Melbourne Health - Community services across the care continuum
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HARP services provide specialist treatment, care planning, education and support to help people with chronic and complex health issues to manage independently in the community and reduce the risk of being admitted to hospital.
HARP services people with chronic and complex health issues, providing:
- short term support and intervention
- assessment
- integrated care planning and coordination
- education and monitoring
- service linkages
- GP liaison
to enable clients to better manage their condition in the community and reduce avoidable hospital admissions.
HARP is a partnership between:
- The Royal Melbourne Hospital
- Merri Health
- cohealth
- Bolton Clarke
Specialised services
HARP Cardiac Services
Chronic heart failure
specialist cardiac consultation
monitoring and support of the client and carer's individual needs
- multi-disciplinary education re: medication management, fluid balance, diet and the awareness of the Cardiac Action Plan to reduce recurrence of acute exacerbations
- 8 week exercise and education program (or home exercise program)
- outreach home visits and home exercise program as required
Cardiac Coach
- telephone coaching post discharge after a cardiac event to reduce coronary risk factors
HARP Respiratory Services
- development of Respiratory Action Plans in liaison with local GP and/or respiratory physician
- 8 week pulmonary rehabilitation program
- transitional exercise program
- outreach home visits and home exercise program as required
- support and education for people with complex or new home oxygen
- education and support for people with complex discharge issues associated with respiratory disease
HARP Diabetes Services
Diabetes Foot Unit
- evidence-based, best practice management across the care continuum for people with diabetes-related foot complications
Diabetes Co-Management Service
- education and self management support to people with complex diabetes issues
- appropriate monitoring, review of treatment and clinical management
- coordination of clinical review to other health professionals including the capacity for dietetic and endocrinology review
HARP Service Facilitation Team
Care Facilitation Team
- specialist care facilitation in collaboration with the client, GP and other service providers with the aim of sustaining clients in the community
- individualised support which may include education, information provision, advocacy, facilitating connection with community health, housing, employment, mental health or other specialist services.
HARP Medication Management Service
HARP pharmacists provide consultations and home visits to:
- facilitate medication compliance
- provide drug information
- provide patient counselling and advice on therapeutic drug monitoring
- liaise with primary health care providers about the most effective, safe, efficient and economical drug therapy to optimise patient care
Eligibility
HARP is a service for people with chronic and complex health issues who have had:
- one or more avoidable ED presentation or hospital admission in the past 12 months or are at imminent risk ofhospitalisation and community services cannot meet their needs
- have complex medical or psychosocial needs and would benefit from short term, intensive input
- live in the local government areas of Melbourne, Moreland and Moonee Valley City councils
Referrals
To refer a patient, complete and fax your referral to Direct Access Unit on (03) 8387 2217.
The Direct Access Unit welcomes phone enquiries. To discuss referrals (potential or existing) please contact (03) 8387 2333.
You can use the following forms or a template from your own system.
Referrals should include:
patient details including address, date of birth and contact phone numbers
the reason for referral
- relevant clinical history for the patient
- list of current medications
- any risks to clients or staff
the name of the consultant (for Medicare clinics)
- your details and provider number (if applicable)
Once a referral has been received, a HARP Clinician will phone the patient to discuss their needs and organise appropriate services. The HARP Clinician will provide the patient with their phone number and patients are encouraged to contact them if they have any concerns.