Results:

Achievements: Tested Model of Care

Aim & Driver Diagram:

Vision: To enable patients at high risk of readmission to self-manage and remain well at home Problem: •  In the year ending February 2010:

• 64,409 patients presented to ED 88,565 times • Total bed days for the year were 25,768

Example: Over $2,500 worth of unused medications retrieved

from one home visit

Impact: •  The VHIU model of care is effective at reducing EC

presentations and readmissions for high risk patients

•  The inter-disciplinary team (IDT) assessment of the patient in their home is key to understanding and providing for their healthcare needs

•  The combined perspective of the range of disciplines involved, provides a holistic and practical plan to meet the needs of the patient

•  The integrated case management approach bridges the gap between the hospital and community, improving the quality of care for the patient and their quality of life

Next Steps: •  This model of care will translate well to include teams

based in community settings

To increase the number of patients enrolled into Very High Intensity User programme from 120 cases to 600* cases by July 2013. This may result in a reduction in unplanned presentation and admission to Middlemore Hospital.  

Referral

Pa$ent  &  Family  

Secondary  care  referrals  

Primary  Drivers   Secondary  Drivers  

Network and relationship

Model of Care

GP  Referral  

Resource  –  Skilled  Team  

Shared  Documenta$on  

Home  Visit  

Assessment  &  Care  Plans  

Mul$ple  EC  presenta$on  

Healthcare    Professions  

Community  Resources  

Measures:  1.  Readmission  2.  Presenta1on  4.  Admissions  5.  LOS  6.  Days  between  presenta1on  

The VHIU* – Link Team A model of integrated care that helps patients at high risk of readmission

*Very High Intensity Users

The Collaborative Team:

Clinical Lead: Project Lead: Professor Harry Rea Ta-Mera Rolland

Team: Collaborative Support: Contributors:

Pamela Hill Alison Howitt Amanda Seabrook Tanya Naea Lucy Hall Rosie Whittington Olive Wilson Clare Moss Gray Maingay Prem Kumar Lavinia Buchanan Kate Martin Karen Long Katy Boulton Tua Teara Fiona Smyth Richard Small Priya Francis

Fay Burke Christine Lynch Meg Goodman Fiona Horwood

Numbers of Patients Enrolled into VHIU

149

14

23 25

34

46

28

49

4138

35 35

48

3943

47

0

5

10

15

20

25

30

35

40

45

50

January/12

February/12

March/12

April/12

May/12

June/12

July/12

August/12

September/12

October/12

November/12

December/12

January/13

February/13

March/13

April/13

May/13

Month/Year

Patie

nts

Series2

Preliminary data for 205 patients for 6 months.

Analysis of controls required.

Average days between referral and First Home Visit

17

8

13 13

22

13 14

6

10

14

4

18

7

11 119

6

0

5

10

15

20

25

30

35

40

45

50

January/12

February/12

March/12

April/12

May/12

June/12

July/12

August/12

September/12

October/12

November/12

December/12

January/13

February/13

March/13

April/13

May/13

Month/Year

Ave

rage

Day

s

Patient

Right Place• Home Visit• GP surgery• Pt venue choice

Right Health Care Professional• Consultant Physician• Health Psychologist• Nurse• Pharmacist• Physiotherapist• Social Worker

Right Assessments• Triage• Risk Assessment Guide • QoL - EQ-5D• Case Review

Right TimeContacting patient within • 48hrs urgent • 10 working days non-urgent

Right Follow-up• Monitoring• Review• Discharge

Right ReferralsLinking patients to• Community Care• GP practice • Whanau Ora & Fanau Ola • WINZ / HNZ (Income / Housing)• Community Pharmacy

Right Care Plan• Shared care plan• Individualised• IDT Case Review

Patient

Right Place• Home Visit• GP surgery• Pt venue choice

Right Health Care Professional• Consultant Physician• Health Psychologist• Nurse• Pharmacist• Physiotherapist• Social Worker

Right Assessments• Triage• Risk Assessment Guide • QoL - EQ-5D• Case Review

Right TimeContacting patient within • 48hrs urgent • 10 working days non-urgent

Right Follow-up• Monitoring• Review• Discharge

Right ReferralsLinking patients to• Community Care• GP practice • Whanau Ora & Fanau Ola • WINZ / HNZ (Income / Housing)• Community Pharmacy

Right Care Plan• Shared care plan• Individualised• IDT Case Review

Acute Bed Days Saved(Data for 6 months prior and 6 months post enrolment)

2110

1382

0

500

1000

1500

2000

2500

Pre VHIU Enrolment Post VHIU Enrolment

Acute bed days

728 days saved35% reduction following VHIU Intervention

Reduction in ED Presentations(Data for 6 months prior and 6 months post enrolment)

718

398

0

100

200

300

400

500

600

700

800

Pre VHIU Enrolment Post VHIU Enrolment

ED presentations

320 presentations saved45% reduction following VHIU Intervention

Collaborative Team:Clinical Lead: Professor Harry Rea Team: Ta-Mera Rolland, Pamela Hill, Lucy Hall, Gray Maingay, Karen Long, Fiona Smyth, Alison Howitt, Rosie Whittington, Prem Kumar

Problem: In the year ending February 2010:• 64,409 patients presented to Emergency Care (EC) 88,565 times • Total bed days for the year were 25,768

Example:Over $2,500 worth of unused medications retrieved from one home visit.

Driver Diagram:

To increase the number of patients enrolled into Very High Intensity User programme from 120 cases to 600 cases by July 2013. This may result in a reduction in unplanned presentation and admission to Middlemore Hospital.  

Referral

Pa$ent  &  Family  

Secondary  care  referrals  

Primary  Drivers   Secondary  Drivers  

Network and relationship

Model of Care

GP  Referral  

Resource  –  Skilled  Team  

Shared  Documenta$on  

Home  Visit  

Assessment  &  Care  Plans  

Mul$ple  EC  presenta$on  

Healthcare    Professions  

Community  Resources  

Measures:  1.  Readmission  2.  Presenta1on  4.  Admissions  5.  LOS  6.  Days  between  presenta1on  

Achievements: Tested Model of Care

Results:

www.koawatea.co.nzH E A L T H S Y S T E M I N N O V A T I O N A N D I M P R O V E M E N T

“ Last year I went to hospital 28 times! By looking after myself and having a better understanding of my condition I’ve only been twice so far this year.”George Patient

towa r ds s u sta I n a B l e h e a lt h c a r e

Contributors:Amanda Seabrook, Tanya Naea, Olive Wilson, Clare Moss, Lavinia Buchanan, Kate Martin, Katy Boulton, Tua Teara, Richard Small, Priya Francis, Fay Burke, Christine Lynch, Meg Goodman, Fiona Horwood, Rajiv Gupta, Juliet Ireland, Christine Scott and John Griffiths

Our Aim:To expand the integrated case management programme aimed at keeping people with complex heath needs well and at home by bridging the gaps between healthcare providers and their patients.

Impact:• The VHIU model of care reduced EC presentations and readmissions for high risk patients• The inter-disciplinary team (IDT) assessment of the patient in their home is key to understanding and providing for their healthcare needs• The combined perspective of the range of disciplines involved, provides a holistic and practical plan to meet the needs of the patient• The integrated case management approach bridges the gap between the hospital & community, improving the quality of care for the patient and their quality of life.

Next Steps:• Refining the interdisciplinary (IDT) Model of Care including patient feedback• Ongoing networking and relationship building with our primary care and community partners• Coaching and mentoring to improve IDT practice throughout the Counties Manukau healthcare system• Further development of team processes, including patient centric care plans to align with the National Shared Care IT framework• Evaluate change in patient specific clinical measures, for example HbA1c, International Normalised Ratio (INR) and attendance at outpatient appointments

The VHIU* - Link Team A model of integrated care that helps patients at high risk of readmission

*Very High Intensity Users

Aug

-13

Jul-13

Jun-

13

May

-13

Apr

-13

Mar

-13

Feb-

13

Jan-

13

Dec

-12

Nov

-12

Oct

-12

Sep

-12

Aug

-12

Jul-12

Jun-

12

May

-12

Apr

-12

Mar

-12

Feb-

12

Jan-

12

100

80

60

40

20

0

Month/Year

Num

ber

of P

atie

nts

_X=29.7

UCL=52.6

LCL=6.7

Baseline

I Chart of Total Number of Patients Enrolled to VHIU

with primary careTesting of V HIU model

GP referralIncrease in

Aug

-13

Jul-13

Jun-

13

May

-13

Apr

-13

Mar

-13

Feb-

13

Jan-

13

Dec

-12

Nov

-12

Oct

-12

Sep

-12

Aug

-12

Jul-12

Jun-

12

May

-12

Apr

-12

Mar

-12

Feb-

12

Jan-

12

35

30

25

20

15

10

5

0

Month/Year

Num

ber

of D

ays

_X=12.58

UCL=30.86

Baseline

I Chart of Time to First Home Visit in Days

Triage processA cuity included in

display testedWhiteboard for v isual

Target number of patients enrolled into VHIU exceeded. Total Patients 843.

There is a shift in process indicating a decrease in the time to first home visit.