Bridging the health/social care divide – integrated care from the perspective of disability providers.

Introduction: People with disabilities living in group homes often have complex health needs, are high health service users, and may need support from their disability service provider to access health services. Who is it for: This study is relevant to policymakers and service providers (including management and front-line health professionals) in the health and social care sectors. Involvement/Engagement: The study was funded by the Western Australian Department of Health, involving the Disability Health Network, a multi-sector collaboration including consumers, families and carers, health professionals, policy makers and academics aiming to improve health outcomes for people with disability. We worked with a large disability provider (DP) of group homes in Perth, Western Australia to co-design a health appointment form used for all occasions of health service use. What happened: An observational case-study was conducted within the DP between August 2019 and January 2021. De-identified information from each health appointment form was uploaded to a purpose-build surveillance tool in REDCap by delegated staff members from the DP. The health appointment form included details regarding type of and reason for the health service attended, together with information regarding follow-up required, and the level of support provided to the client. Quarterly reports were provided to the DP for the first year, including case examples for high-service users, the focus of this paper. Results: Service use: Over an 18-month period, 3,600 health service visits were attributed to 160 clients (SD=15 Md=20 IQR=10 to 33). The ten most frequent service users collectively had 577 service events (16%). Service use by these clients were largely in the community setting (GP n=232; allied health n=201; mental health n=58; pathology n=27; dental n=15; and private specialist n=14). Use of hospital-based services was limited (outpatients n=17; emergency department n=9; and hospital admission n=4). Follow-up included return appointments (n=91), referrals to other health professionals (n=80), change to medication regime (n=107). Support for accessing healthcare: The DP provided staff to attend with the client on most occasions (support worker n=497; house manager n=58; team leader n=1), with 21 occasions where no staff were required. At times, this support required additional resourcing (94 hours of backfill/overtime). Guardians or medical decision-makers were contacted 289 times requiring an additional 84 hours of staff time, with a medical decision needed 85/289. In most instances, transport was provided by the DP’s organisational vehicle (n=407), with a quarter of service events occurring within the group home requiring no transport (n=153), and remaining transport via ambulance (n=12), family (n=3) and public transport (n=2). Learning and next steps: For people with disability in group homes, DPs are an essential part of the care team. Integrated care requires strong lines of communication between the health service and DP and understanding of the logistical requirements for supporting many clients with diverse health needs. Next steps include: 1.developing guidance for embedding robust processes necessary for effective care plans including optimal preventative care and health information exchange, and 2.building health literacy of the front-line workforce providing support to clients to access healthcare.