Department of Human Services

Patient Flow Collaborative Learning Session 4

Breakout session 1

Room M5 and M6

Alison McMillan and Prue Beams

Department of Human Services

Breakout session 1

Room M5 and M6 9.50 – 10.35

Rowena CliftPatient Flow CoordinatorBallarat Health Patient Flow Collaborative

5th May, 2005

Smoothing the path for complex medical patients

Smoothing

The Pathway for

Complex Medical Patients

BHS and HARP

Funded under 2001/2002 HARP funding round

“Targeting Care Management Across the Continuum”

GOAL STATEMENT

To develop and enhance an effective working partnership between primary care providers and Ballarat Health Services to improve health outcomes for patients over 65 years with COPD

and CHF

Aims...

To be achieved through:

• Supporting people’s independence and capacity to live within the community

• Increasing capacity within the health system to respond to patient needs

• Clearer clinical pathways to deliver better continuity of care

• Creating unity and structure between public hospitals and community care sectors

We love a challenge

Collaborating agenciesCollaborating agencies

• Division of General Practice

• Ballarat District Nursing & Health Care

• Ballarat City Council

• Ballarat Community Health Centre

• Primary Care Partnerships

• Ballarat Health Services

Collaboration + Cooperation = Success

Project imperativesProject imperatives

• Reduced number of attendances of ED

• Reduced number of admissions to acute medical wards

• Reduced number of readmissions per episode

• Improved efficiency in resource management between all health sectors

• Improved consumer satisfaction

• Improved health outcomes via improved management and community support

Continued...Continued...

• Improved timing of intervention during acute exacerbations to reduce severity of symptoms

• Improved clinical decision making based on evidence based practice

• Improved access to treatment options

Target populationTarget population

• Over the age of 65 years

• Primary diagnosis of COPD and/or CCF

• Multiple attendances at ED and/or multiple emergency admission to acute hospital (ie 3 or more admissions in 2 years)

• In 2004 model trialed with Unstable Angina

Model of CareModel of Care

• Preliminary multidisciplinary comprehensive assessment in the community

• Primary Physician assessment

• Case Conference

- Physician

- GP

- Nursing

- Allied Health

- Community Service Providers

Model of CareModel of Care

Individual Care Plans for each client including:

- links to community-based chronic disease self-management programs

- agreed triage processes involving GP’s and/or HARP nursing staff when medical/social crises occur

- 24 hour short term in-home crisis intervention

- facilitated access to ED/MAP if appropriate

- development of comprehensive discharge strategies on admission to acute care using individual care plans

HARP Outcomes Jan 2004 - Dec 2004 Patients

Managed for 6 months

3932

12.8

154.1

12 6 7.1

35.6

77 83

9.2

241.7

3924

4.7

113.4

0

20

40

60

80

100

120

140

160

180

200

220

240

260

Pre Int Jan 03 to June 03 39 32 12.8 154.1

Post Int Jan 04 to June 04 12 6 7.1 35.6

Pre Int July 03 to Dec 03 77 83 9.2 241.7

Post Int July 04 to Dec 04 39 24 4.7 113.4

Number of presentations to

ED

Number of admissions

Average length of stay

Bed days utilised

HARP Outcomes July 2003 - Dec 2004 Patients

Managed for 12 months or more

7159

19.6

215.8

31 26

7.5

117.6

5445

11.8

255.8

2813

2.7

74.8

020406080

100120140160180200220240260

Pre Int July 02 to June 03 71 59 19.6 215.8

Post Int July 03 to June 04 31 26 7.5 117.6

Pre Int Jan 03 to Dec 03 54 45 11.8 255.8

Post Int Jan 04 to Dec 04 28 13 2.7 74.8

Number of presentations to ED

Number of admissions

Average length of stay

Bed days utilised

Outcomes Jan 04 to June 04Outcomes Jan 04 to June 04

0

3

6

9

12

15

18

21

24

27

Pre Intervention(on assessment)

4 13 8 6 14 2 13 12 4 0 4 8 3 11 9 1 5 5 1 3 7 6

Post Intervention(near or at discharge)

1 1 4 6 9 1 10 7 1 0 2 16 6 7 4 0 3 1 10 3 1 2

Client A

Client B

Client C

Client D

Client E

Client F

Client G

Client H

Client I

Client J

Client K

Client L

Client M

Client N

Client O

Client P

Client Q

Client R

Client S

Client T

Client U

Client V

72.7% of clients have shown a decrease in severity of symptoms

13.6% remained the same

13.6% of clients have shown an increase in severity of symptoms

Interpretation of Total ScoreTotal Score Depression Severity

1-4 Minimal depression

5-9 Mild depression

10-14 Moderate depression

15-19 Moderatelyseveredepression

20-27 Severedepression

Outcomes July 04 to Dec 04

0

2

4

6

8

10

12

14

16

18

20

Pre Intervention(on assessment)

6 1 3 4 13 10 2 6 13 9 0 4 0 10 2 11 2 3 0 8 13

Post Intervention(near or at discharge)

5 0 1 3 9 3 0 4 14 3 0 1 0 7 1 2 2 11 0 2 1

Client A

Client B

Client C

Client D

Client E

Client F

Client G

Client H

Client I

Client J

Client K

Client L

Client M

Client N

Client O

Client P

Client Q

Client R

Client S

Client T

Client U

QOL Measurement

Interpretation of Total ScoreTotal Score Depression Severity

1-4 Minimal depression

5-9 Mild depression

10-14 Moderate depression

15-19 Moderatelyseveredepression

20-27 Severedepression

71% of clients have shown a decrease in severity of symptoms

19% remained the same

10% of clients have shown an increase in severity of symptoms

65+ with 2 or more medical issues presenting with falls, fractures, osteoarthritis, or requiring ortho surgery, currently on ortho outpatient waiting list

Medical IssuesDiabetesCCFCOPDCognitive disordersFallsContinenceDepression/Social Isolation

GP engagement

Assessment report to be compiled by GP including full

health assessment

Primary in home assessment by Ortho Nurse

(screening for further multidisciplinary assessment eg

Physio, OT, Social Work, Dietetics)

1. ? Further Clinic discussion required

2. Viewed by Medical Specialist

Case ConferenceMedical Specialist (who reviewed patient)Ortho Nurse, Allied Health, GP

Medical Treatment PlanIndividualised case management plan

GP for Ongoing review

Health Issues

Discharge

Review in ClinicProceeds to theatre

Appropriate Specialist Medical Clinic Eg # clinic CADAMS

Inpatient admission

Discharge to GP

Triaged by CNC

Clinic appointment made

*Flagged medical issues

CompOP Project – Proposed PathwayCompOP Project – Proposed Pathway

Triage by Ortho CNC Contact for involvement Informed consent signed

OR

To develop, test and evaluate a model for collaborative complex patient care for patients,

65 years and over with orthopedic issues which: takes account of preventative, specialist and acute care options has a multidisciplinary,

multi-service approach to care identifies effective options for enhanced community

based care Is transferable across a range of population.

CompOP ObjectivesCompOP Objectives

• A coordinated, collaborative service provider/hospital approach to the prevention and management of complex medical issues through agreed individual service pathways (care management plans)

• Availability of service coordinator to facilitate responses as appropriate

• Targeting those patients with optimal potential to benefit from medical specialist outpatient clinics

1) To reduce outpatient presentations through:

• Enhancing health status on admission for those requiring surgery

• The use of agreed individual service pathways to facilitate planned service provision and coordination for discharge with appropriate services and supports

2) Minimise length of stay for those requiring surgery by:

• Clear clinical and service pathways across the patient continuum

• Single point of contact for those patients with complex medical issues

• Enhanced links for those with complex conditions to appropriate self management resources and other community based programs as required

• Access to specialised multidisciplinary assessment and care planning

• Enhanced hospital admission and discharge processes

3) To improve health outcomes and continuity of care processes with the development of:

• Decrease length of stay for target group

• Decrease presentations to outpatients per patient

• Decrease “Did not attends” per clinic for target group

• Decrease “Not ready for care” on waiting lists for those requiring surgery

• Increase in diversity of outpatient treatment options

CompOP Outcome MeasuresCompOP Outcome Measures

Results to DateResults to Date

The outpatients appointments list was reviewed

• 404 patients were on the list

• 159 medical records were audited

• 56 patients were living in Ballarat with 38 patients fitting the target population

• 94 patients were booked for 12 monthly review following previous Orthopaedic Surgery

Questions

?

Morning TeaMorning Tea

Meet us back here for

Innovations in length of stay reduction and opportunities to

bundle care

at 10.55

Department of Human Services

Breakout session 2Room M5 and M6

10.55 – 11.45

Wendy BezzinaPatient Flow CoordinatorLaTrobe Regional Hospital

5th May, 2005

Innovations in length of stay reduction and opportunities to bundle care

Ensure the clinical process delivered key elements of care for optimal patient outcomes

Encourage clinical teams to manage unwarranted variation in care delivery

Measure compliance daily, ensuring a consistently high standard of care

LOS Care Bundling ToolLOS Care Bundling Tool

The LOS Care Bundling Tool presented in the “Innovations to Improve LOS Management” toolkit was used to;

Diagnostic workDiagnostic work

The LOS Care Bundle Tool has been utilised for a period of 2 weeks prior to this presentation.

From our diagnostic work, we were able to determine we were 100% compliant at 10:30am every day, in all areas other than “Discharge by 10:30am”.

We will continue to use the LOS Care Bundle Tool going forward to assess compliance and assess the impact of other discharge planning efforts.

LOS Management Care BundleLOS Management Care Bundle

BedDischarge medication

Follow up arrangements

e.g. OPD

Day/time of discharge

communicated to patient/carer

Letter to General

PractitionerTransport

plan overall

1 1 1 1 1 2 12 1 1 1 1 2 13 1 1 1 1 2 14 1 1 1 2 2 15 1 1 1 0 2 06 1 0 2 0 2 0

7

2 - Component not needed

Compliance rates are then shown in the "Compliance Data" worksheet and graphs for each component and overall compliance are displayed on the other worksheets. Formatting of the graphs (such as changing the graph title) can be done in the usual way.

Length Of Stay Management Care Bundle

0 - Component not complied with1 - Component complied with

This measurement tool has been developed to assist with calculating and compliance with the length of stay management care bundle. The tool consists of several automatic data sheets, data needs to be entered into the audit sheet only.

In the audit sheet information should be entered for each patient and component as follows:

The Care Bundle results:If all the components are complied with, the overall rating will be 1, which means the Care Bundlehas been complied

If all the elements are complied with, and/or they are not required, eg transport, the overall rating will be 1.

If one or more components are not completed, thenthe overall rating will be 0, which means the Care Bundle not complied

What if you're not implementing all 5 components?

The sheet has been set up to monitor compliance for 5 components in this care bundle. If the patient does not need a component of the care bundle, enter number 2, which means 'not needed', see example below in yellow.

Using '2' will mean the compliance for this component is 'not needed' but will not affect the way compliance is calculated.

Audit No. or Date

Component

LOS Management Care Bundle LOS Management Care Bundle - a typical day- a typical day

BedDischarge medication

Follow up arrangements

e.g. OPD

Day/time of discharge

communicated to patient/carer

DISCHARGED BY 1030HRS

Transportplan

Overall

1 2 2 2 2 2 12 2 2 2 2 2 13 1 1 1 0 1 04 2 2 2 2 2 15 2 2 2 2 2 16 1 1 1 0 1 07 1 1 1 0 1 08 2 2 2 2 2 19 2 2 2 2 2 1

10 2 2 2 2 2 111 2 2 2 2 2 112 2 2 2 2 2 113 2 2 2 2 2 114 2 2 2 2 2 115 2 2 2 2 2 116 2 2 2 2 2 117 2 2 2 2 2 118 2 2 2 2 2 119 2 2 2 2 2 120 1 2 1 0 1 021 1 2 1 0 1 022 2 2 2 2 2 123 2 2 2 2 2 124 1 2 1 0 1 025 2 2 2 2 2 126 2 2 2 2 2 127 2 2 2 2 2 128 2 2 2 2 2 129 1 1 1 0 1 0

30 2 2 2 2 2 1

No. of patients where compliance is achieved 30 30 30 23 30 23

Compliance % 100.00 100.00 100.00 76.67 100.00 76.67

Component

18/04/2005

Constraint Area - LOSConstraint Area - LOS

Our average LOS in our Acute (Med/Surg) Units is historically between 3.5 - 4 days

Since the commencement of the PFC and implementation of various improvement initiatives our LOS has remained invariable.

The LOS Care Bundling Tool has clearly identified our major barrier in decreasing our LOS is Medical staff discharge practices.

Historically, we have discharged approx 8% of patients by 10:30am in our Medical and Surgical wards.Constraints to increasing this are;

Medical rounds done late in the day No prioritisation of patient rounds Medical Staff not flagging possible discharges Discharge planning not appropriately prepared Patient Transport not arriving at ‘booked’ times NUM’s not having a clear level of responsibility for

LOS, Discharge Planning and ED Admissions

Discharge Planning / CoordinationDischarge Planning / Coordination

Discharge Planning / CoordinationDischarge Planning / Coordination - Improvement Initiatives - Improvement Initiatives

Our Chief Medical Officer has met with Acute Medical Staff and followed up meetings with letters requesting their assistance in the following;

identifying anticipated LOS for each patient

identifying at least 2 patients per day for discharge the following day

agreement on guidelines empowering Registrars to perform discharges without Consultant review

prioritising ward rounds where patients identified for discharge, are seen at the commencement of the round

Discharge Planning / CoordinationDischarge Planning / Coordination - Improvement Initiatives cont … - Improvement Initiatives cont …

Our Acute Medical Unit Manager has developed a ‘Unit specific’ orientation for all new Medical Staff specifically addressing;

expected admission procedures

discharge planning practices

patient transfers

pharmacy procedures

One of our Acute AUM’s has recently developed a ‘Discharge Envelope’ to help patients participate in their own discharge. The envelope includes;

points detailing expected discharge time and procedure

a checklist detailing what they require prior to discharge

room inside for any information patients will take with them

Discharge Planning / CoordinationDischarge Planning / Coordination - Improvement Initiatives cont … - Improvement Initiatives cont …

All NUM’s have been removed from ‘clinical’ duties and have had KRA’s developed that detail their responsibilities in relation to;

95% Admissions from ED within 12 hours

40% patients discharged by 10:30am daily

LOS at State Average

All KRA’s feed back into the LRH Strategic Directions, Operating Plan and Statement of Priorities and are reviewed quarterly.

ProgressProgress

Positive impacts to date;Discharges by 10:30am have increased from

approx 8% to an average of 23% during the month of March.

While our average Acute LOS has remained fairly static between 3.5 - 4 days over the past 12 months, it’s hoped that improvements in Medical Staff discharge practices will see further progress.

Lessons learntLessons learnt

What worked well;

The Care Bundle Tool is very easy to use and only takes minutes each day to complete

What would you now do differently and why? As always, Hospital Policies need to be in place to

support any changes that are being implemented.

Desired ImpactDesired Impact

Our expected impact will be;95% Admissions from ED within 12 hours

40% patients discharged by 10:30am daily

LOS at State Average

Next StepsNext Steps

Further work on Medical Staff discharge practices

Questions

Contact: Wen Bezzina PFC Coordinator wbezzina@lrh.com.au (03) 5173 8139

?

LunchLunch

Meet us back here for

Team tabletop presentations

at 12.45

Team presentations12.45– 3.15

Prue Beams Room M5 and M6

•Melbourne Health

•Bayside Health

•LaTrobe Regional Hospital

•Goulburn Valley Health

•Northern Health

•Metropolitan Ambulance Service

Tabletop presentationsTabletop presentations

The aim of this session is to;• Promote discussion• Share “peer to peer” practical

experiences of innovation• Increase energy for change and shared

learning• Spread ideas between teams

Session formatSession format

• 2 teams per table• Team A has 15 minutes to share experiences

with team B• Whistle blows• Team B has 15 minutes to share experiences

with team A• Rotation 1• Continued….• Working afternoon tea is available

Session formatSession format

Time Activity Rotation

1.00 – 1.15 15 minutes

Melbourne Health presents to Bayside HealthLaTrobe Regional Hospital presents to Goulburn Valley HealthNorthern Health presents to Metropolitan Ambulance Service

1.15 –1.30

15 minutes

Bayside Health presents to Melbourne HealthGoulburn Valley Health presents to LaTrobe Regional HospitalMetropolitan Ambulance Service presents to Northern Health

1.35 – 1.50

15 minutes

Melbourne Health presents to Metropolitan Ambulance Service

LaTrobe Regional Hospital presents to Bayside Health

Northern Health presents to Goulburn Valley Health

Rotation 1

1.50– 2.05

15 minutes

Metropolitan Ambulance Service presents to Melbourne Health

Bayside Health presents to LaTrobe Regional Hospital

Goulburn Valley Health presents to Northern Health

Session formatSession format

Time Activity Rotation

2.10 – 2.25 15 minutes

Melbourne Health presents to Goulburn Valley HealthBayside Health presents to Metropolitan Ambulance ServiceNorthern Health presents to LaTrobe Regional Hospital

Rotation 2

2.25 –2.40

15 minutes

Goulburn Valley Health presents to Melbourne HealthMetropolitan Ambulance Service presents to Bayside Health LaTrobe Regional Hospital presents to Northern Health

2.45 – 3.00

15 minutes

Melbourne Health presents to Northern Health

Bayside Health presents to Goulburn Valley Health

Metropolitan Ambulance Service presents to LaTrobe Regional Hospital

Rotation 3

3.00 – 3.15

15 minutes

Northern Health presents to Melbourne Health

Goulburn Valley Health presents to Bayside Health

LaTrobe Regional Hospital presents to Metropolitan Ambulance Service

Meet us back in the plenary for

Team planning time

at 3.20