The Right Care=Better Health (RC=BH) program launched in the midst of a lockdown, yet has hit the ground running.
In just five months since service delivery began in October last year, the program is reporting high referral numbers, significant patient uptake and positive feedback. A common thread contributing to these successful outcomes is the passion demonstrated by the RC=BH team in tying together the program model, team collaboration and practice integration.
About the program
RC=BH is a new service designed to support patients with complex and chronic needs in eastern and north-eastern Melbourne that recognises the importance of wrap-around services to support people who need it most. Funded by EMPHN and delivered by EACH and DPV Health in collaboration with participating general practices, the program aims to support referred patients to receive personalised support in finding, accessing and fulfilling complex care requirements through local services.
The project aims to provide patients with:
- appropriate and timely, individually tailored, person-centered care
- improved quality of life
- lowered rate of avoidable hospital admissions
Collaboration initiatives key to successful service integration
The innovative service response, delivered by EACH and DPV Health, worked closely with participating general practices to develop and refine patient pathways to ensure that appropriate referral, service provision and communication processes were established.
Collaboration at virtual community of practice events provided an opportunity to streamline the integration of the service within general practices to offer complex health coordination and linking services for referred patients.
Kristal Marrinon, EACH Senior Clinician and RC=BH Coordinator was excited that clinics were onboard and supportive of the program, saying “the success of service integration is a credit to all the work everyone has done collectively as a community of practice building trust and relationships within this program."
Service induction process presses on despite lockdown restrictions
Service delivery began on time last year which is a credit to the hard work of everyone involved to develop and initiate the program in the midst of a lockdown. The physical limitations from lockdown restrictions did not hinder the teams’ efforts to integrate the service into general practices, rather the team harnessed digital technology to aid communication and engagement.
EMPHN undertook pre-program commencement orientation sessions to ensure practice teams were aware of the program goals, deliverables and expectations. The ten participating practices then completed virtual orientation sessions and were provided opportunities to meet their new service teams via Zoom. Once introductions were completed, the practices welcomed service providers EACH and DPV Health into their clinics, setting up rooms to deliver the service and developed processes for the service care coordinators to access clinical software.
Access to clinical software enabled real time access to patient information and progress against their goals, contributing to the successful outcomes reported by the program.
Early indications of program success
Since October 2020, participating general practices have referred 161 patients to the program and 91 patients have enrolled. More than 428 contacts were made such as phone support and face to face consultations. The RC=BH service team have linked patients to a variety of community and health services with up to 27 different types of connections been made. 58 referrals into local services were also initiated by the team. Access to remote home monitoring devices has also been initiated through brokerage to support patient self-management.
The program has already received feedback from patients highlighting the impact the support received has had on their quality of life.
‘I met Remi (Care coordinator, EACH) a number of weeks ago to discuss my mammoth health issues, some of which are diabetes, mactel, endocrine, gastrologic, physio, home help and liaising with my GP as a mediator.
Remi has been instrumental in making my journey with my health issues more doable. He has gone over and above helping me through the processes, and making the necessary referrals.
Remi has been terrific and I feel I have someone looking out for me. Life feels easier.’ Right Care = Better Health patient
‘Upon reading the feedback received, I felt extremely satisfied and had a great sense of accomplishment. But the best part is, it feels like the Right Care = Better Health program is successful, successful in not only improving patient's quality of life and independence, but successful in injecting a new sense of hope, trust and faith in the health system, no matter how big or complex one’s health problems are! This recognition is a reflection on the whole team and is due to a combination of our efforts. Needless to say, it would not have been possible without all of the combined hard work, guidance, support and unrelenting willingness to always help each-other. I am proud to be a part of such an incredible team!’ Remigiusz Siemianow, Care Coordinator EACH