Hospital Admission Risk Program

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

Respiratory service

• 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

Allied health

• 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 management

• 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