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In-roads and Out-roads
in Regional Subacute
Care -
A Central West NSW Experience
Dr Frances Gearon
11th October 2012
Acknowlegements
“The Subacute team”….. •Particularly………
•Dr Ellen Downes (Rehabilitation Physician)
•Dr Sumitha Gounden (Rehabilitation Physician)
•Dr Claire Sui (Rehabilitation Physician)
•Lacey Healey –Outreach Co-ordinator
•Kate Polain – Rehabilitation Clinical Nurse Consultant
•Tracey Drabsch- Physiotherapist
The development of a multidisciplinary team providing in reach and outreach rehabilitation
services in a regional centre.
Summary • Where ?
• Why ?
• What ?
• Who ?
• How ?
Where ?
ORANGE
Communities and Facilities supported by
Orange Health Service
ORANGE
Why ?
Issues to consider
1) Bed Capacity in Orange Health
Service (OHS)
Issues to consider
1. Capacity in OHS
2. Capacity in neighbouring
sites
Issues to consider
1. Capacity in OHS
2. Capacity neighbouring sites
3. Skills
Issues to consider
1. Capacity in OHS
2. Capacity neighbouring sites
3. Skills
4. Relationships
What ?
A Guardian Angel
SOMETHING ……Dropped into
“ - Orange Base Hospital • Fight for access to beds in OBH
• Enhance and support central service
• Improve patient care
• Improve communication/continuity
• Improve consistent patient discharge
planning and goal setting
SOMETHING ……Dropped into
“
• Support and build capacity of services
• Maintain role of “district hospitals”
• Maintain staff skills, interest, competence
• Provide services close to patients’ homes
How ?
COAG June 2009, the Western NSW Local
Health District (WNSWLHD) engaged in
the NSW National Partnership
Agreement securing Commonwealth
funding to enhance Sub-acute Care and
services within the District. WNSWLHD recruited a multidisciplinary team of Senior
Clinicians (Medical, Nursing, Allied Health)
The team brief was to establish a HUB and SPOKE and
Outreach model of care
2
5
1
NSW Health Subacute Care Reform Implementation
Plan
A component of the National Partnership Agreement
on Hospitals and Health Workforce Reform 1. Executive summary
Under the subacute care component of the National Partnership Agreement
on Hospitals and
Health Workforce Reform, NSW is to receive $165.652m. This funding will be
allocated to the 8 Area Health Services (AHSs) in NSW to enhance services across all four subacute care types
– rehabilitation, palliative care, geriatric evaluation and management (GEM), and
psychogeriatric care - targeting older people, children, Aboriginal people and other residents in
geographic areas in urban and rural NSW that are currently under-serviced.
The structure and profile of subacute services varies across NSW. Logically, services are
better developed in areas with larger populations, and especially in the Sydney greater
metropolitan region. Funding will be distributed among AHSs based on a needs-weighted
funding formula that takes into account both historical activity levels and the health needs of
each Area’s population. This funding model has been selected as it provides a strong equity
component. Funding will also be provided to the Children’s Hospital at Westmead as it provides
subacute care to a discrete population group……….
www.gwahs.health.nsw
Mission Statement
Sub-acute Care Team:
“Supporting current services and
existing networks to enhance
rehabilitation, geriatric evaluation,
and overall patient management in
hub and spoke sites”
Communities and Facilities supported by
Orange Health Service
www.gwahs.health.nsw
Acute Care for the Elderly (ACE)
Collaborative Care model with
Physicians
Multidisciplinary team (OT, PT,
Speech Path, Dietetics, SW, Nursing,
medical)
Geriatrician/Rehab Specialist (P/T),
Aged Care CNC
Acute Aged Care Nurse team
(Delerium CNS, ARRCS, ASET etc)
Dedicated weekly case conference
Inpatient Rehabilitation Units
Comprehensive Inpatient
multidisciplinary rehabilitation
based on existing model
Rehab CNC co-ordination
Outpatient rehabilitation
Provision of Management plan
REHAB DAY HOSPITAL
Orthogeriatrics
Collaborative Care model with
Orthopaedics
Geriatrician/Rehab specialist (P/T)
Multidisciplinary team (OT, PT, SP,
Dietetics, SW, Nursing)
Aged Care CNC
Acute Aged Care Nurse team
(Delirium CNS, ARRCS, ASET etc)
NEIGHBOURING
FACILITIES
Existing therapy teams (PT,
OT, SP, Dietetics, SW, Nurses)
Therapy Aide- to continue
recommendations
Completion of rehab
management plan closer to
patient’s home
Liaise with Outreach Co-
ordinator & Hub team to
facilitate goal attainment
Video/Teleconferencing
Ongoing Education through
“HUB TEAM” review on-site
and attendance in larger centres
Increased skills of local staff
Outreach Rehab Co-ordinator (F/T)
Regular conferencing with Neighbouring
Facilities (video/tele) re goal attainment
Scheduled visits on-site for education &
training of staff (increased skills)
Liaise with Base Hospital Rehab and
Outreach Team & LMO about patient goals
AND
NEW
NEW
Improved
Service
NEW
NEW
“THE HUB” OBH inpatient services Community and Neighbouring Facility Service(s)
FACILITATES:
•Timely inpatient geriatric
assessment
•Formulation of plans and goals
•Improved medical management
•Early discharge planning
•Appropriate rehab consults
•Handover to neighbouring teams
with ATTENTION TO DETAIL
Who ?
3
1
31
The “SUBACUTE TEAM”
Rehabilitation
Physician Clinical Nurse
Consultant
Outreach
Coordinator
Physiotherapist
Occupational
Therapist
Speech
Pathologist Dietitian
Social
Worker
Priorities for Sub-acute Team
Improved patient outcomes
BY
• Improved quality and continuity of care
• Timeliness of care
• Communication
Focus
“Ensuring our patients get the right care, at the
right time in the most appropriate place…”
Background
• Set up with Federal Government COAG Subacute Care enhancement funding
• Began in April 2010 & Full team recruited by Sept 2010
• Initial goals – Multidisciplinary inpatient geriatric assessment
– Plan formulation and Goal setting
– Minimisation of post-operative complications (pro-active patient management)
– Early discharge planning or streamlined rehab consults
– Detailed handover and support to neighbouring facility teams to support Sub-Acute Care closer to the patients home
www.gwahs.health.nsw
Challenges Within the Hub
• A New service vs Ingrained culture: Drawing attention to the need to address the “Essentials of Care”
• Communication road blocks: who are you, why do we need you, what is a Rehab service doing in acute care?
Challenges Within the Hub
• Change Management
-new facility
-new service
• Facade of creating “additional workload”
• Facility KPI’s vs Patient Outcomes KPI’s
- advocacy at patient flow meetings
www.gwahs.health.nsw
Challenges • New Team
– Establishing referral criteria, ‘Sub-acute’ very
broad area
– Establishing acceptable systems and
protocols (acceptable to all parties involved)
– Introducing team to broader hospital staff and
broader area team
– Establishing individual team member roles
and complementing existing staff roles
www.gwahs.health.nsw
Finding a starting point:
Ortho geriatric patients
Limited the diagnostic inclusion group to a
“high needs” patient cohort:
- All Fractures
- 65 years and older
- From Orange or a
Neighbouring Facility
Orthogeriatric Best Practise
Guidelines • ACI Orthogeriatric Model of Care: Summary of
evidence 2010.
• Orthogeriatric pt often has complex needs,
benefits from:
– Collaborative multidisciplinary approach
– Effective teamwork
– Coordination of care
– Close working partnership and clear communication
between various specialties and services involved
4
0
www.gwahs.health.nsw
Orthogeriatrics
Collaborative Care
with the
Orthopaedic/Acute
Teams
Sub-Acute Care Team
Multidisciplinary
Team
NF Teams
•Outreach
visits
•Patient
follow up
•Education
•EDUCATION
•EDUCATION
•SUPPORT
•SUPPORT
•SUPPORT
Outreach Co-ordinator
Sub-Acute
Care Team
members
“THE HUB” ORANGE
inpatient Neighbouring Facility
Multidisciplinary
Handover
to Neighbouring
Facilities & Teams
Sub-Acute Care Team Hub and Spoke Model of
Care from OHS
Challenges (cont.) • A Valued Patient group
– Typically working with “low priority” patients
– Justifying Senior Clinician involvement in what was
viewed as low pay off clinical load
– Change Management on an Acute Ward (Pressure
Care, Equipment, Rehab for elderly)
• Missing the support of OT’s!
– Working to establish networks with OT’s
– Why doesn’t everyone understand “functional”!!?
Baseline Hub Audit
• Admission to OBH with a
fractured NOF
• Aged 65 years and over
• Residential address in
neighbouring location (not
including Orange residents)
• Admitted to OBH between
June 2008 – June 2009
• Of 110 patients, 50 MRNs
were selected to audit
www.gwahs.health.nsw
Why we audited • Collect baseline data for orthogeriatric
patients
• Collect quantitative & qualitative data pertaining to the patient journey
• Determine current practice and care process for management of orthogeriatric patients
www.gwahs.health.nsw
Why we audited (cont’d)
• Identify common issues impacting upon patient care and outcomes
• Identify strengths and weaknesses in the care of orthogeriatric patients
• Guide the teams intervention and input
www.gwahs.health.nsw
What was included • Demographic Information
• Admission Information (LOS, # Type, Surgery, Co morbidities)
• Documentation (Pre-Morbid Mobility, WBS, Cause of Injury)
• Pain Management
• Bowel/Bladder Management
• Pressure Care
• Access to Rehabilitation
www.gwahs.health.nsw
What was included (cont)
• Delirium (Screening, Management)
• Complications e.g. UTI, Pressure injury,
• Allied Health Involvement
• Discharge Planning & Handover
• Discharge information e.g. Where, delays
• Readmission
www.gwahs.health.nsw
Other information • 44% of patients developed post operative
delirium/confusion
• A Rehabilitation consult was requested for 66%
of patients
• 14% of patients were admitted to an inpatient
Rehabilitation unit
• On average, discharge planning was initiated 5
days post admission
Other information (cont’d)
• Only 32% of patients had their
weight recorded during admission
• Documented malnutrition,
nutritional risk, poor oral intake:
54%
Where did they go??
28%
24%18%
14%
10%
6%
Nursing home
Back to transferring hospital
Other
Rehabilitation Facility
Hostel/special accomodation
Home with supports
Initially 24% from Nursing Home and 58% from home
Complications during admission
34%
30%28%
20%
16%14% 14% 14%
8%6%
2%
Con
stipat
ion
1st o
ther
No co
mplications U
TI
Pre
ssur
e ulce
r
Electro
lyte
imba
lanc
e
Wou
nd in
fection
Che
st in
fection
2nd othe
rFa
ll
DVT
/PE
www.gwahs.health.nsw
What we did
• Established collaborative care involving the Sub-acute Team and the Orange Health Service Orthopaedic Team for all elderly patients with fractures presenting to OHS……
What we did Increased communication with patient focus:
• Day 0 involvement
• Engagement-Senior Clinical Leaders- Orthopaedic
surgeons & Surgical NUM
• Automatic physician assessment of all #NOF’s
• Case Conference (early assessment and MDT approach
with early planning and goal setting )
• Family/ Carer Involvement
• Handover (Comprehensive and timely)
• Follow up (Access to clinical support and patient review)
www.gwahs.health.nsw
What we did
This team attempted to
implement
ACI
ORTHOGERIATRIC Model of
Care
within OHS and its neighbouring
hospitals
www.gwahs.health.nsw
Planning & Implementing
solutions
This team implemented the Orthogeriatric ACI
Model of Care within OHS and its NF
• To establish baseline information within the OHS
a medical record audit was completed.
Pre Team June 2008 - June 2009
(n=50).
Post Team Sept 2010 - Feb 2011
(n=30).
5
4
Outcomes & Evaluation
Statistically significant increase in:
• Occupational Therapy and Social Work involvement
• Documentation of weight bearing status, pre-morbid mobility and pre-morbid function
• Aperients given
• Paracetamol charted
• Medical discharge summaries sent to the General Practitioners
• Handover information including the patient’s equipment needs, goals and contact details, physiotherapy, dietetics and social work discharge summaries
5
5
5
6
5
7
5
8
Outcomes & Evaluation
Statistically significant increase in:
• Occupational Therapy and Social Work involvement
• Documentation of weight bearing status, pre-morbid mobility and pre-morbid function
• Aperients given
• Paracetamol charted
• Medical discharge summaries sent to the General Practitioners
• Handover information including the patient’s equipment needs, goals and contact details, physiotherapy, dietetics and social work discharge summaries
5
9
Qualitative Assessment
• Education Sessions provided for groups
and one off clinical education
• Advice is always available –phone and site
visits
• Comments from GP’s, Nursing staff and
allied health ……“More support than we
have ever had”.
Qualitative Assessment
• On site visits from the teams Allied
Health/Medical /CNC
• Cowra, Parkes, Forbes patient flow
meeting with OHS via teleconference
Sustaining Change
• The team’s linkages with existing networks such
as the NF and rural AH clinician's enables
informed decisions about handover & follow up
of patients transitioned from OHS.
• The team is aiming for sustainable service
improvement by ensuring the ongoing
multidisciplinary management of this patient
cohort at OHS. This includes regular case
conferences, consistent multidisciplinary verbal
and written handover and supporting staff in
regard to the care of patients with complex co-
morbidities.
6
2
Lessons Learned
• Guidelines with clinical validity and authority to
work from provide a good platform to guide, build
and sustain clinical practice changes
• Consistent Communication and support with
change management
• Consistency of team activity over a prolonged
period is effective in maintaining service provision
• Teams work well with teams
• Networking is key to providing a more seamless
patient journey
6
3
Current Roles
Education
- Education provided in Neighbouring
Facilities and at Orange Health Service re:
Orthogeriatrics best practise, Preventing
Functional Decline, Sub-acute Care.
- Support of other clinicians as
required/requested
• Areas for improvement?
• The verbal handover from Patient Flow
needs improvement
• More assistance with discharge planning
for these patients from Canowindra and
Molong Hospitals
• Support with the Delirium patients in
particular (clinical education and advice)
www.gwahs.health.nsw
Establishing a Model of Care for
the Sub-acute Care Team
Inspiration from:
• Acute Care for the Elderly (ACE) - Hornsby
• Hub & Spoke Rehabilitation
• NSW Agency for Clinical Innovation- Orthogeriatric Model of Care
• Garling Report
Unique dual focus on both Acute and Rehabilitation
phases of the patient journey
Bibliography
1. NSW National Partnership Agreement
2. http://www.coag.gov.au/intergov_agreements/federal_financial_relations/do
cs/national_partnership/national_partnership_on_hospital_and_health_work
force_reform.rtf
3. Australasian Faculty of Rehabilitation Medicine position statement No.9
National rehabilitation Strategy (2009)
http://www.racp.edu.au/index.cfm?objectid=02A28582-E795-54CF-
2A8041E0BD658E1E
4. Acute Care for the Elderly (ACE)
http://www.archi.net.au/resources/moc/older-moc/ace
5. Orthogeriatric Model of Care (Agency of Clinical Innovation)
http://www.health.nsw.gov.au/resources/gmct/agedcare/pdf/aci_orthogeriatri
cs_clinical_practice_guide.pdf
www.gwahs.health.nsw
Current Roles
• Medical
- Involvement with complex medical patients
referred by treating medical team (e.g.
elderly patients at risk of functional decline
during hospital admission).
- Why this patient cohort??
ACE Model (Acute Care of the Elderly)
• Developed by Hornsby Ku-ring-gai Health Service
• Concepts: – Multidisciplinary team approach from time of admission
– DC planning begins on day of admission (incl. EDD)
– Shared care model between admitting physician and geriatrician
– Ongoing focus on function – to pre-morbid level
– Weekly pharmacy round
• Needs understanding and commitment from all staff, pt’s and family
• Aim to keep elderly pt’s as active and independent as possible during acute phase of illness
Current Roles
• Neighbouring Facilities
- Comprehensive handover summary.
- Follow-up by Outreach Coordinator for all patients transitioned to neighbouring facilities for sub-acute care.
- Involvement from individual disciplines as required, follow-up with local teams.
- Review for possible readmission for rehab at OHS.
- Review for possible assistance for setting goals/programs while at Neighbouring Facilities.
Thank you
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