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A Piece of Your Heart, Who Fits Where in Your Heart Failure Care? DIAGNOSTICS SOLUTION EVALUATION Local research within HNELHD discovered a high incidence of readmission and mortality in people with Heart Failure over a 10 year period.(1) HNELHD strategic plan has a vision “healthy people – now and into the future” - keeping people healthy and in the community providing world class clinical services with timely access and effective infrastructure.(3) A service review identified opportunities to improve the model of care and improve the outcomes for patients with Heart Failure.(2) In 2017 1008 patients were admitted with primary diagnosis of Heart Failure. Only 26% of these patients were managed by the current Heart Failure Service provided by Hospital in The Home. “No one told me I’m dying” “I wasn’t sure so I took my old and new pills” “I’m waiting to hear about my appointment with the specialist” (7 weeks post D/C) “I didn’t know I was in hospital for my heart, I thought it was a kidney infection” Only 3% of inpatients had education documented Cardiovascular Investigation form changed to pink on Community HealthPathways as this is how it is recognised in Acute Facility PatientInfo public website providing patients with consistent information Fostering relationships between primary and acute care services Improvement in utilisation for Heart Failure Community HealthPathways This project is being developed in line with the Centre for Healthcare Redesign Methodology supported by the NSW Agency for Clinical Innovation Integration: Increasing use of the Community Heart Failure HealthPathway at start of the project then sustained over time following the revision in July 2018 as shown by the below trend line. Heart Failure Discharge Plan Development & Integration Health Pathways Community and Hospital HealthPathway Heart Failure Service Model Telephone support service Key Solutions This project resulted in a redesign of the existing HF services to provide coordination of care access across both acute and community using a telehealth model. The approach aims to optimise the patients care in hospital and provide navigation on discharge to ensure the patient is connected to appropriate services in the community. The research, service review and strategic vision for HNELHD showed that there was an opportunity to strengthen the relationship between acute, community and primary care and enable innovation to minimise clinical variation and waste. There is variation in the way that care is delivered to patients admitted with a primary diagnosis of heart failure in the Greater Newcastle Sector. We would like to thank our Executive Sponsor Karen Kelly, Executive Director – Greater Metropolitan Health Services, our Reinforcing Sponsor Phil Way – Clinical Network Manager HNELHD and Clinical Lead A/Professor Aaron Sverdlov. We also extend our sincerest thanks to Judith Swan, Knowledge Manager – Partnerships, Innovation and Research HNELHD. Length of Stay, readmission rate and patient reported outcome measures will be monitored by new Heart Failure service as full implementation occurs. Quick Wins Conclusion Acknowledgment Contacts Diagnostics DESIGNED FOR SCALABILITY AND TRANSFER TO OTHER SECTORS Greater Newcastle Sector Results Sustaining Change Key relationships built Processes to monitor outcomes New way of working is clearly documented and agreed by stakeholders New Position Description developed and recruitment completed for Heart Failure nursing position Method The New Journey for People with Heart Failure in Greater Newcastle Sector References Al-Omary MS, Davies AJ, Khan AA, McGee M, Bastian B, Leitch J, et al. Heart Failure Hospitalisations in the Hunter New England Area Over 10 years. A Changing Trend. Heart, Lung & Circulation. 2017; 26(6):627-30. Hunter New England Local Health District. Cardiology Stream Heart Failure Service Review, March 2017. Hunter New England Local Health District. Looking forward to 2021 Strategic Plan for Hunter New England Local Health District. 2018. http ://www.hnehealth.nsw.gov.au/about/Pages/Our-Plans-and-Priorities.aspx Case for change Goal To provide coordinated, equitable access and patient centred Heart Failure (HF) care for people in Greater Newcastle Sector (GNS), transitioning between acute and primary care. Julie Rutherford: [email protected] Marika Mackenzie: [email protected] Rachel Sales: [email protected] Reduce Length of Stay for patients admitted with HF by 10% from 6.2 days to 5.6 days by October 2020 Reduce 28 day readmission rate for HF only primary diagnosis by 10% from 5.6% to 5.0% by October 2020 Improve the experience for Heart Failure patients transitioning from acute facilities to community Objectives Julie Rutherford, Marika Mackenzie, Rachel Sales

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Page 1: A piece of your heart [poster] - NSW Agency for Clinical ... · Rachel Sales: Rachel.sales@hnehealth.nsw.gov.au. Reduce Length of Stay for patients admitted . with HF by 10% from

A Piece of Your Heart, Who Fits Where in Your Heart Failure Care?

DIAGNOSTICS

SOLUTION

EVALUATION

Local research within HNELHD discovered ahigh incidence of readmission andmortality in people with Heart Failure overa 10 year period.(1)

HNELHD strategic plan has a vision“healthy people – now and into thefuture” - keeping people healthy and inthe community providing world classclinical services with timely access andeffective infrastructure.(3)

A service review identified opportunitiesto improve the model of care and improvethe outcomes for patients with HeartFailure.(2)

In 2017 1008 patients were admitted withprimary diagnosis of Heart Failure.

Only 26% of these patients were managed bythe current Heart Failure Service provided byHospital in The Home.

“No one told me I’m dying”“I wasn’t sure so I took my old and new pills”

“I’m waiting to hear about my appointment with the specialist” (7 weeks post D/C)

“I didn’t know I was in hospital for my heart, I thought it was a kidney infection”

Only 3% of inpatients

had education documented

Cardiovascular Investigation form changed to pink on CommunityHealthPathways as this is how it is recognised in Acute Facility

PatientInfo public website providing patients with consistent information

Fostering relationships betweenprimary and acute care services

Improvement in utilisation for Heart FailureCommunity HealthPathways

This project is being developed in line with theCentre for Healthcare Redesign Methodologysupported by the NSW Agency for ClinicalInnovation

Integration: Increasing use of the Community HeartFailure HealthPathway at start of the project thensustained over time following the revision in July 2018as shown by the below trend line.

Heart Failure Discharge PlanDevelopment & Integration

Health PathwaysCommunity and Hospital

HealthPathway

Heart Failure Service ModelTelephone support service

Key Solutions

This project resulted in a redesign of the existing HF services to provide coordination of care access across both acute and community using a telehealth model. The approachaims to optimise the patients care in hospital and provide navigation on discharge to ensure the patient is connected to appropriate services in the community.

The research, service review and strategic vision for HNELHD showed that there was an opportunity tostrengthen the relationship between acute, community and primary care and enable innovation to minimiseclinical variation and waste.

There is variation in the way that care is delivered to patients admitted with a primary diagnosis of heartfailure in the Greater Newcastle Sector.

We would like to thank our Executive Sponsor Karen Kelly, Executive Director – Greater Metropolitan Health Services, our Reinforcing Sponsor Phil Way – Clinical NetworkManager HNELHD and Clinical Lead A/Professor Aaron Sverdlov. We also extend our sincerest thanks to Judith Swan, Knowledge Manager – Partnerships, Innovation andResearch HNELHD.

Length of Stay, readmission rate and patient reportedoutcome measures will be monitored by new HeartFailure service as full implementation occurs.

Quick Wins

Conclusion

Acknowledgment

Contacts

Diagnostics

DESIGNED FOR SCALABILITY AND TRANSFER TO OTHER SECTORS

Greater NewcastleSector

Results

Sustaining ChangeKey relationships built

Processes to monitor outcomes

New way of working is clearly documented andagreed by stakeholders

New Position Description developed andrecruitment completed for Heart Failure nursingposition

Method The New Journey for People with Heart Failure in Greater Newcastle Sector

ReferencesAl-Omary MS, Davies AJ, Khan AA, McGee M, Bastian B, Leitch J, et al. Heart Failure Hospitalisations in the Hunter New England Area Over 10 years. A Changing Trend. Heart, Lung & Circulation. 2017; 26(6):627-30. Hunter New England Local Health District. Cardiology StreamHeart Failure Service Review, March 2017. Hunter New England Local Health District. Looking forward to 2021 Strategic Plan for Hunter New England Local Health District. 2018. http://www.hnehealth.nsw.gov.au/about/Pages/Our-Plans-and-Priorities.aspx

Case for change GoalTo provide coordinated, equitable access and patientcentred Heart Failure (HF) care for people in GreaterNewcastle Sector (GNS), transitioning between acute andprimary care.

Julie Rutherford: [email protected] Mackenzie: [email protected] Sales: [email protected]

Reduce Length of Stay for patients admitted with HF by 10% from 6.2 days to 5.6 days

by October 2020

Reduce 28 day readmission rate for HF only primary diagnosis by 10% from

5.6% to 5.0% by October 2020

Improve the experience for Heart Failure patients transitioning from acute facilities to community

Objectives

Julie Rutherford, Marika Mackenzie, Rachel Sales

BRITISH SOCIETY FOR HEART FAILURE · e. Extending the specialist care to more patients admitted with heart failure. For Multidisciplinary HF Teams and HF leads and Networks This audit

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