Hospital Admission Risk Program (HARP) works with clients to improve their understanding of their health and psychosocial conditions, build their capacity for self-management and self-determination, and coordinate access to services for long term support.
Clinical service overview
The key objectives of HARP are to:
- improve the capacity for people with chronic and complex health and psychosocial conditions to manage their well being
- coordinate access to integrated care and services within and across hospital sectors
- reduce avoidable hospital admissions and emergency department presentations
- address issues of equitable access to health care for individuals
Clients may be enrolled in the HARP program for up to one year and if required can be re-referred if their clinical or social situation changes.
The HARP client receives comprehensive initial and ongoing assessment to develop their goals of care and the strategies and interventions required to achieve those goals. Every client can access the full suite of HARP services throughout their admission onto the program.
The HARP Model of Care offers the following:
Complex disease management
- patients are seen by a multidisciplinary team that is inclusive of Nurses, Pharmacists and Medical Physicians in one of our four clinic environments at The Alfred, Caulfield Hospital, Sandringham Hospital and Inner South Community Health
- nurse-led care coordination is delivered across the acute and community sectors, working with the patient's GP and the General Medicine Physicians to integrate health care for patients
- patients receive education and support to manage their chronic health conditions as well as being referred onto appropriate community services
- HARP Nurse Coordinators provide a hospital point of contact for patients in the community
Pulmonary Rehabilitation (PR)
- pulmonary rehabilitation is offered to patients who suffer with chronic lung disease (COPD, emphysema, chronic bronchitis, bronchiectasis, chronic asthma and pulmonary fibrosis)
- our program aims to improve exercise tolerance, reduce breathlessness during normal activities, and help patients to improve their quality of life
- the program runs for a total of eight weeks and this includes exercise and education components
- the program is located at Inner South Community Health and from September 2016, it will also operate out of Caulfield Hospital
- upon completion our Allied Health Assistant will help patients develop an exercise regime at their local gym or community centre
- Pulmonary Rehabilitation is also offered at The Alfred campus through the Physiotherapy Department
- specialist nurses deliver intensive clinical support to patients living in the community with chronic lung disease
- the nurses teach patients self-management skills, deliver education about their disease, and facilitate linkage to services within the hospital and in the community
Mobile Assessment and Treatment Service (MATS)
- MATS is a rapid response clinical outreach service for elderly people living in the community and in Residential Aged Care
- the MATS team is geriatrician led, and consists of an aged care nurse practitioner, medical registrars, and registered nurses
- referrals to MATS from the community should be directed to the service on 1800 007 656
- within the HARP team there is a range of allied health professionals who assess and treat people in their home
- allied health disciplines include pharmacy, occupational therapy, physiotherapy, social work and dietetics
- the Allied Health team work within HARP to provide comprehensive multi-disciplinary care
- case managers develop a care plan with clients that is goal directed
- clients receive care coordination to support access to services
- case management varies in intensity depending on the needs of the client and their carers
- access to healthcare, welfare, housing and community services for long term care needs are a key focus
- case managers work with clients to develop strategies for managing the issues that adversely impact their health and wellbeing
Coaching for heart health
- The COACH service is overseen by Alfred Health’s Nutrition Department
- COACH provides secondary prevention of coronary heart disease by assisting patients to establish and achieve goals that minimize cardiac risk factors
- COACH is an over the phone 'coaching' service. Phone calls are structured using an evidence based approach to discuss with patients the progress of their agreed goals and strategies to maintain their health
- the program runs for one year with the aim of generating lifestyle changes to reduce cardiac risk factors
- clients enrolled in the COACH program are proactively recruited from The Alfred inpatient units by the COACH nutrition staff
Refer your patient
Fax referral to us
Caulfield Access is responsible for intake, information and referral processing for a wide range of community and ambulatory services.
We accept referrals from GPs, specialists, family, carers, case managers and patients.
We also welcomes phone enquiries to discuss potential referrals or an existing referral. Referrals are triaged depending on priority.
Patients requiring immediate assessment should be sent to the Emergency & Trauma Centre.
To refer a patient to a community service either:
- complete the Service Coordination Tool Template (SCTT) and submit electronically, or
- complete and fax your SCTT referral form to Caulfield Access Unit
Consider making referrals for chronic conditions indefinite.
Once a referral has been received, a Care Coordinator will phone the patient to discuss their needs and organise appropriate services. The Care Coordinator will provide the patient with their phone number. Patients are encouraged to contact the Care Coordinator if they have any concerns.
- Referral enquiries (03) 9076 6776
- Referral fax (03) 9076 6773
Special referral instructions
Referrals to MATS should be made directly by calling 1800 007 656