The Southcare model demonstrated the effectiveness of a planned, considered approach to aged care. By considering the clients needs for a simple point of contact and requirement for ease of access to services the Southcare model enables the local community to benefit from a range of Aged Care services. Using the quality framework to develop new services and continual quality improvement and evaluation, large referral numbers and high levels of community satisfaction demonstrate the value of this model for aged care. Integration of acute sector and community aged care services has provided clients with a continuum of care that meets best practice guidelines.

To have one access point for appropriate services through integration and co-location of staff and services for the convenience of the aged care person and their carer.

The Southcare model was devised in 1993 as a response to the problems with the service provision involved with small stand alone community teams. Under the vision of the Aged Care Director and Manager the teams were merged into a Department of Aged Care (Stathers, 1998). The integration and co-location of staff and resources allowed an efficient, equitable and quality based model of service to be developed.

Using a service development process based on investigation of the problem through file audits and focus groups of staff and clients. The quality assurance measure of effectiveness of the Southcare model was developed to produce a single point of entry to the service, a common database for client records, shared aged care assessment tools on admission that indicated referral sources.

The model was based on the Case Management principle and use of the unified client record allowed services to develop so that they met the individual's needs and were accompanied with high levels of satisfaction. The management team has remained a flat administrative structure to maintain the specialist teams but to also allow maximum responsiveness to service needs.

The sustainability of the Southcare model has been shown by its durability over the past 12 years. New services have been developed such as the Chronic Care Team (Sutherland Heart and Lung Health Team), Continence Service, Mobility and Falls awareness programs, Clinical Nurse Consultant service in Aged Care and the Aged Care Services Emergency Team in line with recommended approaches. A range of service improvement projects conducted 1994-2005 are outlined below:

• Development of mobility programs
• Continence Service
• Positive Living
• Equipment Lending Pool
• Wellness program
• Innovative HACC services
• Transfer of aged care slow stream rehabilitation beds to the inpatient unit at Sutherland hospital
• Chronic care team (SHALT) developed
• Falls data collection and development of Falls Prevention Program
• Acute aged care ward 28 beds transferred to Southcare Management
• Aged care services emergency team (ASET) team developed
• Outdoor mobility group commenced
• ComPacks commenced
• Transition Aged Care Community Team (TACTS) developed.

Staff commitment to the vision of quality improvement has allowed the Southcare model to meet new challenges in providing aged care services for community and acute sector patients in line with best practice (Naylor et al 1999). It has been a continual journey using a quality framework as the guide. The effectiveness of the model has been demonstrated by the use of the service by local people, their General Practitioners, Medical Specialists and the growth of referral figures between 1994 and 2004.

The Southcare model when comparing NAPOOS usage has demonstrated increased access and availability of services. The development of new services using this framework and the increased referral numbers of existing services demonstrates community confidence in the effectiveness of this model of aged care delivery. The strategy of providing a single point of referral and contact for all community aged care services is confirmed by user acceptance and satisfaction reports conducted regularly. The development of a faxed referral from in 2000 for intake increased referrals from Emergency Department from 4 per month to 26 per month and reduced verbal complaints. The provision of equipment by the Equipment Lending Pool and its accessibility to residents was confirmed as effective by a review conducted in 1998-2000. Customer satisfaction reviews for a range of Southcare team activities – SHALT, ASET, Positive Living and Dementia Respite services have continually provided high levels of satisfaction, compliance and attendance (Diment et al 1999; Hallum, 1995).

The Southcare model provides an effective way of utilising community and aged care resources to the benefit of the local community. Centralised intake, data management, and assessment generates a record of care that can be easily reviewed by all teams and provide a fast responsive service to local needs. The amalgamation of community and aged care services at Sutherland Hospital using the Southcare model is a truly wonderful journey that could easily be adapted in areas with the will to review their service delivery methods and embrace a new model of service delivery.

• Diment, C. and Keating, W. 1999 Report of Occupational therapy customer survey. Southcare publication.
• Hallum, V. 1995 Sutherland community options programme: new directions pilot project report. Southcare publication.
• Naylor, M.D., Brooten, D., Campbell, R., Jacobsen, B.S., Mezey, M.D., Pauly, M.V. and Schwartz, J.S. 1999 Comprehensive discharge planning and home follow-up of hospitalised elders: A randomised clinical control trial. JAMA 281, 7, 613-620.
• Stathers, G. 1998 Southcare 1998: Preparing for the millennium. Southcare publication.

NUM, Southcare Dementia Monitoring
South Eastern Sydney Illawarra Area Health Service
Phone: 02 9540 7916