The The Sutherland Sutherland

ProjectProject

KATE BONE ABHI Integration

Coordinator

ABHI’s Journey ‘A Path For Care Integration’

• Background • Setting• Aim• Approach • Findings• Resources • Evaluation

Integrated care refers to

"methods and organisations to provide the most cost-effective and caring services to those with the greatest health needs and to ensure continuity of care and co-ordination between different services".

J. Integrated care –development issues from an international perspective: models and issues. Healthcare Review , 2(5) March,1998.

Background

The Sutherland Hospital

320 acute beds,110 Aged Care 9 ACAU (MAU)

Project Objective

• Improve communication between health care providers, focusing on the transfer of aged care chronically ill patients between TSH & GP.

• Evaluate & develop discharge planning processes.

• Develop strategies to increase knowledge and use of GP services available to support patients in their own setting.

Approach

• Direction & guidance from ABHI Advisory Committee.

• Observation & assessment of discharge process.

• Surveys & questionnaires. • Develop and implement interventions

informed by the data.• Evaluate progress.

Findings

• Pre-conceived Myths & Views.

• Inadequate Discharge Planning processes.

• Incomplete Discharge Summaries.

• Delayed communication of Discharge

Summaries.

Pre-Conceived Myths & Views

Myths/Views• High proportion of

patients re-admitted due to medication errors.

• High proportion of ‘frequent flyers’ especially from RACF’s

• All Patients discharge see GP within 3 days

Facts & Figures• 25% re-admission not

related to medication errors.

• Small percentage of ‘frequent flyers’

• 55% patients see GP within timeframe

Discharge Planning ProcessWard View Point

• Rushed no EDD used• Reactive process• Risk assessment tools

not completed• Not Patient Centred• Multi-system disparate

Patients View Point

• No planned EDD• Needs not taken into

consideration• Unclear information• Information overload• Inadequate medications

information

Discharge Summaries

2008

• 100% Hand Written• 35% Difficult to read• 12% illegible.• 15% patients details

absent • 78% Vague on follow up

requirements.

2009

• 25% Hand Written• 75% Typed• 12% Difficult to read• 6% illegible.• 0% patients details absent • 92% Vague on follow up

requirements.

GP Survey

2008• 25% illegible following fax• 33.3% NOT received• 100% NO contact details.• >50% satisfied with

content.• 100% Not notified of

death. • 25% GPs hesitant to act

without medical discharge summary

2009• 20% illegible following fax• 25% NOT received• 25% NO contact details.• ? % satisfied with content • 100% Not notified of

death.• 20% GPs hesitant to act

without medical discharge summary

Discharge Referrals

Resources

1. Basic Care (action) Plan.

2. Typed Discharge Summary.

3. Patient Held Record.

Basic Care (action) Plan

Aim

Addressed concerns & problems identified through patent ,carer interviews. Reduce number of complaints ward received following discharge.

Approach

Outline simple plan of care for the first 48-72 hours following discharge.

Typed Discharge SummaryAim

Develop typed discharge summary template to addressed problems identified through baseline audit for transfer of data.

Approach

Through education sessions facilitated by GP highlight the importance of legible discharge summaries.

Patient Held Record (Yellow Envelope)Aim • Raise awareness of the need for patients to take

active role in their health care issues when transferred to hospital.

• To support safe delivery of clinical information when a patient has been discharged home.

Approach• Older persons deemed to be high risk of re-

admission or with multiple co-morbidities and complex health needs who do not reside within low or high level RACF.

Initial Pilot Results

Pilot Sites• 2 ILU’s, ED, NSW ambulance, 2 GP Practices,

ACAU & aged care wards.Evaluation • written surveys and semi-structured face to-face

interviews.Results • (99%) users thought the Envelope provided useful

and significant data.• (87%) said it was easy to use.• All interviewees thought the Envelope had raised an

awareness of the patients need to have critical clinical information in one place.

Challenges

• ABHI role is consultative - no “control of or authority” over patients being discharged.

• “ABHI person” seen as outsider• Staff on wards stretched and stressed.• High turn over of NUM’s • Lack of designated staff

to identify ‘complex patient’• The Area Health Service

Barriers

• Difficulty engaging staff & senior clinicians• Turf protection• IT system unable to support proposed

changes• Time to change• Change overload• The Area Health Service

Evaluation - What worked?• Clinical leader with clear vision and focused

goal • Clear direction from Advisory Group• Aged Care CNC dedicated drive theprocess at executive level.• Being on site in their face• Families, carers, health professionals havewelcomed and embraced Patient Held Record(Yellow Envelope).

Evaluation - Lessons learnt

• Implementation hindered by unstable

workforce (high turnover staff).• Prevention message needs to be

communicated strongly by both sides• Primarily a nurse driven process of care –• Pre-conceived myths & views.• Communication vital at exec level with

Divisions CEO’s

Questions