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  • 1. Eastern Health’s Ambulatory and Community Services Program Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  • 2. Eastern Health • 2nd largest health service in Victoria • The largest geographical area (2,816 square kilometres over six shires) • 750,000+ residents (2011 Census) • Public health services to an additional 400,000+ people from neighbouring shires • 8,400+ employees
  • 3. Eastern Health Sites Over 50 facilities including: • Hospitals  Angliss Hospital  Box Hill Hospital • Healesville & District Hospital  Maroondah Hospital • Peter James Centre • Wantirna Health • Yarra Ranges Health • Residential care facilities • Edward Street (Upper Ferntree Gully) • Monda Lodge (Healesville) • Mooroolbark • Northside (East Burwood) • Community-based facilities • Multiple community-based rehabilitation, mental health, drug and alcohol and transition care facilities • • • • • • • • • • • • • Mental health facilities South Ward (Peter James Centre) Upton House (Box Hill Hospital) Inpatient units 1 and 2 (Maroondah Hospital) Adolescent Inpatient unit (Box Hill Hospital) Prevention and Recovery Care (PARC) Centres (Box Hill and Ringwood East) Community care units (Camberwell, Ringwood East) Community Health Service Yarra Valley Community Health Statewide Services Spectrum Borderline Personality Disorder Service Turning Point Alcohol & Drug Centre Wellington House
  • 4. Bed Numbers • A total of 1266 beds, comprising: – 711 hospital beds for patients staying longer than one day – 150 hospital beds for patients staying less than one day – 117 beds for people who need mental health services in hospital – 120 beds for residential care clients – 74 beds for people who need mental health services in a community-based setting – 94 beds for people requiring transition care 2012-2013
  • 5. Background Structure prior to 2009: • “Outer East” and “Central East” • Site specific programs including Hospital in the Home, Allied Health and Ambulatory, Community Health • Restructure in 2009 with new CEO - “Eastern Health in name, thinking and service delivery” • 8 Directorates including Acute Health, Access and Support Services and Continuing Care Community and Mental Health • 2010 Ambulatory Services and Community Services - separate programs • Aligned to create Ambulatory and Community Services (ACS) Program in 2012
  • 6. Streams of Care within ACS from 2012 Executive Director Continuing Care Community and Mental Health Director of Nursing Ambulatory and Community Services Associate Program Director Ambulatory and Community Services (Eastern@Home and Aged Care) Program Director Ambulatory and Community Services Executive Clinical Director Ambulatory and Community Services Associate Program Director Ambulatory and Community Services Associate Program Director Ambulatory and Community Services (Health Independence and Community Access) (Chronic Care & Wellbeing and Community Health)
  • 7. Eastern@Home and Aged Care • • • • • • • HITH Eastern Residential InReach ACAS Rapid Outreach Response (HARP) TCP Complex Care Clinic GEM@Home
  • 8. GEM@Home • Integrated care for older people with multiple and complex health care needs who can be managed at home • Alternative to an inpatient GEM admission • Geriatrician-led 4 week program • Interdisciplinary (Nurse, SW, OT, PT) • Functional goals • Works closely with ACAS, Rapid Outreach Response, Complex Care Clinic, HARP
  • 9. Health Independence and Community Access • Community Rehabilitation • Pulmonary, Cardiac Phase 2, Heart Failure, Oncology Rehabilitation • Specialist Clinics • VPRS • Early Supported Discharge for Stroke • Community Access Unit
  • 10. Chronic Care & Wellbeing and Community Health • • • • • • HARP Advance Care Planning GP Liaison Aboriginal Health ECASA Community Health – (community and acute-based)
  • 11. ACS • 396EFT (nursing, allied health) • Situated across all EH acute and subacute sites • 2012-2013 activity: – 176,637 SACS, HARP, RIR contacts – 2,806 completed episodes – 22,364 HITH bed days (ALOS 8.7)
  • 12. Primary Aims of ACS • Improve patient flow • Ensure equity of access • Provide a flexible response to service demand • Support workforce development • Support GP engagement, shared care and care planning • Encourage health self-management
  • 13. • Support consumer engagement • Promote a safe, consumer-focused alternative to inpatient care (Eastern@Home) • Align with Department of Health policy direction • Align with Eastern Health strategic plan and program structure
  • 14. Ambulatory-Sensitive Conditions • Hospitalisation considered potentially avoidable • Admission risk identification • Chronic/complex needs • Early stage preventive care • Early disease screening/management • Substitution/diversion strategies
  • 15. • The most common ambulatory-sensitive conditions for Eastern Health are: – Diabetes complications – Congestive heart failure – Pyelonephritis – Respiratory (asthma/COPD) – Ear, nose and throat infections – Influenza and pneumonia
  • 16. ACS Principles • • • • • • • Substitution / diversion Care co-ordination Clear communication Collaborative goal setting Health self-management Health coaching Seamless transitions
  • 17. • • • • • • Transparency Family involvement Equity of access Evidence based Skilled workforce Innovation
  • 18. Two major improvements were sought: • Shift the equivalent of 30 inpatient beds to Eastern@Home (Hospital in the Home) • Develop integrated Ambulatory and Community Care pathways to support diversion, substitution and end of life care
  • 19. The Eastern@Home experience • • • • • • • Creating Eastern@Home 2010 Hospital in the Home (HITH) Residential InReach (RIR) Benchmarking Expenditure and length of stay Internal audits Clinical Services Plan 2022
  • 20. Who can access Eastern@Home (HITH)? Any public patient of the 52 participating hospitals who is: • assessed as being clinically stable for an at-home “admission” • appropriately supported in the home, i.e. presence of a carer or support person • living in a suitable environment, with access to a telephone • consent to be treated by HITH • suitable for HITH treatment and meets diagnostic criteria http://www.health.vic.gov.au/hith/
  • 21. Who can access Eastern@Home (Residential InReach)? • • • • • • Any patient residing in a residential care facility Consent via self or guardian Requires engagement of GP and facility staff Medical and nursing support Assists with avoidable hospital presentations Links with HARP, Complex Care Clinic
  • 22. Eastern Health context
  • 23. Eastern Health context
  • 24. Percentage of growth: 9.31% Year 1: Sept 2010 – Aug 2011 Year 2: Sept 2011 – Aug 2012 11.08% 31.95% 58.34%
  • 25. • Variance % 100% 164% 474% 218%
  • 26. Eastern@Home (HITH) overnight occupancy timeline – peaks and troughs
  • 27. Eastern@Home (HITH) same day timeline
  • 28. Eastern@Home: Residential InReach winter response • Extended hours of service • Targeted strategy: gastro and pneumonia • Hourly rounding to identify deterioration / end of life care • Pathway development with Ambulance Victoria - ongoing
  • 30. Referrals received
  • 31. Average referrals per day
  • 32. Referral source
  • 33. ACS Referral Sources • • • • • • • • • Emergency Departments Acute medical Acute surgical Sub-acute General Practitioners Residential Care Facilities Self Other Hospitals Community Providers
  • 34. How did we do in HITH? Victorian PRISM report – 2nd Quarter • HITH multiday separations increased by 51.7 % • HITH multiday bed days increased by 53.6 % • Multiday HITH % separations increased by 2.6 % • Multiday HITH % of bed days increased 3.7 % Largest growth in state for this period Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  • 35. Improving patient outcomes and access to emergency care for older people from Residential Aged Care Maryann Street,1 Julie Considine, 1 Goetz Ottmann, 2 Patricia Livingston, 1 Bridie Kent, 1,3 Health – Deakin University Nursing and Midwifery Research Centre 2 Uniting Care Community Options / Deakin University Research Partnership 3 Plymouth University, Plymouth, United Kingdom. 1 Eastern
  • 36. • • • • 140,000+ visits to EH EDs in 2010-2011 23% 65+ 3.4% from RACF 9,500 aged care beds with catchment
  • 37. • Aim: Identify impact of Residential InReach and HITH on ED presentations from RACFs before 2009 and after 2011 • Retrospective cohort study • Primary outcome LOS in ED • Secondary outcomes presentations, representations and admission rate
  • 38. Transfers and Re-presentations within 6 month period 2009 2011 p value 2009 2011 P value Transfers from Residential Aged Care to ED N(%) 2278 (3.6%) 2051 (3.1%) 0.001 Patients with more than one visit N (%) 1002 (44%) 307 (15%) 0.001 Patients with 4 or more visits 2.6% 0.7% 0.001 Maximum ED visits for any patient in 6 months 12 5
  • 39. Conclusions • Average stay in ED for people from RACFs was reduced by 40 minutes compared to 2009 • There were less transfers and re-presentations to ED by people from RACFs • Fewer people were admitted to hospital and the length of stay in ED for admitted patients decreased significantly
  • 40. Integrated Service Delivery • ‘No Wrong Door’ integration across ACS: – HARP and RIR – HARP and HITH – HARP allied health and HITH, RIR – SACS allied health and PAC – GEM@Home, Complex Care Clinic, HARP – TCP and others – ASERT …
  • 41. Development of Ambulatory and Subacute Early Response Team (ASERT) GREAT CARE EVERYWHERE – Getting it Right Upfront (GIRUF) Redesign 2012 Series of workshops focusing on GIRUF conducted between Acute, Subacute and Ambulatory & Community Services.
  • 42. Improvement needs identified via GIRUF workshops • Access to subacute, ambulatory and community services • Transparency of waitlists • Sorting and streaming to the most appropriate location of care
  • 43. The ASERT TeamA Multidisciplinary Approach • Post Acute Care • Access Liaisons • Complex Care Team (Aged Care Nurse Consultants) • HARP • Medical / Geriatricians • Palliative Care Consult Team • ED Care Coordination
  • 44. Proposed ASERT reporting structure and relationship to support teams GP Liaison ACP GEM@Home ESSD Continuing Care ASERT Specialist Medical Consults: Rehab / Pall Care / GEM Inpatient Medical / Nursing Palliative Care Consult ASERT Hosp Adm Risk Program INTAKE ASERT Ambulatory Access Liaison ASERT Ambulatory and Community Services Operations and Development Manager Access Aged Care Assessment Services (ACAS) Hospital Liaison ED Care Coordination Angliss ASERT ED Care Coordination Box Hill Maroondah Eastern @ Home Complex Care / Aged Care Consult ASERT Post Acute Care ASERT Inpatient Allied Health Transition Care Program
  • 45. ASERT • Service improvement strategy: – a single point of contact to access subacute and ambulatory and community services – reduction in waste and unnecessary duplication – streamlining of systems and processes such as referral / intake, needs identification, waitlisting and service provision.
  • 46. • Improved outcomes for clients: – Equitable access to the right service to best meet patients’ individual care needs – Improved continuity of care for patients and their families / carers – Improved timeliness and communication of care needs.
  • 47. ASERT provides: • a streamlined, timely and coordinated response for patients needing subacute, ambulatory or community services • a subacute/Ambulatory and Community Services care plan that ensures the patient has the right care at the right place and at the right time
  • 48. • ASERT does not take over the discharge planning role from the Ward/ED Team • It does assist and work with the ward team to facilitate and identify the discharge plan for patients.
  • 49. Patient Flow Manager (PFM) • PFM upgrades across the network • Ward teams will be able to flag ASERT via PFM • Once flagged this will be pulled into the ASERT Team handover and the team will respond
  • 50. Advance Care Planning Increased number of completed Advance Care Plans (2012-13) Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  • 51. • Integrated service delivery: Advance Care Plans for Eastern Residential InReach clients - benchmarked with other services Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  • 52. • A snapshot audit of compliance to plans April – June 2013 demonstrated 94% compliance • Consumer and staff feedback is consistently positive • ACP is integrated into the inpatient assessment process, and is operational within the Transition Care Program, Hospital Admission Risk Program and Eastern Residential InReach, within the community • Future areas under development Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
  • 53. Some Key Initiatives • The Eastern@Home model • Flexible and integrated service delivery – consumer focus • Clinical governance • Redesigning intake for ease and equity of access: – ASERT - identifiable team / criteria led pull • Fast track pathways (orthopaedic) and stroke (ESD) • Non-admitted GEM@Home (linked to HARP / ACAS)
  • 54. • No waitlist for community rehabilitation services • NHS Productive Community Services • Medicare Locals – telemedicine pilot in residential facilities; after hours GP services • TCP inhouse • Engagement of an Eastern Health GP
  • 55. Where to next? • Enhancing clinical governance to support an evolving model of care • Strategic opportunity with the new BHH redevelopment and the potential of a co-located space in the ED to support NEAT • Redesign project objectives: • Integrated ACS complex care plan • ASERT implementation with PFM
  • 56. Where to next? • Point Prevalence audit – E@H • Expand aged services in the home via an integrated model of care encompassing Rapid Outreach Response (HARP Aged) / Residential InReach and GEM@Home • Enhance interface with Ambulance Victoria and Medicare Locals • GP Liaison opportunities
  • 57. Issues Faced (and beaten?) • Poor understanding of potential for Ambulatory and Community Services as a viable option for a true substitution/diversion model • Lack of trust to support a comprehensive shift from inpatient care to community-based care
  • 58. Recommendations • Leadership from the CEO / Executive and throughout the organisation is imperative • An integrated Ambulatory and Community Services Program facilitates service delivery to meet consumer needs • Integrated planning approach (Redesign principles) before the implementation of new initiatives • Commitment to resolve any issues as they arise in partnership • Implement strategies to support care in the community – clinical governance of ambulatory and community services: readmission rates – lessons learnt • Culture of continuous review and actions focus – What else can we do? What can we do differently?