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Michelle Giles - HNE Local Health Distric - The 'Ins and Outs' of Ambulatory Care: Developing a Model of Care to Improve the Clinical Journey for Aged Care Facility Residents Attending the Ambulatory Care Clinic at RNC

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Michelle Giles delivered the presentation at 2014 Transition Care Conference: Improving Outcomes for Older People. …

Michelle Giles delivered the presentation at 2014 Transition Care Conference: Improving Outcomes for Older People.

The 2014 Transition Care Conference: Improving Outcomes for Older People formed a National account of the consumers' transition care journey within the current aged care environment, highlighted new initiatives to improve TCP access and quality of care, and showcased innovative service delivery models across jurisdictions.

For more information about the event, please visit: http://www.informa.com.au/transitioncareconference14

Published in: Health & Medicine
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  • 1. The  team   Michelle  Giles,  CNC  Research   Anthony  O’Brien,  Associate  Professor,  UoN  &    HNELHD   Wendy  Pudney  Operations  Manager,  ACC   Kerry  Cooper,  CNC  Rheumatology   Linda  Ross,  CNC  Orthopaedics   Lisa  Corbett,  RN   Sushilla  Wagener,  Operations  Manager  ACC   Sheree  Cluff,  CSO,  ACC   Darran  Paul,  Facility  Manager,  Domain  Macquarie  Place   May  2014     A  PARTNERSHIP   IMPROVING  THE  TRANSITIONAL    JOURNEY   FOR  OLDER  RACF  RESIDENTS  ATTENDING   OUTPATIENT  CLINICS  AT  RNC.  
  • 2. The Research Project Developing  a  model  of  care  to  improve  the  clinical  journey  for  aged  care   facility  residents  attending  the  outpatient  ambulatory  care  clinics  at   Royal  Newcastle  Centre  (RNC).   Acknowledgements   Funded  by  a  $15,000  NSW  MOH,  NaMO  Innovation  Scholarship    
  • 3. Transitional  Care  defined   “a  set  of  actions  designed  to  ensure  the  co-­‐ordination  and  continuity  of   health  care  as  patients  transfer  between  different  locations,  or   different  levels  of  care  within  the  same  location”   (Coleman,  2003)  
  • 4. Background   • Older  population  is  increasing  (Commonwealth  of  Australia,  2010).     • Strong  agenda  to  expand  Ambulatory  Care  Services       (Health  Reform  Implementation  Taskforce,  2007).   • Literature  is  sparse  on  RACF  residents  attending  Outpatient  clinics.   • This  cohort  more  likely  to  be  in  transition  (Coleman,  2003;  Kessler  et  al,  2013,  AIHW,  2012).   • Health  care  providers  can  operate  in  isolation  (Coleman  and  Berenson,  2004)   • Good  transitional  care  reduces  risks  of  adverse  events  and  involves  careful  co-­‐ordination  and   continuity  of  healthcare  agencies  and  people  (Coleman,  2003).    
  • 5. Local Background •  Royal  Newcastle  Centre  –  A  large  tertiary  referral  facility   ACC  Staff  were  concerned  that  vulnerable  elderly  residents  were;   •  waiting  for  long  periods  for  appointments  &  ambulance  transports     without  their  medications  or  medication  details  with  no  provisions  for   nutrition  or  fluids  during  that  time.   •  attending  appointment  with  no  escorts     •  attending  appointments  with  no  paperwork  or  medical  history   They  were  also  concerned  that  the  ambulatory  care  environment  lacks   facilities  to  provide  for  quality  care  for  residents  with  mobility  and/  or   cognitive  impairment.  
  • 6. Aim To  provide  safe  high  quality  care  to  elderly  residents  and  improve  the   residents  experience  of  the  transitional  journey  to  the  ambulatory  care   centre.   To  provide  the  most  appropriate  follow-­‐up  care,   by  the  most  appropriate  provider,  in  the  most     appropriate  location.  
  • 7. Methods Design:  Mixed  Method  phased  study   Phase  I     Scoping  project  aimed  at  mapping  current  Ambulatory  Care  (AC)  journey   and  identifying  gaps  in  care  continuity  during  transitional  journey  to  and   from  the  Ambulatory  Care  Centre  (ACC)  for  residents  from  RACF’s.   Data  Collection   • iPMS  &  IMMS  database  exploration  –  6  month  period  in  2013.   • chart  audits  to  map  residents  journey  through  ACC’s   • interviews  with  residents  and  carers     • focus  groups  with  staff  from  ACC  and  RACF’s  
  • 8. Phase  II   Developing  an  integrated  patient  centred  model  of  care  to  improve  the   ambulatory  care  journey  for  residents  from  RACF.   • Collaboration  with  stakeholders  across  all  providers  and  touch  points  in   the  journey   • Model  informed  by  the  findings  from  this  study.  
  • 9. Results Outpatient  Activity     • ACC  out  patient  clinics  -­‐  there  were  42,000  appointments   made  over  a  six  month  period  and  25%  (n  =  10,468)  of   clients  were  in  the  70  years  or  older  age  group  (November   2011  to  April  2013)   • 11  to  12  thousands  episodes  of  care  monthly.   • Could  not  identify  those  from  RACF’s  on  current  iPMS  
  • 10. •  A  large  proportion  of  the  70  years  and   over  clients  are  attending      the   Orthopaedic  fracture  clinic  (n=2337)   •  often  referred  and  appointments   made  during  a  hospital  admission.   •  Mean  age  of  those  over  70  was    78   years.     •  80  plus,    n=  873   •  90  plus,  n  =  117   Orthopaedic Clinic
  • 11. Journey  mapping  
  • 12. Focus  group  and  interview  content  analysis   RACF  Staff   RACF  PATIENT  AND   CARER   ACC  STAFF   Transport     Parking   Communication   Communication   Mobility  aids   Transport     Concern  for   residents   Direction/Signage   Concern  for   residents   Appointments   Lack  of  co-­‐ordinated   Systems/Processes   Transport   Staff   Appointments   Lack  of  co-­‐ordinated   Systems  /Processes   Fear  &  anxiety   Fear  &  anxiety   Fear  &  anxiety                    Direction/Signage    
  • 13. Theme  1    “We  can  book  pa+ent  transport  2  weeks  in  advance  and  come  the   day,  you  ring  up  and  they  say,  oh  no  we  don’t  have  that  booking,  or   you  know,  they  just  don’t  turn  up,  no  phone  call  to  say  we  won’t  be   able  to  make  it  today,  can  we  make  it  another  day…”  (RACF  Staff  FG)     “…/she  came  home  with  a  sling  on  her  arm  but  how  long  do  they  want   us  to  have  it  on  –maybe  two  weeks?  With  having  this  experience  I   have  tried  to  ring  to  speak  to  someone  in  the  clinic  and  it’s  frustra+ng   for  both  par+es…”  (RACF  Staff  FG)     “I  think  one  of  the  key  issues  is  when  a  pa+ent  comes  in  with   transport  and  they  are  on  a  stretcher  and  they  are  elderly…they  oNen   don’t  have  a  carer  with  them  and  we  don’t  know  what  is  wrong  with   them.  We  don’t  know  whether  they  are  diabe+c,  we  don’t  know   whether  they  have  got  demen+a.  We  don’t  know  whether  they  can   mobilise.    You  know  we  have  got  nothing.”  (ACC  Staff  FG)     Inconsistent     and  adhoc   communication    
  • 14. Theme  2   “…they  have  to  sit  there  then  to  wait  for  an   ambulance  and  sometimes  they  can  be  getting  back   here  [RACF}  at  11pm  at  night  and  they  have  sat  there   since  their  appointment,  missed  their  dinner,  missed   their  medications,  missed  everything,  distressed  and   tired.”  (RACF  Staff  FG)     “Last  appointment  I  waited  3  hours  on  my  own  with   no  food  or  drink.  Ambulance  took  me  for  my   appointment,  took  me  to  clinic  and  booked  me  in  at   the  reception  desk…Some  ambulances  are  able  to   wait  if  I  get  straight  in  for  my  appointment  /…../  I   don’t  like  going  home  after  dark.”(Resident  interview)   Just  waiting   around  –   inconsistent  and   unreliable   transport    
  • 15. Theme  3   “…old  people  live  and  breathe  by  the  doctor  and  the  clock  so  they  are   thinking  about  if  they  are  going  to  miss  their  appointment  and  their  going   to  make  the  doctor  cross,  and  they’re  anxious  anyway  and  they  wouldn’t   have  drank  much  for  breakfast  because  they  know  they’re  going  out  and   you  don’t  want  to  be  going  to  the  toilet  because  you  don’t  know  if  you’re   going  to  be  able  to  find  a  toilet  and  so  the  beginning  of  their  dehydra+on   has  already  started  as  it  is.”    (RACF  Staff  FG)   “…they  come  back  and  are  exhausted  and  +red  and  some  of  them  have   been  crying  because  they  have  been  siRng  there  wai+ng.”  (RACF  Staff  FG)   “..yeh  sometimes  they  [residents]  come  back  with  pressure  sores,  they   come  back  with  bruises  on  their  arms,  yeh  like  really  bad,  or  they  have  had   their  arm  hit,  or  something  like  that  and  then  you’ve  got  a  skin  tear  and   you’ve  got  to  fix  it.”  (RACF  Staff  FG)   “I  have  found  that  they  [residents]  are  often  incontinent,  in  wet  clothes  or   wet  pads  and  they  have  been  sitting  in  it  all  day  because  they  haven’t  had   anyone  look  at  them.”  (RACF  Staff  FG)     Is  it  doing  more   harm  than  good  
  • 16. Theme  4   “They  need  a  suitable  facility  or  area  for  managing  demen+a  pa+ents   who  may  need  a  shower,  toile+ng  or  general  hygiene  to  allow  for   personal  care  with  privacy  and  dignity.”  (ACC  Staff  FG)     “…  even  though  there  is  disabled  parking  in  the  big  car  park  across   the  road,  they  have  to  walk  up  stairs  or  up  the  hill  to  get  to  the   hospital.  That  is  not  disabled  parking,  you  know  it  is  just  totally   inadequate  and  it  should  be  addressed”  (Carer  interview)   “Start  with  the  parking,  yep  that  is  very  difficult  at  [this  facility],  well   it  took  two  of  us,  you  can’t  go  on  your  own  you  can’t  just  ask  the   person  to  sit  and  wait  +ll  I  park.  You  have  to  go  with  two  escorts… well,  you  wouldn’t  be  able  to  leave  them  anyway  because  you  can’t   get  the  resident  out  and  sit  them  somewhere  in  case  they’re  not  there   when  you  come  back.”    (RACF  staff  FG)   No  one’s   expectations   are  being  met.    
  • 17. Where  to  from  here     • Increased  risk  to  patient  safety  –  adverse  events  –  falls,  pressure  sores,   dehydration,  distress,  increased  confusion,  delirium,  medication  omissions  or   errors.     • Increased  costs  associated  with  unnecessary  referrals  and  delayed  transport   causing  unnecessary  admissions  to  hospital.     • We  want  to  do  things  a  whole  lot  better.   • We  need  to  collaborate  and  communicate  better  
  • 18. The  Next  Phase   Developing    a  integrated  model  of  care  
  • 19. References   •  Australian Institute of Health and Welfare 2012. Residential aged care in Australia 2010–11: a statistical overview. Aged care statistics series no. 36. Cat. no. AGE 68. Canberra: AIHW. In: AUSTRALIAN INSTITUTE OF HEALTH AND WELFARE (ed.). Canberra: AIHW. •  Coleman, E. A. 2003. Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care for Persons with Continuous Complex Care Needs. Journal of the American Geriatrics Society, 51, 549-555. •  Coleman, E. A. & Berenson, R. A. 2004. Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care. Annals of Internal Medicine, 141, 533-W-99. •  Commonwealth of Australia 2010. Australia to 2050: future challenges. In: DEPARTMENT, A. G. S. (ed.). Canberra: CanPrint Communications Pty Ltd. •  Health Reform Implementation Taskforce 2007. Ambulatory and community-based care: A Framework for non-inpatient care. In: DEPARTMENT OF HEALTH (ed.). Government of WA. •  Kessler, C., Williams, M. C., Moustoukas, J. N. & Pappas, C. 2013. Transitions of care for the geriatric patient in the emergency department. Clinics in Geriatric Medicine, 29, 49-69.
  • 20. Thankyou

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