Moving to a Person Centred Integrated

Acute - Subacute Community Service

Presentation Transfer of Care Conference

22 June 2015

Jenny Collins – Austin Health

Austin Health

• One of Victoria’s largest tertiary health services

• Major academic medical centre providing health services, health

professional education and research

• Austin Health operates 980 beds across acute, sub-acute and

mental health with an annual operating budget of more than $700

million.

• Employing >7,900 people across the Austin Hospital, Heidelberg

Repatriation Hospital (HRH) and the Royal Talbot Rehabilitation

Centre (RTRC).

• Broad catchment serving a population of approx 1.2 million

people

Austin Health

• During 2013-14, Austin Health completed 95,142 inpatient

admissions,177,027 outpatient attendances and 75,366

emergency attendances.

Catchment area

Austin Hospital

Heidelberg Repatriation Hospital

Royal Talbot Rehabilitation Centre

Primary

Secondary

What Are Health Independence Programs

• Deliver health care to support transition from hospital

to home.

• Prevent need for a hospital presentation or stay, with

some people accessing these services directly from

the community.

• Client Centred and integrated delivery of services.

Working from all three sites across Austin Health

Austin Hospital

Heidelberg Repatriation

Hospital

Royal Talbot Rehabilitation

Centre - founded 1907

Drivers For Change Context of Healthcare

• Increasing demand

– Growing population

– Ageing population

– Increasing co-morbidities/chronic disease

– Increased expectations and less access to GPs

• Workforce

– Traditional models stretched but insufficient progress on new models

– Turnover and shortages

– Siloed

• Policy - Constrained funding

– Driving greater integration

– Increased focus toward a positive impact on acute demand

– Shrinking resources

– Department of Health – Health Independence Program Guidelines

What that means to Austin Health

• Increasing complexity of patients

• Increasing age of patients

• Pressure on acute to move patients downstream to

subacute or the community.

• Increasing number of patients that do not fit our traditional

service models.

• Challenges to discharge

Questions?

The Austin HIP Case for Change

WHY Health Independence Program

Integration – Client- Patient

•Deliver person centred care for all HIP clients

•Better Client outcomes - seamless pathway from entry to

hospital to discharge

•Improve the patient experience

•Improve equity of access for HIP eligible clients

•Provide care coordination of complex needs for all HIP

clients

WHY Health Independence Program

Integration – Staff

•Increased opportunity for:

• skilled and experienced staff to ensure a client-centred

continuity of care approach wherever possible

• professional disciplines with regard to practice

•Efficiencies in service delivery and profession supervision

for HIP Staff and Austin Health more broadly

WHY Health Independence Program

Integration – System

•Simplify the HIP service system

•Minimise duplication

•Reduce fragmentation of service delivery across funding

streams

•Increase flexibility in service delivery

•Improved Efficiencies

Integration As the Solution

Planning For Change

• Stakeholder Engagement – Workshop – Outcome: shared

Austin Vision

• Development of the HIP Integrated Service Model

• Establishment of Key Deliverables – Evaluation Framework

• Matching the workforce to the service model

Rehabilitation Services

Specialist Services

Intake &

Fast-Track Care

Management

Complex Care Management

Client Centred

Care

HIP Integrated

Service Model

Building and matching your Service profile

(Old HIP Management Structure)

Manager

HIP

Coordinator HIP Rehabilitation

SACS Coordinator

Continence and Falls & Balance

Clinic

Coordinator Memory/Wound

Coordinator Acute & Chronic

Pain

HIP Team Leader Chronic

Disease

Coordinator Continuing Care

HRC Building Admin Manager

Intake Team Leader

Building and Matching your Service profile

(Old HIP Clinical Structure) Your Workforce

Matching staff to integrated clinical structure

• Align Leadership structure with vision and model of care

• Match like intervention with like

• Broaden senior clinician leadership participation \ Identify

training needs

• Develop a change management strategy

• Executive sign off and approval

Integrated HIP Manager Structure

Manager

HIP/HRC

Manager

Chronic & Complex Care Services

(1 EFT)

HIP Intake & Fast Track

Team Leader

(1 EFT)

HIP Complex Care Management

Team Leader

(1 EFT)

Manager

Specialist Services

(1 EFT)

Team Leader HIP

Rehabilitation Services

(1 EFT)

Team Leader HIP

Specialist Clinics & Intervention Services

(1 EFT)

Manager

HIP Admin & HRC Building

Proposed HIP Integrated Structure

A changed Client Experience

How a person experiences of HIP services and treatment Now

How a person should experience of HIP services and treatment in the Future

Frequent, multiple - varied assessments Person-Centred Care

knowledge and confidence

choices about their treatment

involvement in treatment planning, goals

decision making.

Multiple entry points and criteria

Difficult for people to access and navigate.

A service that is easy to navigate

•Central entry point for whole of HIP

Few opportunities for a ‘fast-tracked’ response. A Service that is Responsive •Timely and efficient •Flexible roles •Screens for patient complexity

Variable service quality Consistent High Quality and Evidence-based

Inflexible Funding models and siloed programs

A service that has integrated pathways

HIP Central Intake profile

• Based at the Repatriation Campus operates 8:30am-4:30pm

• All internal and external referrals into HIP

• >200 contacts a week

64%

36%

Referral sources

Internal referrals

External referrals 78%

22%

Internal Austin Health referrals

Inpatients

Outpatient

0

200

400

600

800

1000

1200

July August September October November December

Nu

mb

er o

f n

ew r

efe

rral

s

New HIP referrals by month

2013

2014

0

100

200

300

400

500

600

700

800

900

1000

January February March April May June

Nu

mb

er o

f n

ew r

efe

rral

s

New HIP referrals by month

2014

2015

46/mth

34/mth

HIP keeps people out of hospital:

Change in ED attendances and hospitalisations 12 months Pre/Post

Intervention for Clients referred in 2013

-6,000

-5,000

-4,000

-3,000

-2,000

-1,000

0

Complex Care

Management

Fast Track Care

Management Rehabilitation Specialist Services

Total change in ED Presentations before to after

Total change in Admissions before to after

Over 1 year:

Standalone ED presentations - 14,644 less

Admissions with/without ED presentation - 7,250

less

Learnings to facilitate success

• Develop a clear vision!

• Clear rationale – Why are we doing this?

• Executive Leadership and support

• Culture Change as well as Service Change

This takes time and may be difficult!

• Stakeholder communication and management

Acknowledgements

• Alan McCubbin

• Evelyn Gould

• HIP Team

Questions?