Lessons Learnt Workshop May 4-5, 2004 - Sydney

1. The Health Roundtable New Zealand Lessons Learnt WorkshopMay 4-5, 2004 - Sydney

2. Index of Presentations Improving the Journey for Chronic Complex Patients • Index of Stream 1a Presentations with Quick Links • Workshop Aims and Honour Code • Session 1a – Improving alternatives to inpatient admissions If you view this document as a “Slide Show”, clicking on the hyperlinked text (the turquoise and underlined text) will take you to that particular page in the report

3. 2. Persuasion 3. Decision 3. Decision 2. Workshop Aim AIM: SHARE INNOVATIONS TO IMPROVE HEALTHCARE Looking for differences! How to speed up action? 1.Knowledge 5. Confirmation The Roundtable Process 4. Implementation

4. 2. HRT Honour Code • All those who participated in the workshop and who have received this set of slides agreed to be governed by the following HRT Honour Code • No participant shall criticise the performance of other member hospitals, or use any of the information to the detriment of a fellow member. • No external distribution of data or conclusions based on Health Roundtable workshops or data is made without the consent of each person contributing materials.

5. Stream 1 - Improving the Journey for Chronic Complex Patients

6. Disease Management Programs for COPD in Primary Care Session 1a – Improving alternatives to inpatient admissions Prof Harry Rea Department of Medicine, University of Auckland, Middlemore Hospital, Auckland, New Zealand

7. Will Acute Growth Swamp Middlemore? • Medical 10% pa • Population growth 2% • Ageing 1% • Trend consistent over 10 years • Prevalence of respiratory disease high

8. Key Problems Random & often frequent visits to GP (cost to patient) Hospital Admission (no cost to patient) Knowledge of disease(s) poor (No planned prevention) Recognition of symptoms poor Exacerbation unrecognised

9. How we did it • COPD Project Started: August 1999 Collaboration between: • GP Practices, Respiratory Physicians, Respiratory Specialist Nurse, Managers, Physiotherapists, Community Services, Patients • Communication channels & support provided • Clinical governance & funding by joint venture between all parties

10. Innovations Implemented EXTRA TIMEwith GP & Practice Nurse Design Care Plan & Review regularly (no cost to patient) DISEASE EDUCATION for practices & patients Supported by practice & respiratory nurse Recognise exacerbation Follow Action Plan Awareness of symptoms & Action Plan (Planned Prevention)

11. Mean Respiratory Bed Days Reduced(Per Patient per annum) CONTROL PATIENTS(n=52) INTERVENTION PATIENTS(n=83) * Respiratory bed days, t-test, mean 2.3 days 95% CI(0.1, 4.4)

12. Health Status Improved Intervention Group (n=84)

13. Lessons Learnt - Practices • Potential to benefit best assessed by general practice • Lack of time greatest barrier • Complex patients can be disincentive • Stable “care team” needed to develop relationships • Building trust with patient (& family) often requires creativity & persistence • Specialist resources must support “general” practice

14. What patients want • Individual Care Plan important for patients • Respect & acknowledgment of beliefs essential • Simple goals and outcomes best • Increased patient confidence better self-management • Patients want information but prefer to leave clinical decisions to GP • Continuity of care in hospital & consistent clinical advice trust

15. Implementation Issues • Recruitment - assessing potential to benefit • Disease priorities depend on practice location • Matching incentives to practices • Co-morbidities = > time with patient • Education & training time essential • Consider practice organisation • Clinical Information Systems

16. Decision Support

17. Session 1aTopic: Improving Alternatives to Inpatient AdmissionCase management- An effective diversionary strategy to manage those with chronic illness/complex needs who frequently present at Emergency Department Presenter: Andrea Leonard Hospital: Barwon Health

18. KEY PROBLEMS • Our target group are high users of acute services, high cost and resource intensive • In 2002, before project implementation, 995 persons accounted for 7045 presentations at ED in a 20 month period. The majority of presentations by individuals were for different chronic conditions/reasons at each attendance

19. INNOVATIONS IMPLEMENTED • The Assertive Case Management Project targets those with chronic illness/complex needs presenting 4 or more times at ED in a 12 month period. • Model is underpinned by recognition health is a resource rather than a state and the adoption of a population health approach. • Focus is on self management, integrated disease management and achieving an integrated service response

20. Innovations Implemented Team works across the system and is not constrained by “artificial” program boundaries. Contributing to integrated services and systems complimentary projects focused on streamlining assessment, integrating direct care, establishing single point of contact forhome base care and simplifying transition from hospital to home

21. HOW WE DID IT • Project Started: 2003 • Project Champion: • Team Composition: Multidisciplinary team comprising 4.6 Community Heath Nurses (one with Psych Reg) Social Worker and Psychologist • Resources Required: $640,000

22. OUTCOMES SO FAR No of referrals (Dec2003) 148 No of clients actively case managed 137 Target group population average EMD Visits 30 Sep ’03 Before case management 5.33 After case management 2.27 Dec ‘03 Before case management 6.3 After case management 2.79

23. LESSONS LEARNT • Multidisciplinary case management is an effective tool for linking clients to primary and social supports • Need for greater executive/ organisation “by in” of project • Need to recognise the complexity of the target group which impacts on outcomes • Need to address levels of depression, anxiety, psychological distress before “condition’

24. Session 1aTopic: Improving Alternatives to Inpatient Admission Early Multidisciplinary Assessment(Beyond MAPU)Presenter: Cam BennettHospital: Royal Brisbane & Women’s Hospital 4-5 May 2004Sydney

25. KEY PROBLEMS • Over 4000 unplanned admissions annually to the Dept of Internal Medicine with :- • Complex care Needs • Hospitalist approach • Attendance at case conferences inconsistent • Organisation of services inconsistent • Staffing of allied health inadequate

26. INNOVATIONS IMPLEMENTED • Consistent, coordinated team with shared goals • Programmed consultant lead early multidisciplinary meetings • Implemented as a controlled study

27. HOW WE DID IT • Project Started: August 2002 • Project Champion: Chairs of Medicine and Allied Health and Director of Finance • Team Composition: Multidisciplinary including administrative staff • Resources required : (next slide)

29. OUTCOMES SO FAR

30. Results: bed day savings 1927 BED DAYS IN 9 MONTHS (7 BEDS PER DAY) EMC

31. Results: acute LOS reduction AVERAGE ACUTE LOS REDUCED FROM 7.35 DAYS TO 6.7 DAYS EMC

32. Cumulative readmission numbers EMC start

33. LESSONS LEARNT • What we recommend to other hospitals on this topic : Try it if you haven’t already and be prepared to invest some money to save some money • What we would do differently : Not to get too caught up in the paperwork and never underestimate the effort required to “maintain the rage” for sustaining large process reorganisations.