Alfred HIV Chronic and Complex Care Management (22kb, pdf)

Paving the Way Project
Paving the Way Project in Central Hume describes protocols and tools to support mental health and well being in the community

Integrated Protocol - No Wrong Door & Care Planning (226kb, MS Powerpoint)
Integrated Protocol 2006 ... paving the way to a 'No Wrong Door' service system (646kb, pdf)
Central Hume Primary Care Partnership Integrated Protocol (226kb, pdf)

Banyule/Nillumbik-Neurological complex care project
Neurological services engaging with associations and local government, mapping service use and delays and providing education about service coordinati27 August, 2009" alt="Adobe PDF icon" width="18" height="18" /> Neurological Complex Care Project Final Report (246kb, pdf)

Developing Care Plans between General Practice and Community Health
Auspiced by Hume Moreland Primary Care Partnership, a model of joint care planning for clients with complex needs in a supported residential service.

Developing Care Plans between General Practice and Community Health: How we did it and what we learnt (75kb. pdf)
Hume Moreland PCP - Service Coordination between General Practice and Community Health (283kb, pdf)

Dementia Transition Care Planning Protocol Project
Moonee Valley Melbourne Primary Care Partnership and Alzheimer’s Australia Victoria, building on existing protocols and the Victorian Service Coordination Practice Manual to support coordinated care for people with Dementia at critical transition/ intervention points.

Dementia Transition Care Report, September 2007 (357kb, pdf)
Interagency Dementia Care Planning Protocol (241kb, pdf)

Inter-agency Care Planning Protocol Pilot Project - North and West Primary Care Partnership Alliance
The development of practices and processes around multi-agency care planning using the Service Coordination Plan.

Interagency Care Planning Protocol Pilot Project Report: Moonee Valley Melbourne PCP, November 2005 (312kb, pdf)

Refugee Health Project - WestBay Alliance and Brimbank/Melton Primary Care Partnerships
Development of a care pathway based on Service Coordination principles and processes, which includes coordinated care planning with the GP, refugee health nurse and other services.

WestBay Alliance & Brimbank/Melton PCP Refugee Health Project (76kb, pdf)

Care Planning
Building a regional framework for moving forward-identifies research, issues, recommendations and planned methodology for advancing care planning/care coordination in the Eastern Metropolitan Region.

Building a regional framework for moving forward - Discussion Paper (650kb, pdf)
EMR Care Planning/Care Coordination Initiative (CPCCI) Proposed Next Steps (123kb, pdf)

South East Healthy Communities Partnership Inter-agency Care Planning Project
South East Healthy Communities Partnership developed protocols for inter-agency care planning. These were trialled during 2007, and recommendations for further action to support implementation were made.
South East Healthy Communities Partnership Inter-agency Care Planning Project Report (260kb, pdf)

Better Living Better Health-Model of Care
Model of care being implemented in the South East Region for people with chronic conditions and complex needs at risk of hospital admission, incorporates care coordination/care planning involving the GP, care coordinator and multidisciplinary health professional team.

Better Living Better Health-Model of Care- model of care (135kb, pdf)

Peninsula Health – Frankston Community Health Service Early Intervention in Chronic Disease
Service model being implemented to provide consistent care planning practices between community health and GPs.

Peninsula Health – Frankston Community Health Service Early Intervention in Chronic Disease (673kb, pdf)

The Care Coordination Process At a Glance October 2006 –Central Vic Health Alliance
Explanations and flow charts describing the elements of care coordination and the development of multi-disciplinary care plans.

Care Coordination Pathway (36kb, pdf)
The Care Coordination Process 'At a Glance' (246kb, pdf)

Better Links - Care Planning in a multidisciplinary practice model
Proposes and tests a model of chronic disease management to facilitate integration of general practice chronic disease management with other community based services in the Upper Hume Region.

Better Links care planning in a multi-disciplinary practice model (1363kb, MS Powerpoint)

Home and Community Care Best Practice Project - Service Coordination for Complex clients
Building on previous work in the Hume Region, a lead agency model for care planning and coordination.

Home and Community Care Best Practice Project - Service Coordination for Complex clients Hume Region (296kb, pdf)

Research

Improved health system performance through better care coordination (692kb, pdf)

Multidisciplinary care plans for diabetes: how are they used? (176kb, pdf)

Managing chronic disease: what makes a general practice effective? (196kb, pdf)

Coordination of care within primary health care and with other sectors: a systematic review (252kb, pdf)

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7 - Care Coordination (932kb, pdf)

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