Hospital Admission Risk Program (HARP)

A short-term rapid response program offered by senior nurses, allied health and medical professionals. Provides advice, support, education and links to services in the community, for people who are at risk of hospital admissions. Services include: Complex care coordination, Dementia support, Heart Failure and Respiratory conditions.

Aims to promote health and wellbeing to support the client to stay well at home and out of hospital.
Assists client/family/carer to understand what is important to them and identify barriers to care.
Assists to coordinate the care required at home and in the community.
Assists with accessing appropriate services to promote independence.
Supports future care planning by identifying issues that may arise in the future.
Provides education and training so the client/family/carer feels more confident in managing their health, medications and medical appointments.
Communicates with the client’s GP and with other services involved, including those within the hospital network.

What to expect from the service?

HARP care is provided by regular home or clinic visits, phone calls and videoconferencing.
Listens carefully to the client/family/carer’s concerns.
Create a plan and goals with the client/family/carer to manage at home and in the community.
Supports a greater understanding of health condition and chronic disease
Assists to problem solve the client’s questions and provides information that will help keep them safe at home.
Links to the right service to get the right support. e.g. Linking to My Aged Care for ongoing services whilst the client is living at home, linking to a speech pathologist for swallowing and speech difficulties.
Ensures the client/family/carer understands how to manage their health including the safe use of medications and provide specific information if required.
Coordinates care with other health professionals and GPs, to ensure a collaborative approach to help the client to stay well at home.
Promote links with GP and specialists to ensure attendance to follow-up appointments as appropriate
Interpreter and AUSLAN services are also available.

HARP team includes: Nurses, Occupational Therapists, Social Workers, Physiotherapists, Pharmacist, Psychologist, Speech Pathologists, Medical Doctors, Geriatricians, and specialised nurses in the management of Heart Failure and Respiratory conditions.

Information

Inclusion criteria:

At least one unplanned hospital admission in the last 12 months or at risk of representation
Requiring services where no other community service can meet clients’ needs
Reside in Northern Health catchment
Northern Health is the primary health service
May live in the community or Residential Aged Care Facilities.

Exclusion criteria:

Patients with acute psychiatric condition – please refer to the area mental health service.
Under 18 years of age
Allied Health services only.

HARP works with clients who are at risk of preventable hospital readmission or presentation due to chronic disease, frailty or complex psychosocial issues. Care Coordinators are from Nursing/Allied health backgrounds and will undertake comprehensive assessment. A plan of care and goals are developed with the client/family/patient, which may lead to referrals to other services, medication review and equipment provision. Care Coordinators liaise with health providers to ensure a cohesive history and holistic approach, which meets the client/family/patient’s goals and aims to avoid preventable hospital presentations.