geri-connect · geriatrician outpatient review decline in gp’s wanting to visit racfs. where we...

Geri-Connect

AN INNOVATIVE APPROACH TO CLINICAL SERVICE DELIVERY

… or how a region

Introduced a new disruptive, clinical service model

supported by technology into Residential Aged Care

Facilities (RACF) which:

Polypharmacy by up to 17%

falls by up to 43%

waiting times by two months

access to clinical services by 90%

new revenue

And kept going….. !!!

About Us

Loddon Mallee Region

Acute Beds

25%

Sub-Acute beds

1%

Aged Care

67%

TCP

3%

others

4%

Regional Bed Profile

Problem – Unmet Demand

Yes

5%

No

95%

RACF Patients with Geriatric

Medical input into care plans2-3 month wait for a

Geriatrician Outpatient

Review

Decline in GP’s wanting to

visit RACFs

Where we started

Health Service 1st Priority 2nd Priority 3rd Priority

Echuca Regional Health Pain Management Geriatrician Services Cancer Services

Swan Hill District Health Geriatrician Services Fractures Clinic

Cohuna District Health Service Geriatrician Services Pre-Surgical Consultations Skin Disorder

Inglewood District Health Service Geriatrician Services Mental Health

Kyabram District Health Service Geriatrician Services Huntington's Disease Orthopaedics

Heathcote Health Geriatrician Services Mental Health Social Worker

Boort District Health Service Geriatrician Services Aged Care Mental Health

Kerang District Health Geriatrician Services Urgent Care Urgent Mental Health

Kyneton District Health Service Trauma Support Geriatrician Services Urgent Mental Health

Rochester and Elmore District Health Geriatrician Services Fractures Clinic

Maryborough District Health Geriatrician Services

Castlemaine Health Geriatrician Services Rehab Support Urgent Care

Robinvale District Health Service Geriatrician Services Trauma Support

GP Services into Aged

Care

Solution

Vision

A self-sustaining specialist Geriatrician virtual service hub to improve equity & quality of care provided to older adults across regional Victoria

Scope

Initial scope of implementing a service into 15 public health service Residential Aged Care Facilities across the Loddon Mallee Region.

What we had to do it with

No Geriatricians No money

Pillars for a sustainable clinical service model

Recurrent funding source

Ability

Technical and Financial Resource

WorkforceDesireClinical

(Market)

Technology

ConceptSustainable

Service Model

Financial

Kick start funding required to

accelerate the program

(provided by Better Care

Victoria

Financially stable

proposition

Scalability

proposition

Implementation/Change Management Approach

Service

Specialist engages and develops ongoing relationship

with GP

Ongoing conversations

Referral Sent

Consultation held

Specialist letter sent

to GP

Care Plan implementted

Triaged

yes

No

GC Clinical Nursing

Coordinator educated

Nursing staff on the value of a Geriatric Service (how and when to

engage)

Point of care nurses

engage with Patients and Families to

identify suitable

residents

Nursing Staff complete Referrals

Discuss/engage with the

GP

Copy of Specialist

letter sent to RACF

approved

No Yes

Addressing risks

Risk Did it eventuate?

GPs won’t refer to the service No

Not all Regional Health Services participate in the service Yes

Unable to recruit sufficient clinical staff

(Consultants & Registrars)

No

RACF Staff will not support the program Yes

MBS items for telehealth no longer supported Not yet!

Poor Technology acceptance No

What did we end up delivering?

Initial Scope:

15 Loddon Mallee (Vic) region public health service RACFs

RACFs = Residential Aged Care Facilities

Innovative

What has been the result

A new disruptive, clinical service model supported by

technology/connectivity into Residential Aged Care

Facilities (RACF) which:

Polypharmacy by up to 17%

falls by up to 43%

waiting times by two months

growth of access to clinical services by 90%

new funding

Diffusion / Integration

in to Regional Health

Service provision

Looking Forward……

2019 onwards: Increased Access, Scope & Evaluation of Outcomes

Loddon Mallee 2017- Hume 2019- 2019 on

Stage 1 Stage 2 Stage 3 The Future

Stages 2 and 3

• Increased scope of service

• Virtual Medicine services to regional and remote health services

Overall VISION:Telehealth enabled shared platform NOT a telehealth service

In CareAt Home

Geri-Connect

Chronic Disease

Management

Aged care

Dementia• Diagnosis• support

RACFsSmall Rural

Hospitals

Common Telehealth, Tele-monitoring & Technology Platform

Stage 1Stage 2 & 3

Where we started… and where we are now
















Care
















Care
















Care

Plus more

Tele - ICU

Endocrinology

Tele Paediatrics Aged Care

Assessments

(ACAS)

Transition

Care (TCP)

Assessment

Tele Palliative Care CDAMS Clinic

Mental Health

MDT’s

Oncology MDT’s

>250 Telehealth

Consultations,

Assessments or

MDT’s per

month

Opportunity:

Development of a

Virtual Hospital and Ambulatory Outreach

services

eConsults

Tele - ICU

Multi-Disciplinary

Teams

Inpatient / Hospital Outpatient / Community

Consultations

Remote Monitoring

Foundations

Mental Heath

Tele - Stroke

UCC Support

Hospital in the Home

Assessments

E-Advice

In Hospital telemetry

Remote Patient Monitoring

Electronic Patient Record

Quality Programs

Sepsis Program

Community Health System

Loddon Mallee Virtual Hospital Architecture

eCredentialling

Ongoing Development

Clinical Service Foundation

Educational Outreach, Feedback and upskilling- Staff and community

Continuous Evaluation, QI & Research

Geri-Connect

Questions?

Authors:

Assoc Prof Marc Budge [email protected]

Jackie Plunkett [email protected]

mailto:[email protected]

mailto:[email protected]

Spares

Assessment and

Prevention

Electronic Health Record

Personal Health Record

‘Home’ monitoring

andSelf

Management

Information Connectivity / Sharing

Service Management

Evidence Base and Pathways

Co

ord

inate

d D

evelo

pm

en

t

Fu

nd

ing

Marc Budge

2009

Stage 3: Development of a comprehensive,

Ambulatory and Outreach Health Service…. for Older Adults

7. Awaited Outcome: Connect @ HomeCurrent BCV Innovation project Bid: April 2019

Connect@Home:• To optimise the management and outcomes of people with

chronic disease and other acute illnesses through remote monitoring of patients;

• directing clinical resources to patients in a more effective and timely manner;

• Hospital in the Home (HITH), Commonwealth Home Support Program (CHSP), Hospital Admission Risk Program (HARP), Home and Community Care Program for Younger People (HACC PYP) programs, and a shared relationship with the client’s local GP.

• The intention of remote health monitoring is the seamless transition of clients and client clinical information throughout the care continuum seamlessly. PRELUDE TO ->

Assessment and

Prevention

Electronic patient Record

My Health Record

‘Home’ monitoring

andSelf

Management

Information Connectivity / Sharing

Service Management

Evidence Base and Pathways

Co

ord

inate

d D

evelo

pm

en

t

Fu

nd

ing

Marc Budge

2009

Keeping it all together

https://www.kingsfund.org.uk/publications/making-sense-integrated-care-systems

https://www.kingsfund.org.uk/publications/making-sense-integrated-care-systems

https://www.kingsfund.org.uk/sites/default/files/2018-09/Year-of-integrated-care-systems-reviewing-journey-so-far-full-report.pdf

https://www.kingsfund.org.uk/sites/default/files/2018-09/Year-of-integrated-care-systems-reviewing-journey-so-far-full-report.pdf

geri-connect · geriatrician outpatient review decline in gp’s wanting to visit racfs. where we...

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