Engaging with Community Health Services to Strengthen Avoidance Strategies and Reduce Hospital LOS: Moving to a Post Acute 7 Day Model Kim FraserNursing DirectorPost Acute Care Service

Sub Acute and Ambulatory Services

Journey to Post Acute 7 day Model

• Comparison of old and new model

• Imperatives for change• Developing and

implementing the new model of care

• Benefits and challenges of new model

• Lessons learnt

Metro North Hospital and Health Service

• 850,000 population• 4157 square kilometres• Brisbane River to north of

Kilcoy• Rural, regional and tertiary

hospitals• Acute, post acute, subacute,

rehabilitation, aged care, oncology, palliative care, psychiatric, women’s and newborn services.

Context of Change

• Primary Health Care Service funded by both HACC and State. Provided assessment and care coordination services.

Change to …

• Post Acute Care Service which provides State funded services to patients discharged from hospital or diverted from ED.

Seismic Shift

• Moving from a 15 year unchanged model of care

• Skilled and valued staff in old model of care

• Old model no longer met changing health imperatives

• Skills and service model required drastic overhaul

• Profound change

Old and New Models OLD

Post Acute Care Service

• Referrals hospital only

• Frail aged / chronic disease / all ages

• Intervention based

• No wait list and rapid response

• Average 2 week LOS - Time Limited care journeys

• 4 MD teams (100 FTE)

• Home and clinic model

• 7 day a week model

•Team managed flow processes

NEW

Primary Health Care Service

• Referrals community / hospital

• Frail aged and disabled / chronic disease

• Assessment and care coordination

• Lengthy wait lists

• Longer term care

• 9 MD teams (200 FTE)

• Home visiting model

• Monday to Friday

• Clinician managed case loads

Understanding Why

• National Health Reform• Understand current state• Describe potential future

state• Communicate early in the

planned change process• Engage with staff and

discipline leads• Engage with Unions

Engagement with Partners

• Determining who are the partners

• Understanding and sharing key coordination imperatives for each partner

• Reinforcing a partnership approach – we work together!

Analysing Current State

• Review and analyse components of service delivery

• Determine improvement strategies

• Releasing time to care • Improve client flow• Determine effectiveness

of improvement strategies

Findings

• Extensive case loads• Concept of hovering• Existing definition of complex

client too sensitive• Long wait list• Access block• Inability to respond to referrals

as per priority response framework

Moving from Access Block

To Efficient Patient Flow

Focus of Flow

• Whilst still operating from old model of care

• Expectations of service that staff will manage caseloads and focus on timely discharge

• Became part of everyday language

• Ongoing audits

Increasing Internal Capacity• By reviewing and analysing components

of service delivery the Service was able to:– Achieve greater face-to-face activity – Improve client flow– Decrease wait times– Improve responsiveness to high

priority clients

Key Elements to Change

1. Engage Staff

& stakeholders

2. Service Profile

3. Clear Staff Roles

4. Journeys of Care

• Multiple forums• All levels of management• Range of communication strategies

• Define aim, objectives• Budget• Skill mix• Care journeys• Location and hours etc

• Develop & assign R&R• Duty Statements• Engagement• Performance & Dev. Plan

• Discipline developed• Time Limited• Measurable

Key Elements to Change

5. Role of Team

6. Skill Development

7. Monitoring and reporting capacity

8. Stakeholder and consumer feedback

• Huddles• Rapid pace• Strong coordination• Journey Boards

• Skill gap analysis• Implement required training• Just-in-time• Procedures & Instructions

• Based on FTE• Trial and error• Staff feedback

• Formal and informal processes• Staff participation in solutions

Partnering with Stakeholders

Pre-acute Inpatient Acute Post Acute

Continuum of Care

Patient; GP;

Family/Carer

Patient; medical team; nursing; allied health; discharge planners; family/carer

Patient; Family/Carer; PACS MD Team; GP

• Preventative Care

• Prevent unnecessary ED / hospital pres.

• Disease Prevention

• LOS management

• Inpatient utilisation management

• Reduce readmissions

• Partner with long term care providers

• Standardise care

• Reduce readmissions

Stakeholders

Involved:

Care Coordination Imperatives:

Referral Management: Reduce the Blockages

• Focused on what the stakeholders required

• Seven day a week model• Minimum of information required to

produce referral• Increase skill mix (clinician)• Electronic referrals• Future electronic referral system to

enable mobile technology at the bedside

Attitude Adjustment

• Partnership with acute hospitals – we are one of the same

• Be open to (and act on) feedback

• Continuum of care• Patients who are well enough

to go home should be home• NEVER SAY NO

Demand for Service

Demand for Service April 2013 to Sept 2013

925

11331044

12881335

1589

0

200

400

600

800

1000

1200

1400

1600

1800

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13

Num

ber o

f Ref

erra

ls

Seven-Day Rostering

• Requires skill development

• Awareness of Awards

• Union agreement

• Time for managing and maintaining roster

• Building casual positions to support planned and unplanned leave

Seven-Day Rostering

• Staff involvement by: – Allowing plenty of lead in

time– Scheduling time to hear

concerns and respond to those concerns

– Support Union involvement– Where possible self

rostering approach

Getting the Skill Mix Right

• Establishment of a Coordinating Nurse Role for each shift

• Formalising the role with documented responsibilities

• Expectation of all clinical nurses to undertake task

Back up Support

• Nurse Unit Manager rotation on-call

• Nursing Director on-call

Benefits of New Model

• Team work

• Strong acceptance from partners

• Strong patient focus

• Accountability

• Adherence to LOS

• Skill development

Challenges of New Model

• Pace of work rapid

• Workload management

• Resources must match demand

• Social impacts of 7 day roster on some staff

• Recruitment of appropriately skilled staff

Lessons Learnt

• Influencing culture has been difficult – however, NEAT and NEST targets became an engagement factor between acute and post acute services

• If staff have participated in engagement processes, outcomes improve.

• Relationship building does not stop – requires energy and commitment

• Not everyone will be happy with new model

• Expect staff change over – enables recruitment of right skill mix

Lessons Learnt

• Line Manager expertise• Change management• Communication and team

engagement skills• Monitoring, supporting and

coaching• Line Manager support • Messages need to be

heard multiple times

Lessons Learnt

Questions?