The Health Roundtable1-1d_HRT1212-Session_AUSTEN_GOSFORD_NSW

Care Coordination decreases hospital reliance-Case Study

Presenter: Alison Austen

Central Coast LHD NSW

Innovation Poster SessionHRT1215 – Innovation AwardsSydney 11th and 12th Oct 2012

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Implementing NSW Connecting Care Program to target patients with chronic disease at high risk of admission.

Identify patients with frequent admission via 3rd admission Flag and direct referrals.

Patients often have low capacity to prioritise health and poor self management.

Lack of coordinated care between services. Lower level triage categories in ED and Frequent

unplanned admissions to Hospital impacting on patient flow.

Central Coast has a low ratio of GP FTEs per population, which are lower than the recommended national levels.

KEY PROBLEM

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AIM OF THIS INNOVATION

Minimise unplanned hospital admissions/ ED presentations

Establish Shared Care Plans and increase quality GP involvement

Coordinate patient care Organise Specialist review as appropriate Confirm Diagnosis –Improve patient disease knowledge Increase medication compliance Provide a process of monitoring to identify

exacerbations Reduce pressure on Emergency and hospital admissions Supporting Transfer of Care policy

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BASELINE DATA Influenced by residents at

Dpt Housing complex On parole Not contactable by phone Previously attended Smoking

Cessation clinic once ? capacity to change Client aware of problems

with short term memory MMSE – 24/30 ACE – 78/100 HAD – Anxiety 12/21 Depression 8/21 K 10 - 29

Male 59 yrs Multiple presentations to A&E

and Hospital admissions 2010 - 9 A&E LOS 3 to 9 hrs

and 2 admissions 3 & 4 days 2011 - 7 A&E LOS 1 to 14 hrs

and 1 admission over night Short of Breath - ? Asthma Direct referral from Continuing

Care Nurses Minimal GP contact Smoker

Tobacco since aged 13years Cannabis $100 F/n since

30yrs4

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KEY CHANGES IMPLEMENTED

Enrolled into Connecting Care program February 2012 for case management

14 home Visits, 3 GP visits, 2 specialist visits, and multiple phone case management with other service providers.

GP contact Respiratory Physician/ non charge clinic Memory assessment prior to behaviour change Referral for Neuropsychologist assessment Neurologist review

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OUTCOMES SO FAR

1 ED presentation since enrolment in 2012 – compared to 16 ED presentations over the previous two years.

Diagnosis confirmed-COPD not Asthma and Medications adjusted

Neuropsychologist review - Client recommended for (financial)

guardianship Neurologist review - MRI this week to investigate vascular

dementia Referral to Complex Care Allied Health Social Work for

assistance with appointing public trustee for Power of Attorney

Improve social support – example Neighbors, and Parole. Planned smoking cessation 6

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LESSONS LEARNT

The need to assess clients capacity & motivation to change

Necessity of one to one holistic assessment preferably in home environment

Continuous long term reinforcement of instructions–clients may not have capacity to initiate instructions given-health coaching

Benefits of accessing specialist services - case study example-home memory assessment

Importance of communication with other services eg Medical, Community - case study example - Parole office

High risk clients need one to one input though supported case management 7