Hospital Admission Risk Program (HARP) Partnerships in Health (PIH)

HARP is a State Government funded program designed to assist in the better management of Victoria’s Acute Hospital Services. HARP has been developed to offer those with chronic health conditions and care needs a real alternative to hospital admission.

The development of HARP services recognises that with improved access to community services, health education and support, many people can continue to live independently without the need for regular hospital admission.

HARP PIH represents a unique cooperation between Melbourne Health (including the Royal Melbourne Hospital), Doutta Galla Community Health, Merri Community Health Service, Royal District Nursing Service and the Melbourne General Practice Network. HARP staff are based throughout the partnership agencies and work cooperatively with Hospital and Community Services to promote seamlessly smooth care and support.

HARP is an interim (short term) service that focuses on linking clients into appropriate community supports. It is designed to make sure that clients get the right care in the right place. HARP services are provided in clients’ homes, general practices and on the campuses of the partnership agencies.

The aim of the HARP PIH is to assist you to live at home and to improve your health and quality of life. In particular, it can assist you to identify the support you may need to manage your chronic illness in the community and to co-ordinate referrals to appropriate services.

Why am I involved?

You may have been referred by a number of different professionals including the Royal Melbourne Hospital, your doctor, your local community health service or another service from which you currently receive care. All referrals are processed by the Direct Access Unit (DAU) at Melbourne Health.

To be accepted onto the program, you must live in the catchment areas (Moreland, Moonee Valley, and Melbourne), have recently presented to, or admitted to the Royal Melbourne Hospital (or other nearby hospital), be at immediate risk of going into hospital, and have complex needs and/or significant complications as a result of chronic disease (such as heart disease, chronic respiratory disease and diabetes).

What happens once I start with HARP PIH?

Once accepted onto the program, you would be allocated a key worker in the service area most appropriate to your needs. On the first visit, the key worker will spend 1-2 hours with you getting to understand your specific health needs. After listening to you describe the things you can do well and the things you may experience difficulty with, they help to develop a care plan. The key worker may also talk to family members, other community services, health care professionals and doctors to make sure all of your care needs are met. They also can help to coordinate aspects of your care plan, as you require.

Fees:

There is generally no charge for this service. Small fees apply for some services such as group involvement and the diabetes foot service.

HARP has three disease specific streams (cardiac, respiratory and diabetes) and an aged and complex care stream. Each stream is made up of several different service components:

(For further detail on the services listed see below)

Cardiac services
Heartwise, Cardiac Coach

Respiratory services
Melbourne Easy Breathers, respiratory outreach nurse

Diabetes services
Diabetes Co-Management, Diabetes Foot Program

Aged and complex care services
Care facilitation team, psychosocial program, falls and balance team, medication management

Heartwise
A program for people living with moderate-severe Chronic Cardiac Failure (CCF). It includes an eight week exercise and education program, which includes medication management, fluid balance, diet, and an awareness of the Cardiac Action Plan to reduce recurrence of acute exacerbations.

Cardiac Coach
A telephone coaching program for people who have been admitted to hospital following a heart attack, or who have undergone cardiac surgery. On returning home, a Cardiac Coach will maintain phone contact to assist people to reduce risk factors associated with heart disease, such as cholesterol levels, physical activity, and smoking.

Melbourne Easy Breathers
A program for people living with Chronic Obstructive Airways Disease, or other major respiratory disorders. It includes an eight week pulmonary rehabilitation program, which includes education and self management support, and an awareness of appropriate Respiratory Action Plans to reduce recurrence of acute exacerbations

Respiratory outreach nurse
Provides support and education for people who require oxygen at home.

Diabetes Co-Management
A program for people living with unstable Diabetes and/or associated complications from Diabetes. It provides education and self management support, along with appropriate monitoring, review of treatment and clinical management.

Diabetes Foot Program
A program for people living with significant diabetic foot related problems such as a foot ulcer or peripheral neuropathy. It provides evidence based best practice care and management.

Care Facilitation Team
A program for people living with complex issues impacting on their capacity to manage their health. It provides short term case management, comprehensive, holistic assessment, and individualised support.

Psychosocial Program
A program for people living with complex psycho-social issues such as social isolation, mental health, or drug and alcohol issues which impact on their capacity to manage their health. It provides short term case management, comprehensive, holistic assessment, and individualised support, including advocacy and facilitating connection with housing, employment, mental health, or other specialist health services.

Falls and Balance Team
A program for people who have had a fall which resulted in an admission to hospital or a presentation to an Emergency Department. It includes a 10 week exercise and education program, which includes falls prevention strategies, to reduce risk of further falls.

Medication Management
A program for people at risk with medication related issues. It provides drug information, patient counselling, therapeutic drug monitoring, liaison with local pharmacies about the most effective, safe, efficient and economical utilisation of drug therapy.