what is Service Coordination?

Service Coordination aims to place consumers at the center of service delivery – ensuring they have access to the services they need, opportunities for early intervention and improved outcomes.

In a nut-shell, the practice of Service Coordination supports more effective ways of working with people with complex and multiple needs.

Click on each person below to hear what they have to say about Service Coordination.

Long term consumer-’m Ellie. I get so sick of having to repeat my personal situation and history to the different services that work with me to help me manage my health and dependency issues. But after saying that, it appears that the different services are talking with one another or something because when I go to an appointment they know all about me and why I’m there. I always receive my dates for my appointments now when I get referred to another service. They ask me what I want and what is important to me and ask for my permission before they send my information to any-one. I feel that I have more control over what happens to me and my private information. Maybe that has something to do with Service Coordination – services talking to each other.

Mental health specialist – Hi, my name is Melany, and I’m a mental health professional working in Gippsland. What can I say about Service Coordination and the Practice Manual – it’s priceless. It improves our working relationships, promotes common standards and practices between services and it reduces duplication of Assessments for a start. It also has that person – centered focus that we’re continuing to implement into our organization.

Disability services- Hello, I’m Brad. Service Coordination isn’t new really. However, there have been some changes and updates to the practices, good practice indicators and templates agencies use, such as common referral tools etc. that promotes relationships between organizations and improves consistency and provides greater transparency. What are the latest Service Coordination updates – you’ll find everything you need to know within this course and in your Practice Manual.

Why do we need Service Coordination?

The concept of Service Coordination was originally introduced in response to problems experienced by consumers.

Click on each of the key words below for more information about the problems experienced.

1. Lack of information- there was a lack of information about what services are available and how the service system works.
2. Inconsistent practice- our consumers experienced inconsistent practice in identifying needs, assessment and privacy.
3. Poor coordination- We had a lack of coordination between different agencies.
4. Lack of transparency- there was a lack of clear and transparent referral pathways.
5. Inconsistent quality- we realized there was an inconsistent quality in information being provided to consumers in regards to screening, assessment, care/case planning and referral for example
6. Poor information sharing- generally – there was poor information sharing and feedback when referral are made.

Screen 4Core objectives of Service Coordination

Informed- consumers can make choices and informed decisions about their care

Convenient-consumers and carers are able to access appropriate services in a timely and convenient manner

Engagement- increase engagement of consumer and carers in the services and programs they need.

Service- improved access to services outcomes by providing a seamless and coordinated system

Participation- consumers participate in the management of their care and care information

Accuracy- consumers and carers can access accurate and relevant information

Screen 5- Benefits for the consumers

Service Coordination enables agencies to work together to provide a coordinated and integrated response to consumer needs.

Click on each of the consumer benefits below for more information

Local- consumers receive up to date information about services in their local area and their support options. I

Faster -consumers experience a faster response time for request and can expect the same standards of service and approach from each organization.

Streamlined- consumers are supported with the ability to contact the most appropriate service. They experience clear entry points, referral pathway that are easy to navigate, transparent and consistently applied.

Engaged- consumers are supported to be actively engaged in the planning and delivery and receive support appropriate to their needs wishes, circumstances, abilities safety and cultural background.

Coordinated- consumers can be confident that information will be transferred for the purpose if a referral in a way that doesn’t require them to repeat the information. They also experience a more coordinate response to their needs from a range of service providers

Screen 6– service delivery priorities- we need to place consumers at the entre of service delivery

Service coordination supports more effective ways of working with people.

Screen 7- Benefits for service providers

By aligning systems, process and practice, services can better communicate and work with each other to share information that will improve consumer outcomes. The partnership approach has provided agencies with an appreciation of their role within the wider service system

Partnership- The service provider is able to improve their working relationships and networks to identify local issues and problem solving opportunities.

Practice manual- Common practice standards clearly document expectations around key areas of practice between agencies, and defined roles and responsibilities are clearly identified.

Support- Service providers have access to resources that support Service Coordination practice, such as common referral tools (e.g. Service Coordination Tool Templates (SCTT)) and the Human Services Directory. Service Coordination will facilitate stronger relationships between services built around agreed and documented practice standard

Engagement- There’s an increased awareness of the need for a continuing focus on consumer engagement and consumer driven decision making

Efficiency- Service providers will experience efficiencies including improved waiting list management, reduced duplication of assessment services and streamlined referral processes.

Quality- Service Coordination aligns with accreditation standards for providing quality services and programs, and sustaining quality external relationship

Screen 8- Do you coordinate your services?

As previously mentioned, Service Coordination places consumers at the center of service delivery to ensure they have access to the services they need, opportunities for early intervention and improved outcomes.

Service Coordination enables services (e.g. aged care, disability, mental health, justice, housing, general practice and alcohol and other drugs) to function independently while also working in a cohesive and coordinated way to provide consumers with a seamless and integrated response. That service delivery

Screen 9 Founding principles- what are the founding principles of Service Coordination? Click on each of the points below to learn about the founding principles that Service Coordination is built upon.

A central focus on consumers- This means that service delivery needs to be driven by the needs of consumers and the community rather than the needs of the system or those who practice in it

Partnerships and collaboration- This refers to services working together and taking responsibility for the interests of consumers, not only within their own organization, but across the service system as a whole.

The social model of health- This framework is concerned with addressing the social and environmental determinants of health and wellbeing such as education and housing as well as the biological and medical factors.

Competent staff- This means that the operational elements and processes of Service Coordination must be undertaken by staff members that are appropriately skilled, qualified, experienced, supervised and supported

A duty of care- A duty to take reasonable care of a person. The duty of care extends to Service Coordination where staff have a duty of care to provide accurate and timely information and assist consumers with referrals.

Protection of information- The protection of consumers’ information is one of the most important principles of Service Coordination. This includes maintaining client confidentiality, protecting the privacy of consumers’ personal information and obtaining consumers’ consent to their information being collected and used for specified purposes, including being shared with another provider.

Engagement of other sectors- Service Coordination embraces the broadest range of partnerships across organization types (small to large, non-government to government etc) and across disciplines. A key role for program/service networks (e.g. Primary Care Partnerships) includes aligning systems and processes between services within a geographical location.

Consistency in practice standards- Service Coordination enables agencies to remain independent of each other as entities but work in a cohesive and coordinated way to ensure that consumers experience a seamless and integrated response

Screen 10 – Establishing common operational language

In order to facilitate Service Coordination, it’s important that we all use common operational language. The Operational Elements and processes below provide a common language and understanding for services to work together and ensure that consumers have a seamless and coordinated care. See if you can correctly match the Operational Element to the corresponding description.

Initial contact– first contact with the service system e.g. via outreach, drop in center, phone call, presentation at reception, etc.

Initial needs identifications– determine the full range of social and health needs, including eligibility, priority and risk.

Assessment- an investigative process using professional and interpersonal skills to uncover relevant issues to develop a care/case plan.

Care/case planning– this element involves discussion, negotiation and decision-making involving service providers and consumers to define goals and strategies, actions and services to achieve those goals.

The four elements of the Service Coordination framework represent a holistic service process. In some services the Initial Contact and Initial Needs Identification may be carried out by the same person and Assessment is conducted by a different person for example. However, in other services, one person may conduct several or all elements. Of course, which elements are most relevant to you will be based on your service and specific roles to be driven by the needs of consumers and the community rather than the needs of the system or those who practice in it.

Operational elements

Welcome to the Four Operational Elements section.

The four elements of the Service Coordination framework represent a holistic service process. Your role within the process will determine which operational elements are most relevant to you.

In order to ensure this training is customized to your learning needs, you only need to review the element relevant to your role. However, you’re very welcome to review each of the operational elements in order to gain a greater appreciation of the full service process

Who conducts Initial Contact

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Consumers instigate Initial Contact most commonly by telephone or in person, but also possibly through a friend or relative. Initial Contact may also be part of an outreach program.

Initial Contact happens differently in every agency. In some agencies Initial Contact will be carried out by reception or front of house staff. In other agencies it may be done by a Duty Worker or Information Officer. Elsewhere, it may be the responsibility of the Service Coordinator Intake Worker.

Initial Contact and Initial Needs Identification may be carried out by a single staff member such as the Service Coordinator or Duty Worker. In other agencies, Initial Contact may be the responsibility of a range of different staff, and Initial Contact and Initial Needs Identification may be completed over a number of days.

Screen 3-formalising initial contact

All agencies provide some initial contact

Service coordination formalizing the role of initial contact and has meant a change to th responsibilities and practice of many front of house staff and health/welfare professionals.

Screen 4 of 7 -Context of Initial Contact

Let’s take a moment to understand the role of Initial Contact using a practical situation. Below are two different consumer scenarios. Click on the scenario that best aligns to the service provided by your agency; you may even wish to review both scenarios to extend your understanding across difference service groups.

Gary’s story- Gary is in his mid-30s, lives on his own and is unemployed. Gary’s sister-in-law rang a counselling service at a local community health center and made an appointment for Gary to see someone as she’s concerned that he’s not coping after his marriage breakup

Mary & Stan’s Story

Mary and Stan are a couple in their 70s and live in Footscray. Mary is frail, and Stan is a diabetic and has trouble walking. Their daughter, Anne, concerned for their health and wellbeing, searched the internet to find the contact details of the local community health service

Anne made initial contact with the intake worker, Doris, at the western region health Centre. Doris explained the range of services available at the Centre and discussed need to collect a range of information to determine which service would be most appropriate. Stan and Mary agreed to participate in an initial needs identification process the following day.

Screen 5 of 7- Resources to support Initial Contact

Take a moment to read through the ‘Practice Indicators’ found within Section 3 of the Service Coordination Practice Manual.

There are a number of resources designed specifically to support Initial Contact good practice. The Service Coordination Practice Manual contains a list of practice indicators that are designed to be easy to followwith the specific tools and templates used to facilitate the Initial Contact process.

Some agencies begin to complete the SCTT Consumer Information form during the Initial Contact process. If this is relevant to you, or if you’re interested, you can refer to the Service Coordination Tool Templates (SCTT) to familiarize yourself with the specific tools and templates used to facilitate the Initial Contact process

If your agency does not provide the services required, you can search for the service within your area using the Directory our agency does not provide the services required, you can search for the service within your area using the Human Services Directory

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Welcome to the Additional Processes topic.

In order to facilitate Service Coordination, it’s important that we all use common operational language. The Operational Elements outlined within the previous topic provide a common language and understanding for services to work together and ensure that consumers have seamless and coordinated care.

The four elements of the Service Coordination framework represent a holistic service process. Underpinning each Operational Element is a number of additional processes. Consider these additional processes as the glue that holds the pieces of Service Coordination together.

Screen 2-What are the additional processes?

The four Operational Elements of Service Coordination enables service providers to work together to provide a coordinated and integrated response to consumer needs. The operational cycle is a dynamic process that is supported with a number of additional fundamental processes.

Information-the first process involves the provision of relevant and appropriate information to consumers.

Consent- The flow of information between consumers and service providers is vital for effective Service Coordination, and in most circumstances obtaining consent is a mandatory obligation

Referral- Referral relates to the transmission of a consumer’s personal and/or health information relating to a consumer from one service provider to another. This is done with the consumer’s consent and for the purpose of further Assessment, care or treatment.

Exchange- Information exchange between service providers at key points reduces duplication and highlights gaps in service provision so that they can be addressed.

Delivery- Effective service delivery is achieved when the consumer is linked to service providers who provide coordinated care and without duplication of services.

Exiting- Exiting can occur at any stage of the Service Coordination process and is generally managed in accordance with local protocols.

The first process involves the provision of relevant and appropriate information to consumers.

Screen 3 Provision of information

How important is the provision of information

Providing information that is relevant to the consumer’s needs may be undertaken at any and all stages of the Service Coordination process.

When choosing the type and complexity of information, service providers will be receptive to and guided by the consumer’s needs, learning styles and capacity to understand the information. This will take into account issues such as preferred language, visual or cognitive requirements

Health literacy- An understanding of ‘Health Literacy’ may assist service providers to check that consumers have understood and importantly are able to use the information that is being provided.

Health Literacy means more than being able to read pamphlets and successfully make appointments. Health Literacy is defined as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (World Health Organization 1998).

Information Literacy extends beyond health. It’s equally applicable to the other elements of, and understanding that underpins, Service Coordination. It’s generally accepted that ‘Information Literacy’ is the degree to which individuals have the capacity to obtain, understand and use information.

Cultural & linguistic competency

Culture affects how people communicate, understand and respond to information. Cultural competence is the ability of organizations and practitioners to recognize the cultural beliefs, values, attitudes, traditions, language preferences and practices of diverse populations and to apply that knowledge to produce a positive outcome.

Service providers have their own culture and language. Many adopt the language of their specialty as a result of their training and work environment. This can negatively affect how service providers communicate with consumers – if you use acronyms and work related colloquialism, your consumers may not know what you’re talking about.

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Communication strategies

Teach back- this method allows you to confirm the consumer understands what you’ve told them by getting them to reiterate the information back to you

Asking- Try something as simple as asking consumers what strategies may help them to understand and act on the information, acknowledging that many people have difficulty understanding health or medical type information.

Atmosphere- always create an atmosphere of respect and comfort with the consumer

Scaffold- try to scaffold the amount and level of information. Where practical, also consider limiting the information given to consumers during one sitting.

Prompts- Consider providing information with visual prompts, diagrams and use colorful cues where relevant (especially when explaining information to young children for example.)

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Consent to share information

Workers in health and community services have a legal and ethical obligation to support and maintain the rights and safety of consumers. This includes maintaining consumers’ privacy and confidentiality, and respecting information about the consumer and its source.

Legislation- there are 2 Acts relevant to service coordination

1. Health records act 2001, which regulates the collection and handling of consumer information by health service providers in the state public sector. It also seeks to govern acts or practices in the Victorian private health sector.
2. Information privacy act,2000, which regulates the collection and handling of all personal information, except health information, in the public sector in Victoria.

Critical element- the protection of consumer’s information is one of the most important principles of service coordination. Service coordination models and strategies should incorporate clear arrangements for maintaining consumer confidentiality. It’s critical that we protect the privacy of consumer’s personal information and obtain consumer’s consent to their information being collected and used for specified purpose, including being shared with another provider as part of a referral. This information gives service providers a more comprehensive picture lof the consumer’s circumstances and wellbeing. However, some of the information may not be directly related to the primary reason for a referral, so consent must b obtained to share this additional information.

Screen 8 of1 8 consent

Consumer information should only be disclosed to those who require it and only after receiving consent from the consumer

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Referral

What does the term ‘referral’ mean, when used within the context of Service Coordination? Referral is the transmission, with consent, of a consumer’s information from one service provider to another for the purpose of further Assessment or service provision.

Objectives

1. Assist consumers in a seamless and timely manner, by streamlining access to appropriate services through self-referral or assisted referral
2. Empower consumers to participate in decisions about their care
3. Respect a consumer’s right and privacy
4. Facilitate choice ad understanding
5. Enable referrals to be conducted efficiently and effectively
6. Minimize risk
7. Meet duty-of-care requirements.

Good practice indictors-goo practice indicators, detailed in the Victorian service coordination practice manual, set out the expected response times for the acknowledgement of referrals. For example, the service provider who receives a referral is expected to:

Acknowledge urgent referrals within 2 working days of receipt

Acknowledge non-urgent referrals within 7 working day of receipt

Screen 10- Exchange of information

Information exchange is the transmission, with consent, of a consumer’s information from one service to another for the purpose of informing decision-making and coordinating service provision. Exchange of information between services reduces duplication of assessment/services and identifies service gaps.

Information exchange between services and service providers may occur throughout the consumer’s care pathway including:

• acknowledgement of referral
• following Assessment or intervention
• Care/Case Planning, review or change in service delivery
• Handover, transition or exiting service.

Let’s take a moment to consolidate what you’ve just learnt about consent and information exchange. Visit the SCTT website. Locate and review the two page SCTT Summary Information Exchange form.

Screen11 – Service delivery

Let’s learn the basics about service delivery. Service delivery is generally undertaken in accordance with local protocols, the needs of the consumer, and the level of skill of the person providing the service.

Effective service delivery is achieved when the consumer is linked to service providers who provide access and coordinated care that meets their full range of needs in a timely manner and without duplication of services.

Service coordination practice manual

The service provider’s work is supported by the Victorian service coordination practice manual. The practice manual sets out agreed objectives, consumer outcomes, good practice indicators, statewide tools, and resources required for effective service coordination

Support Resources topic.

A broad range of programs/services across Victoria have developed practice standards for how they should work together i.e. disability, homelessness services, mental health, community health and problem gambling services.

As mentioned throughout this course, these practice standards are documented in the Victorian Service Coordination Practice Manual. However, it’s recognized that programs/services also have their own individual operational procedures and protocols to guide practice within their specific service.

Within this topic you will be introduced to the networks/partnerships that share the Service Coordination practice standards, along with the various support resources that you’ll rely on to facilitate Service Coordination.

After completing this topic, it’s expected you will be able to:

• discuss how SCTT is used to communicate between partnering services
• explain the importance of maintaining privacy and obtaining consumer referral consent
• describe the purpose of the Human Services Directory.

Page 2 of 10

Partnerships and networks

Effective implementation of Service Coordination principles is achieved through committed and collaborative partnerships. Local partnerships support agencies to work together and take responsibility for the interests of consumers – not only within their own agency, but across the service system as a whole. It all starts with fostering relationships and building trust.

Achieving shared commitment, mutual respect and trust is no small accomplishment, and requires organizations to reach consensus on the nature of the problems they see and the outcomes sought.

The Victorian Government currently funds local partnership networks to provide administration support and facilitate organizations to come together to agree on how they’ll put Service Coordination principles into practice, such as the Primary Care Partnerships.

Page 3 of 10- Support and templates

The Service Coordination Practice Manual has been created to support a broad range of programs/services across Victoria – it has been developed to identify the practice standards for how these programs/services should work together.

The Service Coordination Tool Templates (SCTT) facilitates the Operational Element of Service Coordination.

The SCTT support the collection and recording of Initial Contact, Initial Needs Identification, Referral and Shared Care/Case Planning information in a standardized way. This can assist service providers to share relevant information to support better outcomes for consumers.

Referrals using the SCTT

Templates replace over 300 different tools

Used by more than 600 services across the state

Integrated into over 30 different consumer information management system

Over 500 services make referrals using SCTT through secure electronic systems

Page 6 of 10 – Privacy and consent support

As outlined in an earlier topic, maintaining consumer privacy is paramount, especially in regards to information such as health and service history, name, age or sex for example.

Because privacy and consent is a sensitive issue, and given it’s so critical to the success of Service Coordination, the Office of Health Services Commissioner provides free training in this area. Click on the calendar for more information

The SCTT contains copies of the Consumer Privacy Information brochure along with the Consumer Consent form – these are provided in multiple languages.

Review the Service Coordination Tool Templates (SCTT) and make sure your agency is utilising the resources, tools and templates available.

Human Services Directory

Several times throughout this course we’ve referred to the Human Service Directory (HSD). The HSD is a great central resource designed to support you and your agency.

What is it exactly? It’s the statewide comprehensive repository of health and human services (agencies). It exists to assist with the referral and access to different services

Consumers, carers and workers my search on the HSD for over 15,000 service sites and 24,000 practitioners.

Why is it relevant to me? Agencies and practitioners can register their details on the HSD to ensure that information is kept up to date. Agencies/ practitioners ae sent a reminder every six months and, if there is no response after repeated attempts, the related information is hidden from public view.

Some examples of who uses the data are the Better health channel and also the Arthritis Map’ (www.arthritismap.com.au) which has a consumer/health planning activities.