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Managing Increasing Demand for
Hospital Care
Dr Sherene DevanesenCEO
Peninsula Health
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Managing Increasing Demand for Hospital Care
Increasing Demand:
Demographic trendsChanges to social infrastructureNew technologyConsumer Expectations
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Managing Increasing Demand for Hospital Care
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Managing Increasing Demand for Hospital Care
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Managing Increasing Demand for Hospital Care
“What Americans want is quite simple; all the health care they or their doctors can imagine, virtually free, without added taxes for health care and without out of pocket costs .... That’s all. Call it part of the American Dream.”
- Professor Reinhardt, Princeton University.
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Managing Increasing Demand for Hospital Care
Implications of poor demand managementFinancial / economicPoor consumer outcomes
Good demand managementEffective servicesAppropriate servicesMultiple settings
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Managing Increasing Demand for Hospital Care
Health Care in Australia
Commonwealth (Federal) Government
- Residential Care Australian Healthcare Agreement
- Pharmaceutical Benefits Scheme
- Payments to doctors for ambulatory care States- Public hospital services
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Managing Increasing Demand for Hospital Care
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Managing Increasing Demand for Hospital Care
Access to hospitals
Emergency Planned orElective
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E6 - ED Presentations – Frankston & Rosebud HospitalsPeninsula Health
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual Prev Yr
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Managing Increasing Demand for Hospital Care
Emergency Access
Growth in ED Presentations:OvercrowdingDysfunctionLong waiting timesDelays in admission
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Managing Increasing Demand for Hospital Care
Studies
Canberra HospitalDeaths in those who experienced overcrowdingIncrease in hospital mortality at 10 days
Western AustraliaDeaths of those who experienced overcrowdingLonger ED length of stayLonger physician waiting time
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Managing Increasing Demand for Hospital Care
Studies (cont.)
Western AustraliaStrategies
Reduce wasteReduce misuse / overuseImprove chronic disease managementMatch bed supply with demandOptimise hospital inpatient flow
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Managing Increasing Demand for Hospital Care
Studies (cont.)California
46% of users of EDs believed the care could have been provided by a primary care practitioner.Key factors in use of EDs by avoidable users:
Lack of access to outside EDsLack of adviceLack of alternativesPositive attitude to EDs
Chronic conditionsPopulation 32%ED users 44%
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Managing Increasing Demand for Hospital Care
Consequence of use of EDsfor non-urgent needs
Divert / delay resources for acute patientsMore expensive than other settings
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Managing Increasing Demand for Hospital Care
Control Measures
Prevention of Better care forPresentation those with acute(minimising conditions requiringAvoidable use) Emergency care
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Managing Increasing Demand for Hospital Care
Prevention of Presentations
Population based interventionsSmokingNutritionAlcoholPhysical activityInjuries
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Managing Increasing Demand for Hospital Care
Prevention of Presentations (cont.)
Provision of information
“Nurse-on-call” strategy – June 2006
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Managing Increasing Demand for Hospital Care
Patients referred in the following manner:
Ambulance 5%ED 19%Primary Care provider 42%Self care 33%Other 1%
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Managing Increasing Demand for Hospital Care
“Better Health Channel”
Health information internet site
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Managing Increasing Demand for Hospital Care
Prevention of Presentations (cont.)
Primary care interventions:VaccinationsScreening, eg
Breast, colonoscopy
Acute conditions treated at home, egDehydrationCellulitisPelvic inflammatory disease
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Managing Increasing Demand for Hospital Care
Prevention of Presentations (cont.)
Chronic Disease Management, egHypertensionHeart FailureDiabetesChronic Lung DiseaseSocial Issues
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Managing Increasing Demand for Hospital Care
Chronic Disease management (cont.)
Chronic diseases 50%
Management – requires shift from focus on acute symptoms
$515m for 5 years from Australian Government
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Managing Increasing Demand for Hospital Care
Chronic Disease Management (cont.)
Self Management Support
Education Plannedvisits
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Managing Increasing Demand for Hospital Care
Chronic Disease Management (cont.)WHO – Innovative care for Chronic Conditions Framework
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Managing Increasing Demand for Hospital Care
Prevention of Presentations (cont.)
Diversion and Substitution
Multidisciplinary teams in EDs
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Prevention of Presentations (cont.)
Diversion and substitution
Collocated GP clinics
Urgent care centres
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Managing Increasing Demand for Hospital Care
Better Management of Patients Requiring Emergency Care
Ambulance diversion or bypassLess than 3%
Assessment and Observation UnitsPeninsula Health – Medical Assessment Unit
Only 31% admitted to hospitalLength of stay decreased
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Managing Increasing Demand for Hospital Care
Better Management of Patients Requiring Emergency Care (cont.)
Information Technology Tracking systems
Workforce rolesPhysiotherapist in ED
Good outcomes
Streamlining for lower acuity patients
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Managing Increasing Demand for Hospital Care
Better Management of Patients Requiring Emergency Care (cont.)
Bed management practices
Better management of Mental Health patients in EDs
Triage tool at PHLength of stay decrease
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ED1 - % Time on Bypass (DHS KPI 1)
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual (%) Prev Yr DHS Target
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ED2 - % Patients Admitted within 8 Hours (DHS KPI 2)
0%10%20%30%40%50%60%70%80%90%
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual Prev Yr DHS Target
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ED3 - % Non Admitted Patients with LOS < 4 Hrs (DHS KPI 3)
0%10%20%30%40%50%60%70%80%90%
100%
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual Prev Yr DHS Target
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ED4 - Patients LOS > 24 Hours (DHS KPI 4)
0
10
20
30
40
50
60
70
80
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual Prev Yr DHS Target
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Managing Increasing Demand for Hospital Care
Planned or Elective Presentations
Pre and post hospital care in OutpatientsIntroduction of Allied Health practitioners in Outpatient
Clinics, egPhysiotherapists in Orthopaedic Clinic
Planned admission for medical care in stand-alone centre
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Managing Increasing Demand for Hospital Care
Planned or Elective Presentations (cont.)
Procedural (Surgical) ServicesCategorisationWaiting listMinimisation of cancellationsDay of surgery admissions
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Managing Increasing Demand for Hospital Care
Planned or Elective Presentations (cont.)
Other strategiesOther public hospitalsNew centre for State-wide accessUse of private sector“Medihotels”
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EL1 - Total Patients on Waiting List (DHS KPI 7)
2,000
2,200
2,400
2,600
2,800
3,000
3,200
3,400
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay JunActual Prev Yr DHS Target
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EL5 - Hospital Initiated Postponement (HIPs) per 100 W/L Admissions (DHS KPI 8)
0
5
10
15
20
25
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual Prev Yr DHS Target
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W1 - Average Waiting Time -Category 1 (Days)
0
5
10
15
20
25
30
35
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual Prev Yr DHS Threshold
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W2 - Average Waiting Time -Category 2 (Days)
0
50
100
150
200
250
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual Prev Yr DHS Threshold
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W3 - Average Waiting Time -Category 3 (Days)
0
50
100
150
200
250
300
350
400
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual Prev Yr PH Threshold
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D2 – DOSA General Surgery
50%
60%
70%
80%
90%
100%
Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun
Actual Prev Yr PH Target
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Example of Performance thresholds used to allocate bonus funding points
Percentage of operating time on hospital bypass
Bonus Points Criteria Bonus Points
Less than or equal to 3.0% 3
3.1% to 4.0% 2
4.1% to 5.0% 1
Greater than 5.0% 0
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DHS - KEY PERFORMANCE INDICATORS & BONUS FRAMEWORK 2005/2006
TargetEmergencyED1 - % Time on Bypass (DHS KPI 1) 3%
ED2 - % Patients Admitted within 8 Hours (DHS KPI 2) 80%
ED3 - % Non Admitted Patients with LOS < 4 Hrs (DHS KPI 3) 80%
ED4 – Patients LOS > 24 Hours (DHS KPI 4) 0
ED5 – Category 1 - % Patients Seen Immediately (DHS KPI 9) 100%
Elective SurgeryEL1 – Total Patients on Waiting List (DHS KPI 7)
EL3 - % Category 2 Waiting more than 90 Days (DHS KPI 5) 0%
EL4 - % Category 3 Waiting more than 365 Days (DHS KPI 6) 0%
EL5 – Hospital Initiated Postponement (HIPs) per 100 W/L Admissions (DHS KPI 8) 15
EL2 - % Category 1 Admitted within 30 Days (DHS KPI 10) 100%
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Managing Increasing Demand for Hospital Care
Other StrategiesService integration to improve patient journeysGood forecasting and planningRole delineationDevelopment of clinical networksNew workforce strategies
New workforce roles
Defining a queuing strategyGood discharge planning
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Managing Increasing Demand for Hospital Care
Consumers - 3 segments
Healthy populationInformation or health promotion, disease preventionEarly intervention strategies
‘At risk’ populationIdentificationSelf management support
‘High acuity’ patientsAppropriate and effective hospital care
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Managing Increasing Demand for Hospital Care
Conclusion
CollaborationStronger relationships between sectorsChanged relationshipsShift to community models of care
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Managing Increasing Demand for Hospital Care
Conclusion (cont.)
Shift:
From To________________________________________Episodic care Continuums of careProvider focus Consumer focusAcute care settings Multiple care settings