Integrated Care for NDIS Participants with Complex Needs

Abstract

This presentation reviews the results of five recent Australian studies we have been involved with addressing the question of health and economic outcomes and the optimal model of service for this population. Through these studies the authors propose an integrated model of care and are developing a service for roll out with the NDIS to adress these critical issues. Health professionals in hospitals are poorly prepared to work effectively with individuals with disability who present with health needs. Their primary focus on acute care means there is a lesser degree of experience and familiarity with the disability support needs of patients. Some of the consequences of this poor understanding include communication difficulties leading to misdiagnosis, poor access to services, variable treatment outcomes and negative quality of life for individuals. Increased costs for the health system can also result from poor interactions with health professionals and increased use of health resources. The use of Integrated Care Principles assures the best possible clinical outcomes for this population. Nonetheless these priciples are rarely utilised and these individuals fall in the chasm between disabiltiy services and health services. Integrated Care involves partnering with a patient’s service provider, primary care provider, specialists, and both private and public hospitals as well as dental, allied health and disability care providers to enable disability and health workers to continue providing support to patients with disability alongside hospital healthcare professionals. This model promises to deliver the following benefits Attending to the patient’s disability needs supports his/her health improvement and recovery while in hospital. Maintenance of improved health and well being outcomes post discharge from acute care to the community including Improved coordination and delivery of health responses in the acute setting. Improved health outcomes at discharge. Enhanced capacity in the disability sector workforce to manage the complex health needs of individuals in community settings. Improved understanding and management of the health needs of individuals with disability. Improved health service practice for people with complex needs within the acute care setting. Improved inpatient health outcomes. Through input of disability support workers, reduced demand on scarce health resources to manage disability needs of inpatients. Reduced hospital readmission rates through improved health outcomes at discharge and in community settings. Improved collaboration with Disability Services/NDIS regarding discharge planning, discharge options and transition arrangements to community care for individuals with di Development of a disability workforce with skills and capacity to successfully manage More effective use of health resources to manage the complex health needs of individuals with disability. Reduced hospital readmission rates through improved health outcomes at discharge and in community settings. Identification and implementation of integrated services pathways that maintain established health and well being outcomes in community and residential settings post discharge. Improved management of complex health needs by disability service providers. Improved collaboration and partnership between health and disability/NDIS services including contribution of expertise and services as needed. Shorten hospital length of stay.