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Transition Care Program
Recognising and responding to the
deteriorating client: reducing
readmission and avoidable hospital
presentations
Transfer of Care Conference
Sydney 2015
Northern Adelaide Local Health Network
Outline
Program outline & demographics
Project trigger
Project aims
Initial plan
Implementation strategies
Evaluation
Outcomes
Future directions
Program outline &
demographics
73 beds
4 residential aged care facilities
5 community providers
Brokered service using collaborative
partnership model
Lower socioeconomic population
Increasing acuity
Multiple co-morbidities
Frequent ED presentations and
readmissions
Low entry Barthel score
Project Trigger
Adverse events/ Incident reports
Hospital readmission rate/ reason
ED presentation rate/ reason
Service audit outcomes
Case Manager feedback
Clinical reference group discussion
Project aims
Provide education, mentoring and tools to
assist RACF staff to recognise the early
signs of clinical deterioration to:
Improve client outcomes
Reduce adverse events/incident reports
Reduce avoidable ED presentations
Reduce hospital readmissions from
unrecognised clinical deterioration
Initial Plan
Identify initial project site and meet with
key staff
Develop an observation chart and
decision support tool for staff
Develop staff education tools and roll out
plan
Planned evaluation at 3 and 6 months
Date
Time
Room
Staff Initial
Re
sp
s
≥ 36
31 – 35
21 – 30
9 – 20
≤ 8
Sp
O2 O2 L/min
≤ 94
91- 93
< 90
Te
mp
(0C
)
≥ 38.6
37.6 – 38.5
36.1 – 37.5
35.1 – 36
< 35
↔ B
loo
d P
res
su
re a
nd
H
ea
rt R
ate
(•)
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
Flu
ids
In
Progressive Total
Flu
ids
Ou
t
Nausea
Pain Score
BGL
Wound
Conscious state
Incidents
Chart example
Implementation strategies
Regular communication with project site
and meetings with key staff
RACF staff completed 2 training sessions
and evaluation process
RACF Staff mentored by TCP staff on site
on using the observation chart and
decision support tool
Client outcomes reviewed weekly with
team on site
Client outcomes discussed at case
management meetings
3 month evaluation
Evaluation
Discharge destination trending
Readmission analysis
Incident report analysis
Barthel entry and exit scores
Case management record review
Reflective practice sessions with RACF
staff
Clinical reference group feedback
Outcomes
Return to hospital comparison
Main reason for readmission COPD/ CCF exacerbation
Incident rate comparison
Year 2012
Baseline 2013 2014 2015
Readmission rate 40% 31% 27% 23%
Year 2012
2013 2014 2015
COPD/ CCF 50% 40% 32% 20%
Post
implementation2013 2014 2015
SAC 1 / 2 3% SAC 1 / 2 1% 1% 1%
Baseline
Outcomes
Barthel score comparison
Informal and formal Feedback Education surveys
Clinical reference group
ED Liaisons
Barthel
scores
(average)
Admission 35 53 53 49
Discharge 47 57 53 57
2012 2013 2014 2015
Further Quality improvements
Pre-admission:
Daily triage of potential clients
Admission to GEM before TCP
Request for Chronic disease
management plan
During program:
Fortnightly Geriatrician reviews in RACF
Implementation of an ED flagging system
Urgent and non urgent Hospital transfer
decision support tools
Future directions
Chronic disease management plans to
support early detection of clinical
deterioration for all clients as part of a
standardized discharge package
Weekly case management meeting with
Geriatricians
Questions?
Thank you
Lesley Heap
Clinical Service Coordinator
Transition Care Program
Northern Area Geriatric Service
Northern Adelaide Local Health Network
Phone: 8396 1345
Mobile: 0466 408 012
email: [email protected]
