The Health Roundtable

Central Network Respiratory Coordinated Care Program Innovation

Presenter: Benjamin KwanStaff specialist respiratory and sleep medicine St George and Sutherland hospital network. Medical director of SESLHD central network RCCP (respiratory coordinated care program):

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

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INTRODUCTION

SESLHD Central Network Respiratory Coordinated Care Program (RCCP) is a collaborative approach between respiratory physicians, nurses, physiotherapists, social workers, community services personnel and GPs.

9 Team members undertake regular home visits to improve management of chronic obstructive pulmonary disease (COPD) in community.

Monthly average of 375 chronic participants with a mean age of 76.2 years

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KEY PROBLEM

Increased number of patient presentations to Emergency Department Increased infective and non infective exacerbations Access to medical services

Inadequate nursing and physiotherapist resources to meet growing community demand.

Recurrent presentations and prolonged hospital stay for COPD patients who are outside ENABLE NSW “Domiciliary Home O2” criteria

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AIM OF THIS INNOVATION

Reduce hospital admission and readmission rates Reduce direct COPD presentations to Emergency

Departments across SESLHD (STG & TSH Hospitals)

Improve access to hospital medical specialist service

Improve accuracy of stage of disease and management

Optimise participants’ respiratory condition to help them live as independently as possible in their home

Provide extra supplementary medical support to the community team 4

Triage Assessment

Diagnostics to transfer to ward

Ward D/C

RCCP

CommunitySelf

Management

•Early identification of RCCP patient to RCCP

•Early identification of respiratory patients to resp. Team & RCCP

•Dedicated Adv/Basic trainee attached to RCCP

•Streamlined oxygen prescribing process•Hospital oxygen lending pool

•Appropriate referral to RCCP

•Appropriate discharge via RCCP

•Sustained TSH RCCP patient load ratio of 1:125

•Proactive clinic referral if no GP access within 5 days after dc

PrivateClinic

•Utilisation of GOLD standard

Solutions design

Current and New systems – RCCP

•GP, ED and Specialist referrals to Clinic

Access

LOS

No. of Admissions

Measurement of success

No. of Readmissions (28 & 56 days)

vi Quality of care in hospital

viiQuality of care in the community

viii

Increased RCCP capacity

Qualitative Benefits

No. of Presentations

i

ii

iii

iv

v

•Med registrar home visit

RapidAccessClinic

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BASELINE DATA

Describe the issue or preferably show baseline measures e.g. rate of this problem over time prior to the innovation

Mean National admissions per patient per year for COPD = 1.35(2010/2011)

Mean National hospital bed days length of stay for COPD – 6.7 (2010/2011)

The 2011 National mean number of bed days for the 375 chronic RCCP pts is 3391 hospital bed days (1.35 x 375 x 6.7 OR average of 283 bed days per MONTH)

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KEY CHANGES IMPLEMENTED

Allocation of a medical registrar to attend home visit with RCCP staff

Newly established Rapid Access Respiratory outpatient clinic COPD patients assessed by RCCP to require further

medical input will either be referred directly to the weekly respiratory outpatient clinic or assessed on one of the weekly medical registrar accompanied home visit.

Clinic and registrar home visit days are spaced apart (Tues / Thurs) to provide a more continuous medical input throughout the working week.

GPs are notified of review outcome either by clinic letter or via direct phone call. 7

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KEY CHANGES IMPLEMENTED

Provision of Home O2 to COPD patients who are borderline outside of ENABLE criteria i.e. P02 56-70mmHg in addition to 2 hospital admissions in the previous 12 months This group made up 6% of cohort but contributed to

12% of total admissions over 2010-2011. Those fitting with the above criteria has hospital

funded hospital for 12 months with regular medical review and monitored by RCCP.

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OUTCOMES SO FAR As from January to September 2012 inclusive,

the provision of the aforementioned innovations have; reduced admission rates for 5 pts outside of Enable 02 criteria (Pre: 12 admissions, post: 2 admissions)

Based on 375 patients Current admission rates per/pt/yr in this timeframe =

0.33 admissions/pt [126 pts] (National mean 1.35 adm/pt)

Current number of bed days = 87.5 bed days per month, i.e,. January to September(National mean of 283 bed days per month)

25% of patients [based on 240 patients] seen in the clinic between 2011-12 were referred directly from RCCP or ED bypassing admission with only 1 admitted directed from clinic.

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LESSONS LEARNT

Model of care has a direct and significant effect in minimising the burden on the acute sector and preventing access block,.

Innovations circumvent hospital admissions are cost efficient, when compared to the cost of ED presentations and hospital length of stay.

Increased medical support improved disease diagnosis and management

Allows outpatient management of chronic diseases, thus enabling patient to remain as independent as possible in their familiar environment

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Acknowledgement and Thanks

Nick Spiliopoulos (NUM of RCCP) Dr Elizabeth Clark Ms Mary Dunford Central Network RCCP staffs Central Network Department of Respiratory and Sleep Medicine Central Network Executives LEAD design team (from KPMG)

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QUESTIONS?

THANK YOU!

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