Michelle goding

Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,

Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health



Eastern Health’s

Ambulatory and Community Services

Program

Eastern Health

• 2nd largest health service in Victoria

• The largest geographical area (2,816 square

kilometres over six shires)

• 750,000+ residents (2011 Census)

• Public health services to an additional 400,000+

people from neighbouring shires

• 8,400+ employees

Eastern Health Sites Over 50 facilities including:

• Hospitals

Angliss Hospital

Box Hill Hospital

• Healesville & District Hospital

Maroondah Hospital

• Peter James Centre

• Wantirna Health

• Yarra Ranges Health

• Residential care facilities

• Edward Street (Upper Ferntree Gully)

• Monda Lodge (Healesville)

• Mooroolbark

• Northside (East Burwood)

• Community-based facilities

• Multiple community-based rehabilitation,

mental health, drug and alcohol and

transition care facilities

• Mental health facilities

• South Ward (Peter James Centre)

• Upton House (Box Hill Hospital)

• Inpatient units 1 and 2 (Maroondah Hospital)

• Adolescent Inpatient unit (Box Hill Hospital)

• Prevention and Recovery Care (PARC)

Centres (Box Hill and Ringwood East)

• Community care units (Camberwell,

Ringwood East)

• Community Health Service

• Yarra Valley Community Health

• Statewide Services

• Spectrum Borderline Personality Disorder

Service

• Turning Point Alcohol & Drug Centre

• Wellington House

Bed Numbers

• A total of 1266 beds, comprising:

– 711 hospital beds for patients staying longer than one day

– 150 hospital beds for patients staying less than one day

– 117 beds for people who need mental health services in

hospital

– 120 beds for residential care clients

– 74 beds for people who need mental health services in a

community-based setting

– 94 beds for people requiring transition care 2012-2013

Background Structure prior to 2009:

• “Outer East” and “Central East”

• Site specific programs including Hospital in the Home, Allied

Health and Ambulatory, Community Health

• Restructure in 2009 with new CEO - “Eastern Health in name,

thinking and service delivery”

• 8 Directorates including Acute Health, Access and Support

Services and Continuing Care Community and Mental Health

• 2010 Ambulatory Services and Community Services - separate

programs

• Aligned to create Ambulatory and Community Services (ACS)

Program in 2012

Program Director Ambulatory and

Community Services

Associate Program Director Ambulatory and Community

Services

(Eastern@Home and Aged Care)


Services

(Health Independence and

Community Access)


Services

(Chronic Care & Wellbeing and Community Health)

Executive Director

Continuing Care Community and Mental Health

Executive Clinical Director

Ambulatory and

Community Services

Director of Nursing

Ambulatory and

Community Services

Streams of Care within ACS from 2012

Eastern@Home and Aged Care

• HITH

• Eastern Residential InReach

• ACAS

• Rapid Outreach Response (HARP)

• TCP

• Complex Care Clinic

• GEM@Home

GEM@Home

• Integrated care for older people with multiple and

complex health care needs who can be managed at

home

• Alternative to an inpatient GEM admission

• Geriatrician-led 4 week program

• Interdisciplinary (Nurse, SW, OT, PT)

• Functional goals

• Works closely with ACAS, Rapid Outreach Response,

Complex Care Clinic, HARP

Health Independence and

Community Access

• Community Rehabilitation

• Pulmonary, Cardiac Phase 2, Heart Failure,

Oncology Rehabilitation

• Specialist Clinics

• VPRS

• Early Supported Discharge for Stroke

• Community Access Unit

Chronic Care & Wellbeing and

Community Health

• HARP

• Advance Care Planning

• GP Liaison

• Aboriginal Health

• ECASA

• Community Health

– (community and acute-based)

ACS

• 396EFT (nursing, allied health)

• Situated across all EH acute and subacute

sites

• 2012-2013 activity:

– 176,637 SACS, HARP, RIR contacts

– 2,806 completed episodes

– 22,364 HITH bed days (ALOS 8.7)

Primary Aims of ACS

• Improve patient flow

• Ensure equity of access

• Provide a flexible response to service

demand

• Support workforce development

• Support GP engagement, shared care and

care planning

• Encourage health self-management

• Support consumer engagement

• Promote a safe, consumer-focused

alternative to inpatient care

(Eastern@Home)

• Align with Department of Health policy

direction

• Align with Eastern Health strategic plan

and program structure

Ambulatory-Sensitive Conditions

• Hospitalisation considered potentially

avoidable

• Admission risk identification

• Chronic/complex needs

• Early stage preventive care

• Early disease screening/management

• Substitution/diversion strategies

• The most common ambulatory-sensitive

conditions for Eastern Health are:

– Diabetes complications

– Congestive heart failure

– Pyelonephritis

– Respiratory (asthma/COPD)

– Ear, nose and throat infections

– Influenza and pneumonia

ACS Principles

• Substitution / diversion

• Care co-ordination

• Clear communication

• Collaborative goal setting

• Health self-management

• Health coaching

• Seamless transitions

• Transparency

• Family involvement

• Equity of access

• Evidence based

• Skilled workforce

• Innovation

Two major improvements were sought:

• Shift the equivalent of 30 inpatient beds to

Eastern@Home (Hospital in the Home)

• Develop integrated Ambulatory and

Community Care pathways to support

diversion, substitution and end of life care

The Eastern@Home experience

• Creating Eastern@Home 2010

• Hospital in the Home (HITH)

• Residential InReach (RIR)

• Benchmarking

• Expenditure and length of stay

• Internal audits

• Clinical Services Plan 2022

Who can access Eastern@Home

(HITH)?

Any public patient of the 52 participating hospitals who is:

• assessed as being clinically stable for an at-home “admission”

• appropriately supported in the home, i.e. presence of a carer

or support person

• living in a suitable environment, with access to a telephone

• consent to be treated by HITH

• suitable for HITH treatment and meets diagnostic criteria

http://www.health.vic.gov.au/hith/





Who can access Eastern@Home

(Residential InReach)?

• Any patient residing in a residential care facility

• Consent via self or guardian

• Requires engagement of GP and facility staff

• Medical and nursing support

• Assists with avoidable hospital presentations

• Links with HARP, Complex Care Clinic

Eastern Health context

Eastern Health context

Percentage of growth: 9.31% 11.08% 31.95% 58.34%

Year 1: Sept 2010 – Aug 2011

Year 2: Sept 2011 – Aug 2012

• Variance % 100% 164% 474% 218%

Eastern@Home (HITH) overnight occupancy timeline –

peaks and troughs

Eastern@Home (HITH) same day timeline

Eastern@Home: Residential InReach

winter response

• Extended hours of service

• Targeted strategy: gastro and pneumonia

• Hourly rounding to identify deterioration /

end of life care

• Pathway development with Ambulance

Victoria - ongoing

Average patient contacts per day

2012-2013

PROGRAM

AVG NO OF INDIVIDUAL PATIENT

CONTACTS PER DAY (ACROSS 7

DAYS) 2012-2013

AGED CARE ASSESSMENT SERVICE 28.1

EASTERN CENTRE AGAINST SEXUAL ASSAULT 19.66

HOSPITAL ADMISSION RISK PROGRAM 72.33

EASTERN@HOME 85

POST ACUTE CARE 83.75

RESIDENTIAL INREACH 28.19

SUB-ACUTE AMBULATORY CARE SERVICES (CRP / CLINICS) 382.35

TRANSITION CARE PROGRAM 75.1

YARRA VALLEY COMMUNITY HEALTH 41.1

YARRA VALLEY COMMUNITY HEALTH - DISTRICT NURSING 25.6

TOTAL: 841.18

mailto:EASTERN@HOME

Referrals received

Average referrals per day

Referral source

ACS Referral Sources

• Emergency Departments

• Acute medical

• Acute surgical

• Sub-acute

• General Practitioners

• Residential Care Facilities

• Self

• Other Hospitals

• Community Providers



How did we do in HITH?

Victorian PRISM report – 2nd Quarter

• HITH multiday separations increased by 51.7 %

• HITH multiday bed days increased by 53.6 %

• Multiday HITH % separations increased by 2.6 %

• Multiday HITH % of bed days increased 3.7 %

Largest growth in state for this period

Improving patient outcomes and access to

emergency care for older people from

Residential Aged Care

Maryann Street,1 Julie Considine, 1 Goetz Ottmann, 2 Patricia

Livingston, 1 Bridie Kent, 1,3

1 Eastern Health – Deakin University Nursing and Midwifery Research Centre 2 Uniting Care Community Options / Deakin University Research Partnership 3 Plymouth University, Plymouth, United Kingdom.

• 140,000+ visits to EH EDs in 2010-2011

• 23% 65+

• 3.4% from RACF

• 9,500 aged care beds with catchment

• Aim: Identify impact of Residential

InReach and HITH on ED presentations

from RACFs before 2009 and after 2011

• Retrospective cohort study

• Primary outcome LOS in ED

• Secondary outcomes presentations, re-

presentations and admission rate

2009 2011 p value

Transfers and Re-presentations within

6 month period

2009 2011 P value

Transfers from Residential Aged

Care to ED N(%) 2278 (3.6%) 2051 (3.1%) 0.001

Patients with more than one visit

N (%) 1002 (44%) 307 (15%) 0.001

Patients with 4 or more visits 2.6% 0.7% 0.001

Maximum ED visits for any

patient in 6 months 12 5

Conclusions

• Average stay in ED for people from RACFs was

reduced by 40 minutes compared to 2009

• There were less transfers and re-presentations

to ED by people from RACFs

• Fewer people were admitted to hospital and the

length of stay in ED for admitted patients

decreased significantly

Integrated Service Delivery

• ‘No Wrong Door’ integration across ACS:

– HARP and RIR

– HARP and HITH

– HARP allied health and HITH, RIR

– SACS allied health and PAC

– GEM@Home, Complex Care Clinic, HARP

– TCP and others

– ASERT …

Development of Ambulatory and

Subacute Early Response Team

(ASERT)

GREAT CARE EVERYWHERE

– Getting it Right Upfront (GIRUF) Redesign 2012

Series of workshops focusing on GIRUF conducted

between Acute, Subacute and Ambulatory &

Community Services.

Improvement needs identified via

GIRUF workshops

• Access to subacute, ambulatory and community

services

• Transparency of waitlists

• Sorting and streaming to the most appropriate

location of care

The ASERT Team-

A Multidisciplinary Approach

• Post Acute Care

• Access Liaisons

• Complex Care Team (Aged Care Nurse Consultants)

• HARP

• Medical / Geriatricians

• Palliative Care Consult Team

• ED Care Coordination

Proposed ASERT reporting structure

and relationship to support teams

Ambulatory and Community

Services Operations and Development

Manager Access

Palliative Care

Consult ASERT

Ambulatory Access Liaison ASERT

Complex Care / Aged Care Consult

ASERT

Post Acute Care

ASERT

ED Care Coordination

Angliss ASERT

Hosp Adm Risk Program

INTAKE ASERT

Inpatient Allied

Health

Eastern

@

Home

Continuing Care

ASERT

Specialist

Medical

Consults:

Rehab / Pall Care

/ GEM

Aged Care

Assessment

Services (ACAS)

Hospital

Liaison

Transition Care

Program

Inpatient Medical

/ Nursing

ED Care

Coordination

Box Hill

Maroondah

GP Liaison

ACP

GEM@Home

ESSD

ASERT

• Service improvement strategy:

– a single point of contact to access subacute and

ambulatory and community services

– reduction in waste and unnecessary duplication

– streamlining of systems and processes such as

referral / intake, needs identification, waitlisting and

service provision.

• Improved outcomes for clients:

– Equitable access to the right service to best meet

patients’ individual care needs

– Improved continuity of care for patients and their

families / carers

– Improved timeliness and communication of care

needs.

ASERT provides:

• a streamlined, timely and coordinated response for

patients needing subacute, ambulatory or community

services

• a subacute/Ambulatory and Community Services care

plan that ensures the patient has the right care at the

right place and at the right time

• ASERT does not take over the discharge planning role

from the Ward/ED Team

• It does assist and work with the ward team to facilitate

and identify the discharge plan for patients.

Patient Flow Manager (PFM)

• PFM upgrades across the network

• Ward teams will be able to flag ASERT via PFM

• Once flagged this will be pulled into the ASERT Team

handover and the team will respond



Advance Care Planning

Increased number of completed Advance Care Plans (2012-13)



• Integrated service delivery: Advance Care Plans for Eastern Residential

InReach clients - benchmarked with other services



• A snapshot audit of compliance to plans April – June

2013 demonstrated 94% compliance

• Consumer and staff feedback is consistently positive

• ACP is integrated into the inpatient assessment process,

and is operational within the Transition Care Program,

Hospital Admission Risk Program and Eastern

Residential InReach, within the community

• Future areas under development

Some Key Initiatives

• The Eastern@Home model

• Flexible and integrated service delivery – consumer

focus

• Clinical governance

• Redesigning intake for ease and equity of access:

– ASERT - identifiable team / criteria led pull

• Fast track pathways (orthopaedic) and stroke (ESD)

• Non-admitted GEM@Home (linked to HARP / ACAS)

• No waitlist for community rehabilitation services

• NHS Productive Community Services

• Medicare Locals – telemedicine pilot in residential

facilities; after hours GP services

• TCP inhouse

• Engagement of an Eastern Health GP

Where to next?

• Enhancing clinical governance to support an evolving

model of care

• Strategic opportunity with the new BHH redevelopment

and the potential of a co-located space in the ED to

support NEAT

• Redesign project objectives:

• Integrated ACS complex care plan

• ASERT implementation with PFM

Where to next?

• Point Prevalence audit – E@H

• Expand aged services in the home via an integrated

model of care encompassing Rapid Outreach Response

(HARP Aged) / Residential InReach and GEM@Home

• Enhance interface with Ambulance Victoria and

Medicare Locals

• GP Liaison opportunities

Issues Faced (and beaten?)

• Poor understanding of potential for Ambulatory

and Community Services as a viable option for a

true substitution/diversion model

• Lack of trust to support a comprehensive shift

from inpatient care to community-based care

Recommendations • Leadership from the CEO / Executive and throughout the organisation is

imperative

• An integrated Ambulatory and Community Services Program facilitates

service delivery to meet consumer needs

• Integrated planning approach (Redesign principles) before the

implementation of new initiatives

• Commitment to resolve any issues as they arise in partnership

• Implement strategies to support care in the community – clinical

governance of ambulatory and community services: readmission rates –

lessons learnt

• Culture of continuous review and actions focus –

What else can we do? What can we do differently?

Documents

Michelle goding