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Table 2 Description of each participating service organisation

From: Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia)

Site ID. Service type

Relevant services delivered

Initial project aims/target group for needs assessment

Site #1

Metropolitan municipal council

Ongoing home and community care services (aged care support for activities of daily living, planned activity groups)

To support clients to improve social connectedness, physical/mobility and remain connected to their community while living at home.

Target group: Clients aged 65+ with mobility issues who are difficult to motivate and engage

Site #2

Metropolitan municipal council

Ongoing home and community care services (aged care support for activities of daily living, delivered meals)

Understand how vulnerable clients find, understand and use health information. Specifically to identify indicators for assessment officers to improve their capacity to identify clients with health literacy needs

Target group: All delivered meals clients (a vulnerable client group, i.e. frail aged and socially isolated)

Site #3

Metropolitan community nursing service

Ongoing care for clients at home with chronic conditions including education of clients in self-management

Improved awareness and uptake among all nurses of a standardised approach to diabetes education so that clients are better able to independently self-manage their condition.

Target group: Clients with diabetes and long term wounds

Site #4

Rural community health service

Ongoing and episodic care for clients and community members (on-site and outreach allied health, outreach health promotion including community activity groups)

Engage people from rural and remote communities with (or at risk of) chronic disease to better manage their health, navigate the health system and develop effective relationships with health professionals.

Target group: All clients eligible for services including those with complex conditions

Site #5

Rural community health service

Ongoing and episodic care for clients and community members (on-site allied health, outreach health promotion including community activity groups)

To support clients living with chronic disease and who are disadvantaged to access services and programs. Goals are that clients will: 1) be aware of what health professionals are involved in their care; 2) be aware of how to access health services to assist with chronic disease self-management.

Target group: All clients with chronic disease eligible to receive our services

Site #6

Metropolitan community health service

Ongoing and episodic care for clients and community members (on-site allied health services, community- and centre-based activity groups)

To tailor services to meet the different health literacy needs of clients and to improve clients’ skills and capacity to access services

Target group: Clients with chronic and complex conditions attending planned activity groups and those who receive 1:1 clinical interventions

Site #7

Outer metropolitan community health service

Ongoing and episodic care for clients and community members (on-site allied health services, community nursing service)

To increase community awareness of, and engagement with the service to help people develop the skills to self-manage their health conditions.

Target group: Community members not currently engaged; Existing clients who do not achieve ongoing engagement; Clients with chronic conditions who would benefit from improved self-management skills

Site #8

Metropolitan hospital Admission Risk Program

Ongoing (6–12 weeks) intensive case management for clients with chronic disease at risk of hospital admission. Allied health, nursing

To evaluate and improve the service’s response to patients who are in a crisis (defined by patient) to determine if the response is flexible, appropriate and timely resulting in reduced unplanned readmissions.

Target group: All current clients of the service

Site #9

Regional metropolitan Hospital Admission Risk Program

Ongoing (6–12 weeks) intensive case management for clients with chronic disease at risk of hospital admission. Allied health, primarily nursing

To improve clients’ capacity to access and understand health information and attend appointments. To provide clinicians with a consistent framework for approaching care

Target group: All current clients of the service