The AHDGP Chronic Disease Service Referral Pathways have been created as part of the SA Health GP Plus Practice Nurse Initiative. The pathways have been created to assist General Practice to access services in the Adelaide Hills and include the following pathways:

• Type 2 Diabetes Prevention and Management
• Coronary Heart Disease Prevention and Management
• Asthma and COPD Prevention and Management
• Musculoskeletal Disease Prevention and Management
• Older persons 65+ Health and Social Services

The pathways also include other AHDGP resources:

• Directory of Mental Health Services for GPs
• GP Plus Services for Hospital Avoidance and Supported Early Discharge

Click on the image below to download:

THE PATHWAYS HAVE THE FOLLOWING INFORMATION:

• SCREENING for those at risk of developing the disease and for those already diagnosed with the disease.
• MBS Items that the GP can utilise. 
• SERVICES/PROGRAMS available in the area for at risk patients as well as diagnosed patients are listed. The COMMUNITY PROGRAMS are all funded and low or no cost to the patient. Most programs have a focus on lifestyle changes the patient can make to improve their overall wellbeing and involve allied health professionals, who will assist with changes related to diet, exercise, weight management and health coaching/self management. There is also information on ACUTE CARE SERVICESin the region.
• SELF MANAGEMENT lists services the patient can self refer to.
• RESOURCE lists websites relating to the condition that may be of assistance or interest to practice staff and patients. Website directories to assist in locating local Allied Health Professionals.
• REVERSE SIDE of the pathways has extended information including the Australian screening toolsfor Diabetes and Cardiovascular Disease and extended Medicare Item Number information on Cardiovascular Disease, Asthma and Diabetes.
• OLDER PERSONS PATHWAY outlines information on Helpline and Advocacy numbers, available directory assistance such as the Commonwealth Respite and Carelink Centre, description and referral details of Community Packages of Care and snapshots of Health & Social Services in the local area.

   

 

           Formerly: Out of Hospital Strategies (OOHS)

“Keeping people, living with chronic disease, well and out of Hospital”

This is a project of partnership between Country Health SA and the Adelaide Hills Division of General Practice

The Adelaide Hills Division of General Practice (AHDGP) has been fortunate to gain funding to work with Country Health SA on the current ‘Better Care in the Community; Out of Hospital Strategy’.

The foundation site of Mount Barker Health Services and across the Hills region, is one of thirteen sites across the state that is currently working on this project.

The AHDGP is excited to be part of this primary care focused project, that has an emphasis on health service integration, across General Practice, Community Health Services, Hospital Services, the SA Ambulance Service and non-government organizations to better coordinate care.

The project has objectives around country hospital avoidance and shorten lengths of stay (LOS), exploring potentially avoidable presentations to metropolitan hospitals and the processes of these, all with a focus on wellness through chronic disease management (particular focus on Cardio-vascular, Endocrine and Respiratory conditions) and linkage of services.

General Practice is a key to sustainable chronic disease mangement.  Linkages across General Practice and health services in the Adelaide Hills are strategies of this project.

Patient Liaison Officer positions (RNs) at local Hospitals have shown evidence-based improvement that well coordinated care of patients can reduce LOS and even avoid hospital admissions.

Transitional Care Packages and Country Home Link Packages, and more recently the Rapid Intensive Brokerage Support (RIBS) services are initiatives that form part of the state wide project.

Contact the Adelaide Hills Community Health Service for more information on the early discharge and hospital avoidance services through the RIBS Program.  Phone 8393 1833.

The AHDGP is working closely with local health services to plan and implement initiatives of the OOHS around CDM and integration processes across the Adelaide Hills area.

What is RIBS?

v  Short term, timely and flexible services to support early hospital discharge or hospital avoidance.

v  Support a patient to stay in the community or Residential Aged Care Facility and avoid hospital admission or.

v  Support a patient to return, from hospital to the community or Residential Aged Care Facility with extra support in place

Types of services: Nursing, medication assessment/administration, allied health, personal care, carer respite, emergency accommodation, child care, domestic services, equipment…

More information:

·         GP RIBS Information Sheet (see RESOURCES – to the right)

·         CHL/TCP/RIBS Services of the AHCHS Quick Guide Information Sheet (see RESOURCES – to the right)

• Contact the AHCHS – 8393 1833