SWAHS Clinical Redesign Aged & Chronic Complex

Peter StralowResponding to the Challenge Forum 12 September 2007

Background

Improve interfaces between:•Aged Care•Chronic care Cardiac & Respiratory•Community Health•PACC/NOS•GPs•NGOs

Specifically to improve:•patient intake, •triage, •assessment, •and cross referral between service providers.

Summary of patient interviews

POSITIVE & NEGATIVE ASPECTS OF PATIENT & CARER EXPERIENCE

12 10 8 6 4 2 0 2 4

No. of Patient nterviewees

Positive / Agree

Negative / Disagree

Fast Access to reliable Health care

Involvement in decisions & respect for patients privileges

Physical comfort and a clean, safe environment

Involvement of, and support for families and carers

Smooth transition to and support for self-care

Effective treatment delivered by staff you can trust

Clear comprehensible information delivered throughout journey

Emotional support, empathy and respect

Coordination and continuity of patient care

6 8 10 12

POSITIVE & NEGATIVE ASPECTS OF PATIENT & CARER EXPERIENCE

12 10 8 6 4 2 0 2 4

No. of Patient nterviewees

Positive / Agree

Negative / Disagree

Fast Access to reliable Health care

Involvement in decisions & respect for patients privileges

Physical comfort and a clean, safe environment

Involvement of, and support for families and carers

Smooth transition to and support for self-care

Effective treatment delivered by staff you can trust

Clear comprehensible information delivered throughout journey

Emotional support, empathy and respect

Coordination and continuity of patient care

6 8 10 12

Patient interviews

The staff sometimes don’t give us information as they think we know it all. I’ve been doing this for 40 years. (carer)

They need co-ordinating in one hit.

I had visits by Nepean outreach and the community nurses. There was a bit of a mix up between NOS and the community nurses-one did not know the other was coming”.

Number of patient interviews attended: 21The tool used was the NSW Health Patient and Carer Experience Discussion Record.

In summary… what did we learn?

There is nothing systemically wrong with current practices, however there is;

• Little to no coordination & standardisation across services & clusters

• SWAHS hospital, outreach and community services operate on a ‘hub and spoke’ model to external services such as GPs, RACFs and NGOs

• Knowledge of services and access to information is disjointed with reliance placed on informal ‘experts’ for advice (rightly or wrongly)

• Intake criteria are inconsistent – but should they be standardised?

In summary… what did we learn?

High commitment among staff and evidence of numerous innovations (e.g. OPERA, HOPE Project, HOME First) in models of care.

There was a clear commitment to move forward to a successful program of cohesive, integrated and aligned solutions.

To facilitate this desired outcome the project team identified the need to develop a framework that would provide coherence and rigour in the solution design process.

Chronic care model – best practice

Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

Health System

Organisation of Health Care

Self

Management

Support

Delivery

System

Design

Decision

Statement

Clinical

Information

Systems

Informed

Activated Patient

Prepared,

Proactive,

Practice Team

Functional and Clinical Outcomes

Health System

Organisation of Health Care

Self Management

Support

DeliverySystemDesign

Decision Statement

Clinical Information

Systems

Health System

Organisation of Health Care

Self

Management

Support

Delivery

System

Design

Decision

Statement

Clinical

Information

Systems

Productive InteractionsProductive InteractionsInformed

Activated Patient

Prepared,

Proactive,

Practice Team

Functional and Clinical Outcomes

Community

Resources and Policies

Health System

Organisation of Health Care

Self Management

Support

DeliverySystemDesign

Decision Statement

Clinical Information

Systems

Productive InteractionsProductive InteractionsInformed

Activated Patient

Prepared,

Proactive,

Practice Team

Functional and Clinical Outcomes

Productive InteractionsProductive InteractionsInformed

Activated Patient

Prepared,

Proactive,

Practice Team

Functional and Clinical Outcomes

Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

Health System

Organisation of Health Care

Self

Management

Support

Delivery

System

Design

Decision

Statement

Clinical

Information

Systems

Informed

Activated Patient

Prepared,

Proactive,

Practice Team

Functional and Clinical Outcomes

Health System

Organisation of Health Care

Self Management

Support

DeliverySystemDesign

Decision Statement

Clinical Information

Systems

Health System

Organisation of Health Care

Self

Management

Support

Delivery

System

Design

Decision

Statement

Clinical

Information

Systems

Productive InteractionsProductive InteractionsInformed

Activated Patient

Prepared,

Proactive,

Practice Team

Functional and Clinical Outcomes

Community

Resources and Policies

Health System

Organisation of Health Care

Self Management

Support

DeliverySystemDesign

Decision Statement

Clinical Information

Systems

Productive InteractionsProductive InteractionsInformed

Activated Patient

Prepared,

Proactive,

Practice Team

Functional and Clinical Outcomes

Productive InteractionsProductive InteractionsInformed

Activated Patient

Prepared,

Proactive,

Practice Team

Functional and Clinical Outcomes

Best practice elements to be included in the design of Aged and Chronic models

Hospital NGO / Others Community Health

Patient / Carer / Client

Specialist

Total Care Navigation

Coordinated service provision – home, hospital and centre based Services available across SWAHS, GPs, NGO’s and community services

Mobile service

•

•Electronic health

recordData warehouse

• Service directory• Patient information• Performance data

Ongoing careAcute care / exacerbation

Advance Care Planning

Early intervention and prevention

Hospital NGO / OthersCommunity

HealthPatient /

Carer / ClientSpecialist

GP

GP

Appropriate points of accessCase finding and flagging, Planning monitoring and recall

Navigation hub

••

Hospital NGO / Others Community Health

Patient / Carer / Client

Specialist

Total Care Navigation

Coordinated service provision – home, hospital and centre based Services available across SWAHS, GPs, NGO’s and community services

Mobile service

•

•Electronic health

recordData warehouse

• Service directory• Patient information• Performance data

Ongoing careAcute care / exacerbation

Advance Care Planning

Early intervention and prevention

Hospital NGO / OthersCommunity

HealthPatient /

Carer / ClientSpecialist

GP

GP

Appropriate points of accessCase finding and flagging, Planning monitoring and recall

Navigation hub

••

The ‘Total Care Navigation’ framework

The ‘Total Care Navigation’ framework

• Reflects the focus on enabling patients to access the right services from the right providers at the right time matched to their level of need.

• It provided a way of cohesively considering solutions, their design, their priority and their interconnections, as part of the larger picture.

• In essence, this served as a guide for solution design with a focus on delivering improved patient journeys

• A key focus of the project has been to ensure that strategies are in place to respond to the challenges of winter 2008.

Solutions

Implementation of a system for care coordination

Care coordination including a strategy that places a person in appropriate programs

Systems that flags clients and provides an understanding of the level of engagement e.g. at risk patients

First point of contact early identification

Solutions

Implementation of a Navigation Hub

Single point of access within SWAHS Access to information and advice for patientsService directory that facilitates the identification of pathways for patient care

Utilise existing systems to provide access to patient information

A system that provides required levels of patient information to relevant service providers across the continuum of care

Solutions

Development and implementation of a self management program

Self management programs (stratify low, medium and high) including opportunities for consumers to self manage using communication tools, e.g. electronic home based care

Enhanced participation of GPs in the core management of these patients

Develop and implement a suite of solutions that enhance GP participation in the core process as well as investigate the functions of GP liaison nurses across SWAHS

Solutions

Service enhancements

Rapid access/response

Enhance hospital in home programs including opening up access points

Advance care planning in SWAHS by utilising a model of expansion of Geriatric Medicine into RACFs (GRACE)

Alignment of aged and chronic care services

Carers program of coordinated

Transport services / car parking

Tele-based medicine