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Implementing Community Acute Post Acute Care (CAPAC)

CAPAC Model of Care (2M) APAC/GP Shared Care (380kb)		Planning Where are you now?		Preparing Make it happen		Operationalise Make it stick

Governance		Identify leaders Establish a steering committee		Determine type of CAPAC required Develop a governance plan Establish and Mobilise team Develop key performance indicators Set a timeframe and stick to it		Monitor and evaluate against KPIs

Patient Journey		Define project target group Map the Patient Journey (inlcude carer and/or family perspective)		Document 'new' patient journeys that have been enhanced through the implementation of CAPAC (include carer and/or family perspective)		Regular monitoring of patient, carer and/or family experiences via regular patient journey mapping

Policies and Protocols		Understand current systems Identify gaps in existing clinical and non-clinical policies that may limit establishment of service (eg community health staff able to be rostered for evening shifts)		Develop policies and protocols Develop evidence-based standard practice guidelines Develop appropriate referral systems Develop baseline aggreements with GPs Work with community organisations to develop seamless care processes Create links to rehabilitation and chronic disease management		Ensure ongoing review of policy, guidelines and risks. Refine as required Make comprehensive risk assessments before accepting patients

People Understand who the staff are, how they function and what role they play in the patient journey		Stakeholder analysis		Develop position descriptions for staff to provide multidisciplinary care in the home Provide training to all staff and intensive training and support to staff implementing CAPAC Mentor staff to make transition from providing community to acute care and vice versa		Develop a review process and competency standards Regular management review of knowledge and skills about CAPAC

Resources		Conduct a resource survey: What will you need to complete the project? Identify resources needed to establish and maintain CAPAC		Appoint a project officer Deliver required resources		Monitor resource use and modify as required

Communication		Develop communication plan for internal and external target groups		Execute communication plan. Tell people about the project at every opportunity Identify how results will flow back to the project		Ensure responsive and timely feedback and review process