in-roads and out-roads in regional subacute care · pdf filein-roads and out-roads in regional...

In-roads and Out-roads

in Regional Subacute

Care -

A Central West NSW Experience

Dr Frances Gearon

11th October 2012

Acknowlegements

“The Subacute team”….. •Particularly………

•Dr Ellen Downes (Rehabilitation Physician)

•Dr Sumitha Gounden (Rehabilitation Physician)

•Dr Claire Sui (Rehabilitation Physician)

•Lacey Healey –Outreach Co-ordinator

•Kate Polain – Rehabilitation Clinical Nurse Consultant

•Tracey Drabsch- Physiotherapist

The development of a multidisciplinary team providing in reach and outreach rehabilitation

services in a regional centre.

Summary • Where ?

• Why ?

• What ?

• Who ?

• How ?

Where ?

ORANGE

Communities and Facilities supported by

Orange Health Service

ORANGE

Why ?

Issues to consider

1) Bed Capacity in Orange Health

Service (OHS)

Issues to consider

1. Capacity in OHS

2. Capacity in neighbouring

sites

Issues to consider

1. Capacity in OHS

2. Capacity neighbouring sites

3. Skills

Issues to consider

1. Capacity in OHS

2. Capacity neighbouring sites

3. Skills

4. Relationships

What ?

A Guardian Angel

SOMETHING ……Dropped into

“ - Orange Base Hospital • Fight for access to beds in OBH

• Enhance and support central service

• Improve patient care

• Improve communication/continuity

• Improve consistent patient discharge

planning and goal setting

SOMETHING ……Dropped into

“

• Support and build capacity of services

• Maintain role of “district hospitals”

• Maintain staff skills, interest, competence

• Provide services close to patients’ homes

How ?

COAG June 2009, the Western NSW Local

Health District (WNSWLHD) engaged in

the NSW National Partnership

Agreement securing Commonwealth

funding to enhance Sub-acute Care and

services within the District. WNSWLHD recruited a multidisciplinary team of Senior

Clinicians (Medical, Nursing, Allied Health)

The team brief was to establish a HUB and SPOKE and

Outreach model of care

2

5

1

NSW Health Subacute Care Reform Implementation

Plan

A component of the National Partnership Agreement

on Hospitals and Health Workforce Reform 1. Executive summary

Under the subacute care component of the National Partnership Agreement

on Hospitals and

Health Workforce Reform, NSW is to receive $165.652m. This funding will be

allocated to the 8 Area Health Services (AHSs) in NSW to enhance services across all four subacute care types

– rehabilitation, palliative care, geriatric evaluation and management (GEM), and

psychogeriatric care - targeting older people, children, Aboriginal people and other residents in

geographic areas in urban and rural NSW that are currently under-serviced.

The structure and profile of subacute services varies across NSW. Logically, services are

better developed in areas with larger populations, and especially in the Sydney greater

metropolitan region. Funding will be distributed among AHSs based on a needs-weighted

funding formula that takes into account both historical activity levels and the health needs of

each Area’s population. This funding model has been selected as it provides a strong equity

component. Funding will also be provided to the Children’s Hospital at Westmead as it provides

subacute care to a discrete population group……….

www.gwahs.health.nsw

Mission Statement

Sub-acute Care Team:

“Supporting current services and

existing networks to enhance

rehabilitation, geriatric evaluation,

and overall patient management in

hub and spoke sites”

Communities and Facilities supported by

Orange Health Service

www.gwahs.health.nsw

Acute Care for the Elderly (ACE)

Collaborative Care model with

Physicians

Multidisciplinary team (OT, PT,

Speech Path, Dietetics, SW, Nursing,

medical)

Geriatrician/Rehab Specialist (P/T),

Aged Care CNC

Acute Aged Care Nurse team

(Delerium CNS, ARRCS, ASET etc)

Dedicated weekly case conference

Inpatient Rehabilitation Units

Comprehensive Inpatient

multidisciplinary rehabilitation

based on existing model

Rehab CNC co-ordination

Outpatient rehabilitation

Provision of Management plan

REHAB DAY HOSPITAL

Orthogeriatrics

Collaborative Care model with

Orthopaedics

Geriatrician/Rehab specialist (P/T)

Multidisciplinary team (OT, PT, SP,

Dietetics, SW, Nursing)

Aged Care CNC

Acute Aged Care Nurse team

(Delirium CNS, ARRCS, ASET etc)

NEIGHBOURING

FACILITIES

Existing therapy teams (PT,

OT, SP, Dietetics, SW, Nurses)

Therapy Aide- to continue

recommendations

Completion of rehab

management plan closer to

patient’s home

Liaise with Outreach Co-

ordinator & Hub team to

facilitate goal attainment

Video/Teleconferencing

Ongoing Education through

“HUB TEAM” review on-site

and attendance in larger centres

Increased skills of local staff

Outreach Rehab Co-ordinator (F/T)

Regular conferencing with Neighbouring

Facilities (video/tele) re goal attainment

Scheduled visits on-site for education &

training of staff (increased skills)

Liaise with Base Hospital Rehab and

Outreach Team & LMO about patient goals

AND

NEW

NEW

Improved

Service

NEW

NEW

“THE HUB” OBH inpatient services Community and Neighbouring Facility Service(s)

FACILITATES:

•Timely inpatient geriatric

assessment

•Formulation of plans and goals

•Improved medical management

•Early discharge planning

•Appropriate rehab consults

•Handover to neighbouring teams

with ATTENTION TO DETAIL

Who ?

3

1

31

The “SUBACUTE TEAM”

Rehabilitation

Physician Clinical Nurse

Consultant

Outreach

Coordinator

Physiotherapist

Occupational

Therapist

Speech

Pathologist Dietitian

Social

Worker

Priorities for Sub-acute Team

Improved patient outcomes

BY

• Improved quality and continuity of care

• Timeliness of care

• Communication

Focus

“Ensuring our patients get the right care, at the

right time in the most appropriate place…”

Background

• Set up with Federal Government COAG Subacute Care enhancement funding

• Began in April 2010 & Full team recruited by Sept 2010

• Initial goals – Multidisciplinary inpatient geriatric assessment

– Plan formulation and Goal setting

– Minimisation of post-operative complications (pro-active patient management)

– Early discharge planning or streamlined rehab consults

– Detailed handover and support to neighbouring facility teams to support Sub-Acute Care closer to the patients home

www.gwahs.health.nsw

Challenges Within the Hub

• A New service vs Ingrained culture: Drawing attention to the need to address the “Essentials of Care”

• Communication road blocks: who are you, why do we need you, what is a Rehab service doing in acute care?

Challenges Within the Hub

• Change Management

-new facility

-new service

• Facade of creating “additional workload”

• Facility KPI’s vs Patient Outcomes KPI’s

- advocacy at patient flow meetings

www.gwahs.health.nsw

Challenges • New Team

– Establishing referral criteria, ‘Sub-acute’ very

broad area

– Establishing acceptable systems and

protocols (acceptable to all parties involved)

– Introducing team to broader hospital staff and

broader area team

– Establishing individual team member roles

and complementing existing staff roles

www.gwahs.health.nsw

Finding a starting point:

Ortho geriatric patients

Limited the diagnostic inclusion group to a

“high needs” patient cohort:

- All Fractures

- 65 years and older

- From Orange or a

Neighbouring Facility

Orthogeriatric Best Practise

Guidelines • ACI Orthogeriatric Model of Care: Summary of

evidence 2010.

• Orthogeriatric pt often has complex needs,

benefits from:

– Collaborative multidisciplinary approach

– Effective teamwork

– Coordination of care

– Close working partnership and clear communication

between various specialties and services involved

4

0

www.gwahs.health.nsw

Orthogeriatrics

Collaborative Care

with the

Orthopaedic/Acute

Teams

Sub-Acute Care Team

Multidisciplinary

Team

NF Teams

•Outreach

visits

•Patient

follow up

•Education

•EDUCATION

•EDUCATION

•SUPPORT

•SUPPORT

•SUPPORT

Outreach Co-ordinator

Sub-Acute

Care Team

members

“THE HUB” ORANGE

inpatient Neighbouring Facility

Multidisciplinary

Handover

to Neighbouring

Facilities & Teams

Sub-Acute Care Team Hub and Spoke Model of

Care from OHS

Challenges (cont.) • A Valued Patient group

– Typically working with “low priority” patients

– Justifying Senior Clinician involvement in what was

viewed as low pay off clinical load

– Change Management on an Acute Ward (Pressure

Care, Equipment, Rehab for elderly)

• Missing the support of OT’s!

– Working to establish networks with OT’s

– Why doesn’t everyone understand “functional”!!?

Baseline Hub Audit

• Admission to OBH with a

fractured NOF

• Aged 65 years and over

• Residential address in

neighbouring location (not

including Orange residents)

• Admitted to OBH between

June 2008 – June 2009

• Of 110 patients, 50 MRNs

were selected to audit

www.gwahs.health.nsw

Why we audited • Collect baseline data for orthogeriatric

patients

• Collect quantitative & qualitative data pertaining to the patient journey

• Determine current practice and care process for management of orthogeriatric patients

www.gwahs.health.nsw

Why we audited (cont’d)

• Identify common issues impacting upon patient care and outcomes

• Identify strengths and weaknesses in the care of orthogeriatric patients

• Guide the teams intervention and input

www.gwahs.health.nsw

What was included • Demographic Information

• Admission Information (LOS, # Type, Surgery, Co morbidities)

• Documentation (Pre-Morbid Mobility, WBS, Cause of Injury)

• Pain Management

• Bowel/Bladder Management

• Pressure Care

• Access to Rehabilitation

www.gwahs.health.nsw

What was included (cont)

• Delirium (Screening, Management)

• Complications e.g. UTI, Pressure injury,

• Allied Health Involvement

• Discharge Planning & Handover

• Discharge information e.g. Where, delays

• Readmission

www.gwahs.health.nsw

Other information • 44% of patients developed post operative

delirium/confusion

• A Rehabilitation consult was requested for 66%

of patients

• 14% of patients were admitted to an inpatient

Rehabilitation unit

• On average, discharge planning was initiated 5

days post admission

Other information (cont’d)

• Only 32% of patients had their

weight recorded during admission

• Documented malnutrition,

nutritional risk, poor oral intake:

54%

Where did they go??

28%

24%18%

14%

10%

6%

Nursing home

Back to transferring hospital

Other

Rehabilitation Facility

Hostel/special accomodation

Home with supports

Initially 24% from Nursing Home and 58% from home

Complications during admission

34%

30%28%

20%

16%14% 14% 14%

8%6%

2%

Con

stipat

ion

1st o

ther

No co

mplications U

TI

Pre

ssur

e ulce

r

Electro

lyte

imba

lanc

e

Wou

nd in

fection

Che

st in

fection

2nd othe

rFa

ll

DVT

/PE

www.gwahs.health.nsw

What we did

• Established collaborative care involving the Sub-acute Team and the Orange Health Service Orthopaedic Team for all elderly patients with fractures presenting to OHS……

What we did Increased communication with patient focus:

• Day 0 involvement

• Engagement-Senior Clinical Leaders- Orthopaedic

surgeons & Surgical NUM

• Automatic physician assessment of all #NOF’s

• Case Conference (early assessment and MDT approach

with early planning and goal setting )

• Family/ Carer Involvement

• Handover (Comprehensive and timely)

• Follow up (Access to clinical support and patient review)

www.gwahs.health.nsw

What we did

This team attempted to

implement

ACI

ORTHOGERIATRIC Model of

Care

within OHS and its neighbouring

hospitals

www.gwahs.health.nsw

Planning & Implementing

solutions

This team implemented the Orthogeriatric ACI

Model of Care within OHS and its NF

• To establish baseline information within the OHS

a medical record audit was completed.

Pre Team June 2008 - June 2009

(n=50).

Post Team Sept 2010 - Feb 2011

(n=30).

5

4

Outcomes & Evaluation

Statistically significant increase in:

• Occupational Therapy and Social Work involvement

• Documentation of weight bearing status, pre-morbid mobility and pre-morbid function

• Aperients given

• Paracetamol charted

• Medical discharge summaries sent to the General Practitioners

• Handover information including the patient’s equipment needs, goals and contact details, physiotherapy, dietetics and social work discharge summaries

5

5

5

6

5

7

5

8

Outcomes & Evaluation

Statistically significant increase in:

• Occupational Therapy and Social Work involvement

• Documentation of weight bearing status, pre-morbid mobility and pre-morbid function

• Aperients given

• Paracetamol charted

• Medical discharge summaries sent to the General Practitioners

• Handover information including the patient’s equipment needs, goals and contact details, physiotherapy, dietetics and social work discharge summaries

5

9

Qualitative Assessment

• Education Sessions provided for groups

and one off clinical education

• Advice is always available –phone and site

visits

• Comments from GP’s, Nursing staff and

allied health ……“More support than we

have ever had”.

Qualitative Assessment

• On site visits from the teams Allied

Health/Medical /CNC

• Cowra, Parkes, Forbes patient flow

meeting with OHS via teleconference

Sustaining Change

• The team’s linkages with existing networks such

as the NF and rural AH clinician's enables

informed decisions about handover & follow up

of patients transitioned from OHS.

• The team is aiming for sustainable service

improvement by ensuring the ongoing

multidisciplinary management of this patient

cohort at OHS. This includes regular case

conferences, consistent multidisciplinary verbal

and written handover and supporting staff in

regard to the care of patients with complex co-

morbidities.

6

2

Lessons Learned

• Guidelines with clinical validity and authority to

work from provide a good platform to guide, build

and sustain clinical practice changes

• Consistent Communication and support with

change management

• Consistency of team activity over a prolonged

period is effective in maintaining service provision

• Teams work well with teams

• Networking is key to providing a more seamless

patient journey

6

3

Current Roles

Education

- Education provided in Neighbouring

Facilities and at Orange Health Service re:

Orthogeriatrics best practise, Preventing

Functional Decline, Sub-acute Care.

- Support of other clinicians as

required/requested

• Areas for improvement?

• The verbal handover from Patient Flow

needs improvement

• More assistance with discharge planning

for these patients from Canowindra and

Molong Hospitals

• Support with the Delirium patients in

particular (clinical education and advice)

www.gwahs.health.nsw

Establishing a Model of Care for

the Sub-acute Care Team

Inspiration from:

• Acute Care for the Elderly (ACE) - Hornsby

• Hub & Spoke Rehabilitation

• NSW Agency for Clinical Innovation- Orthogeriatric Model of Care

• Garling Report

Unique dual focus on both Acute and Rehabilitation

phases of the patient journey

Bibliography

1. NSW National Partnership Agreement

2. http://www.coag.gov.au/intergov_agreements/federal_financial_relations/do

cs/national_partnership/national_partnership_on_hospital_and_health_work

force_reform.rtf

3. Australasian Faculty of Rehabilitation Medicine position statement No.9

National rehabilitation Strategy (2009)

http://www.racp.edu.au/index.cfm?objectid=02A28582-E795-54CF-

2A8041E0BD658E1E

4. Acute Care for the Elderly (ACE)

http://www.archi.net.au/resources/moc/older-moc/ace

5. Orthogeriatric Model of Care (Agency of Clinical Innovation)

http://www.health.nsw.gov.au/resources/gmct/agedcare/pdf/aci_orthogeriatri

cs_clinical_practice_guide.pdf

www.gwahs.health.nsw

Current Roles

• Medical

- Involvement with complex medical patients

referred by treating medical team (e.g.

elderly patients at risk of functional decline

during hospital admission).

- Why this patient cohort??

ACE Model (Acute Care of the Elderly)

• Developed by Hornsby Ku-ring-gai Health Service

• Concepts: – Multidisciplinary team approach from time of admission

– DC planning begins on day of admission (incl. EDD)

– Shared care model between admitting physician and geriatrician

– Ongoing focus on function – to pre-morbid level

– Weekly pharmacy round

• Needs understanding and commitment from all staff, pt’s and family

• Aim to keep elderly pt’s as active and independent as possible during acute phase of illness

Current Roles

• Neighbouring Facilities

- Comprehensive handover summary.

- Follow-up by Outreach Coordinator for all patients transitioned to neighbouring facilities for sub-acute care.

- Involvement from individual disciplines as required, follow-up with local teams.

- Review for possible readmission for rehab at OHS.

- Review for possible assistance for setting goals/programs while at Neighbouring Facilities.

Thank you