| Programs and Services - Non-Disease Specific |
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HARP CDM - Non-disease specific services:
 Falls Prevention
Intensive Service Coordination
Intensive Service Coordination – Psychosocial
HARP CDM Liaison at The Royal Melbourne Hospital
Medication Management Service
Psychology
Services provided by HARP CDM Program
The following services are provided for clients referred into the Program:
- Initial and review assessments
- Key worker to coordinate interventions
- Care planning and care coordination
- Client action plans
- Liaison with regular GP
- Education and self management support
- Specialist consultation as appropriate and available
Service duration and hours of operation
Services are offered from 8.30am to 5.00pm Monday to Friday (excluding public holidays).
The service duration depends on the client’s needs and the service component area. HARP CDM aims to provide interim services to address client’s needs and to transition clients into more sustainable services as available and appropriate.
Single point of entry for referral into the program is located at Direct Access Unit.
Falls Prevention Service
The Falls Prevention Service component is an outreach service that targets high risk fallers, ie, those who have had at least one fall-related hospital presentation in the previous 12 months. Clients eligible for the program receive a general assessment and a falls specific assessment, and a care plan is implemented by the key worker and exercise and education groups are organised by the Falls Prevention Service. This service is staffed by physiotherapists, an occupational therapist, community health nurses and an allied health assistant.
The program aims to complement other falls prevention services in the Melbourne, Moonee Valley and Moreland region, including services at MCHS, DGCHS, the RMH Falls and Balance Clinic and community therapy service.
Eligibility: One or more falls in the last 12 months requiring hospitalisation or presentation to an Emergency Department.
Location: The service operates out of Doutta Galla Community Health Service, and runs Strength and Balance groups at Moreland Community Health Service (Brunswick) and Doutta Galla Community Health Service (Moonee Ponds). Services are also offered in client home.
Intensive Service Co-ordination Service
This service component provides interim case management (intensive service coordination) for clients who have presented to hospital and who have complex issues which are likely to cause them to re-present to hospital. The service conducts a comprehensive assessment and develops a care plan in collaboration with the client, GP and other service providers, with the aim of sustaining clients in the community.
Intensive Service Coordination can be involved with clients up to 6 – 12 months or until a long term plan is put in place to ensure clients are well supported in the community.
Eligibility: Have complex psychosocial issues and require intensive service coordination and support to address issues effecting re-presentation to hospital and/or access services/liaise with providers.
Location: Doutta Galla CHS.
Intensive service coordination - Psychosocial
The psychosocial service component works with clients who frequently present to RMH primarily for psychosocial reasons, such as homelessness, at risk of homelessness, substance abuse and mental health issues.
The psychosocial intensive service co-ordinator works with patients to assess their care needs and addresses these by providing information, advocacy and support to connect with housing, employment, education and other specialist health services. Clients are often linked into community resources at Doutta Galla and Moreland Community Health Services, to Area Mental Health Services, to Drug and Alcohol Services and in some instances ongoing case management.
Eligibility: Persons who frequently present to Emergency Department and who have complex psychosocial issues such as social isolation, mental health issues, and homelessness.
Location: Doutta Galla CHS.
HARP CDM Liaison Service
The role of the HARP Liaison Service is to improve the quality and continuity of care received by HARP CDM eligible clients who present predominantly to The Royal Melbourne Hospital General Medical Units through case finding, screening, liaison, key worker role and education.
Eligibility: Patients admitted under the General Medical Units (MU1 to 4) who:
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Have frequent admissions/ED presentations
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Lack clearly identifiable support networks/services, and
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Would benefit from service co-ordination and planning pre- and post-discharge
Location: The HARP Liaison Service operates out of The Royal Melbourne Hospital.
Medication Management Service
The Medication Management Service facilitates medication compliance for frequent attendees, through the provision of drug information, patient counseling and advice on therapeutic drug monitoring. This includes liaison with primary health care providers about the most effective, safe, efficient and economical utilisation of drug therapy with the aim of optimising patient care.
Eligibility: Patients admitted to hospital within the last 12 months or at risk of re-presentation due to medication-related issues.
Please note, this service is not available to clients from an aged-care facility.
MMS is located at The Royal Melbourne Hospital - City Campus.
Patients at risk of medication related issues should be referred to the MMS team. Contact the team on 9342 7907 for assistance with referrals.
Psychology Service
Provision of psychological assessment and treatment to clients of all the PIH HARP service components. The psychologist works closely with the key worker to contribute to assessment and care plans as well as providing short- to medium-term treatment for psychological disorders. Where a client would be better provided for by an alternative community or private service, the psychologist assists with making referrals as appropriate.
Services include (but are not limited to): psychological assessments; cognitive behavioural therapy for mood and anxiety disorders; adjustment disorders; grief counselling; and pain management; as well as the provision of group sessions to the ‘Heartwise’, ‘Strength and Balance’ and ‘Melbourne Easy Breathers’ Programs on a regular basis.
Eligibility: Currently enrolled in another HARP CDM program.
Location: Moreland CHS (Coburg) and Doutta Galla CHS (Moonee Ponds).
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