Integrating Healthcare and Home Care: A Holistic Approach at Ozanam House

Introduction

Mobile GP has implemented a model of integrated healthcare and home care, combining services from Atticus Health with Mark & Sylvie's Home Care. This approach aims to improve access to comprehensive care and enhance the wellbeing of individuals at risk of homelessness. Supported by the Early Interventions Program for Health Ageing in conjunction with the North West Melbourne Primary Health Network (NWMPHN), the program provides a patient-centred solution tailored to individual needs.

1. A Holistic Approach to Healthcare

For those experiencing or at risk of homelessness, consistent and quality healthcare can often be difficult to access. By integrating healthcare and home care, Ozanam House aims to provide a holistic solution, ensuring that individuals not only receive necessary medical attention but also ongoing support for daily living needs.

Atticus Health's Contribution

Atticus Health delivers regular medical and specialist services to Ozanam House residents, including:

• GP Telehealth Services: Providing virtual consultations, making healthcare more accessible.
• Specialist Consultations: Fortnightly visits from a Geriatrician to address the complex needs of older residents.
• Mental Health Support: Weekly appointments with a Mental Health Social Worker to provide psychological and emotional assistance.
• Physiotherapy: Monthly physiotherapy sessions to address mobility and physical health, particularly for those with chronic conditions or ageing-related issues.

These services are designed to meet each resident’s specific needs, focusing on both immediate care and long-term health management.

2. The Role of Mark & Sylvie's Home Care

In addition to medical care, many residents of Ozanam House require support with daily living tasks. Mark & Sylvie's Home Care provides this vital assistance, including:

• Daily Living Support: Helping with essential tasks like meal preparation, personal hygiene, and household chores.
• Personalised Care Plans: For residents aged 65 and over, care plans are tailored to integrate medical and home care services to support independent living.

By addressing both healthcare and home care needs, the model aims to enhance the overall quality of life for residents, supporting them in maintaining their health and independence.

3. Integration for Better Outcomes

This integrated model seeks to improve outcomes by aligning healthcare and home care services. The collaboration with the Early Interventions Program for Health Ageing ensures that the medical and home care teams work together to provide continuous, coordinated care.

A. Coordinated Care
The partnership between Atticus Health, Mark & Sylvie's Home Care, and the Early Interventions for health ageing Program enables a more seamless coordination of services. For example, a resident managing a chronic condition may receive medical treatment from Atticus Health, while the home care team ensures their living environment supports their recovery, assisting with medication management and follow-up care.

B. Continuity of Care
With healthcare and home care integrated, residents experience fewer gaps in their care, reducing the risk of complications. This approach is particularly beneficial for older residents who need both medical monitoring and assistance with daily activities. The combination of services results in fewer hospitalisations and overall improved health outcomes.

C. Patient-Centred Focus
The model revolves around the unique needs of each resident. By engaging key workers and case managers at Ozanam House, care plans are developed with a focus on personalised, comprehensive support, ensuring that individuals receive the right services at the right time.

4. A Real-Life Example

A resident named Reena (name changed for privacy), aged 84, faced multiple health challenges alongside mobility limitations. Through the integrated services provided by Atticus Health and Mark & Sylvie's Home Care:

• Reena receives regular consultations from a GP and Geriatrician to manage her chronic conditions.
• Monthly physiotherapy sessions helped improve her mobility and physical health.
• A personalised home care plan provided assistance with daily activities such as personal care and medication management.

As a result, Reena experiences significant improvements in her health and regained a degree of independence, which allows her to transition towards more stable living arrangements.

Conclusion

The integration of healthcare from Atticus Health, home care from Mark & Sylvie's Home Care, and the Early Interventions Program for Health Ageing at Ozanam House provides a comprehensive model of care for vulnerable populations. By addressing both medical and home care needs, the program strives to offer residents a higher quality of life and a path towards long-term stability.

To learn more about the Mobile GP Project, visit the website here for further information on how this initiative supports community health services.

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About the Author
This article was written by Brett, Project Manager for the Mobile GP program at Ozanam House. With a passion for community health and supporting vulnerable populations, Brett's work focuses on developing integrated healthcare models to improve the quality of life for individuals facing complex challenges.