Metro North Hospital and Health Service
Acuity Measurement of the
Post Acute Client:
Enabling Prioritisation for
Service R...
Metro North Hospital and Health Service
Metro North Hospital
and Health Service
• 850,000 population
• 4,157 square kilome...
Metro North Hospital and Health Service
Objectives of Presentation
• Overview Post Acute Care Service
• Background
• Descr...
Metro North Hospital and Health Service
Brief Overview PACS
• 7 day per week post acute
hospital avoidance
• ED or admitte...
Metro North Hospital and Health Service
PACS
• Service linkages
• High risk for
representation /
readmission
• Support acu...
Metro North Hospital and Health Service
PACS
• Average LOS 14 days
• Average Age 80-89 years
• 55% Female
• Average will r...
Metro North Hospital and Health Service
Background
• 2013 underwent extensive service
redesign
• From HACC and Chronic Dis...
Metro North Hospital and Health Service
Background cont…
• Literature review identified:
– no published evidence (Aust)
– ...
Metro North Hospital and Health Service
Case Management Acuity Tool
• Developed by Hubber, D.L. and Craig,
K. (2007) for u...
Metro North Hospital and Health Service
Acuity Tool Development
• Literature review
• Gap analysis
• Clinical experts moni...
Metro North Hospital and Health Service
Why the Need for an
Acuity Tool?
• Providers of clinical services are
required to ...
Metro North Hospital and Health Service
Acuity Tool
The Acuity Tool:
• Quantifies a client’s complexity (or acuity).
• Lin...
Metro North Hospital and Health Service
What does the CM-Acuity Tool
Measure?
• Dosage
• Acuity
Metro North Hospital and Health Service
Dosage
• Dosage – two main variables:
– The activities carried out by the provider...
Metro North Hospital and Health Service
Dosage cont…
• The four essential elements of
intervention dose are:
– Amount
– Fr...
Metro North Hospital and Health Service
Acuity
• Defined as severity of illness or
client condition that indicates the
nee...
Metro North Hospital and Health Service
Case Management – Acuity Tool©
• The Acuity Tool©: contains indicator,
drivers and...
Metro North Hospital and Health Service
Acuity Tool
• April 2014 – permission from author to
implement tool with minor mod...
Metro North Hospital and Health Service
Metro North Hospital and Health Service
Metro North Hospital and Health Service
Metro North Hospital and Health Service
IncreasingComplexity
Metro North Hospital and Health Service
2 1 2
5
Metro North Hospital and Health Service
2 1 2
5
Metro North Hospital and Health Service
Acuity
Score
Complexity
Score
Priority
Score
3-4 Basic 1
5-6 Good 2
7-8 Fair 3
9-1...
Metro North Hospital and Health Service
Initial Implementation
• Ease of use
• Quick to use (approximately 1-3 minutes)
• ...
Metro North Hospital and Health Service
Test Inter-rater Reliability
• 32 inpatients (RBWH) were assessed prior to
dischar...
Metro North Hospital and Health Service
How has PACS used the Acuity
Tool?
The acuity tool has enabled the Service to:
• C...
Metro North Hospital and Health Service
Case Study - Molly
Metro North Hospital and Health Service
Molly
• Molly 93 year old female
• Presented to ED after fall – large skin
tear on...
Metro North Hospital and Health Service
Molly cont…
• Home had numerous trip hazards
• Not using previously prescribed mob...
Metro North Hospital and Health Service
Metro North Hospital and Health Service
Clinical
Indicators
Psychosocial
Indicators
Environmental
Indicators
CN4
Multiple ...
Metro North Hospital and Health Service
Molly cont…
Over 2 week journey Molly had assistance with:
• Showering and wound c...
Metro North Hospital and Health Service
Metro North Hospital and Health Service
Clinical
Indicators
Psychosocial
Indicators
Environmental
Indicators
CN3
Multiple ...
Metro North Hospital and Health Service
Evaluation
• Data capture commenced April 1, 2014
• Only those patients who had co...
Metro North Hospital and Health Service
Characteristics Number
Total sample size 765
Female 445
(58%)
Male 320
(42%)
Age r...
Metro North Hospital and Health Service
Comparison of Admission and Discharge Acuity Scores.
N=765
0
20
40
60
80
100
120
1...
Metro North Hospital and Health Service
Grouped Acuity Scores on Admission and Discharge
472
(62%)
595
(78%)
293
(38%)
169...
Metro North Hospital and Health Service
Acuity > 7 by Age Group on Admission and Discharge
109
(63%)
152
(64%)
32
(62%)
65...
Metro North Hospital and Health Service
Lesson’s Learned
• Sub drivers not always clear for all
disciplines (including wou...
Metro North Hospital and Health Service
Recommendations
• Conduct further research on the
reliability and validity of the ...
Metro North Hospital and Health Service
Thank You
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Kim Fraser, Metro North Hospital and Health Service, Queensland - Acuity Measurement of the Post-Acute Client- Enabling Prioritisation for Service Response

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Kim Fraser, Nursing Director, Post-Acute Care Service, Subacute and Ambulatory Services, Metro North Hospital and Health Service, Queensland delivered the presentation at the 2014 Discharge Planning Conference.

The 2014 Discharge Planning Conference - Assisting health services to adopt an integrated and consumer directed approach to discharge planning.

For more information about the event, please visit: http://bit.ly/dischargeplan14

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Kim Fraser, Metro North Hospital and Health Service, Queensland - Acuity Measurement of the Post-Acute Client- Enabling Prioritisation for Service Response

  1. 1. Metro North Hospital and Health Service Acuity Measurement of the Post Acute Client: Enabling Prioritisation for Service Response Kim Fraser Nursing Director Post Acute Care Service Sub Acute and Ambulatory Service Metro North Hospital and Health Service
  2. 2. Metro North Hospital and Health Service Metro North Hospital and Health Service • 850,000 population • 4,157 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.
  3. 3. Metro North Hospital and Health Service Objectives of Presentation • Overview Post Acute Care Service • Background • Description of the Acuity Tool • Rationale for use of Acuity tool • Case study • Results of initial implementation • Recommendations
  4. 4. Metro North Hospital and Health Service Brief Overview PACS • 7 day per week post acute hospital avoidance • ED or admitted patient. • Short term MD interventions to address immediate care needs • Rapid response
  5. 5. Metro North Hospital and Health Service PACS • Service linkages • High risk for representation / readmission • Support acute facilities in meeting NEAT / NEST • Average 620 referrals per month
  6. 6. Metro North Hospital and Health Service PACS • Average LOS 14 days • Average Age 80-89 years • 55% Female • Average will require 2.5 disciplines • Inpatient DRG: – Hip replacement with complexity – COPD – Rehabilitation – Patient > 64 years with injuries
  7. 7. Metro North Hospital and Health Service Background • 2013 underwent extensive service redesign • From HACC and Chronic Disease service to a rapid response post acute service • Review of national and international literature on PAC models identified the value of acuity measures
  8. 8. Metro North Hospital and Health Service Background cont… • Literature review identified: – no published evidence (Aust) – 2 published acuity tools (UK and Nth America) – UK tool lacked reliability; resource intensive; not developed for the MD team
  9. 9. Metro North Hospital and Health Service Case Management Acuity Tool • Developed by Hubber, D.L. and Craig, K. (2007) for use within a telephonic chronic disease case management health service • Captures the evidence base of case management activities and measures case management outcomes
  10. 10. Metro North Hospital and Health Service Acuity Tool Development • Literature review • Gap analysis • Clinical experts monitored development and testing of the tool, concepts, scores, differentials and their operating principles • Pilot phase testing (n = 3,000) – interrater reliability testing and content validity • (β) testing for content and appropriateness • Representative sampling size testing • Expert panel reviews
  11. 11. Metro North Hospital and Health Service Why the Need for an Acuity Tool? • Providers of clinical services are required to demonstrate value. • What benefits are achieved beyond the traditional measurements of cost savings or cost avoidance? • How do we measure, compare and then evaluate interventions as to their effectiveness and cost?
  12. 12. Metro North Hospital and Health Service Acuity Tool The Acuity Tool: • Quantifies a client’s complexity (or acuity). • Links duration, quality, quantity and volumes of health care interventions required. • Provides a quantifiable indicator of measurement which can be applied across care points in time from admission to discharge.
  13. 13. Metro North Hospital and Health Service What does the CM-Acuity Tool Measure? • Dosage • Acuity
  14. 14. Metro North Hospital and Health Service Dosage • Dosage – two main variables: – The activities carried out by the provider in the delivery of the intervention – The amount of time these activities take • These variables do not capture the complexity of interventions or complexity of client needs
  15. 15. Metro North Hospital and Health Service Dosage cont… • The four essential elements of intervention dose are: – Amount – Frequency – Duration – Breadth (Huber et al., 2003) • Too much or too little of a dose may result in harm; inefficiency and ineffectiveness
  16. 16. Metro North Hospital and Health Service Acuity • Defined as severity of illness or client condition that indicates the need for intensity of the interventions • Acuity links duration, quality, quantity and volume to key points of service delivery. • Intensity is a term related to acuity that represents the amount of care and complexity of care needed by the patient.
  17. 17. Metro North Hospital and Health Service Case Management – Acuity Tool© • The Acuity Tool©: contains indicator, drivers and subdriver categories. The three indicators take the form of: • Clinical Indicators • Psychosocial indicators • Environmental indicators
  18. 18. Metro North Hospital and Health Service Acuity Tool • April 2014 – permission from author to implement tool with minor modifications. • Tool within Australian context renamed: • Concise Acuity Tool for Australian Healthcare©
  19. 19. Metro North Hospital and Health Service
  20. 20. Metro North Hospital and Health Service
  21. 21. Metro North Hospital and Health Service
  22. 22. Metro North Hospital and Health Service IncreasingComplexity
  23. 23. Metro North Hospital and Health Service 2 1 2 5
  24. 24. Metro North Hospital and Health Service 2 1 2 5
  25. 25. Metro North Hospital and Health Service Acuity Score Complexity Score Priority Score 3-4 Basic 1 5-6 Good 2 7-8 Fair 3 9-10 Moderate 4 11-12 Highest 5
  26. 26. Metro North Hospital and Health Service Initial Implementation • Ease of use • Quick to use (approximately 1-3 minutes) • High clinician engagement • Ability to predict workload capacity • Ability to predict patient flow problems • High scores reflect high complexity • High scores reflect high risk for rehospitalisation • Sub-drivers not sensitive enough for some disciplines
  27. 27. Metro North Hospital and Health Service Test Inter-rater Reliability • 32 inpatients (RBWH) were assessed prior to discharge • 29 patients assessed on admission to PACS • Minimal divergence of scores (from hospital to home) • Higher the score the higher the complexity and the higher the risk of representation/readmission
  28. 28. Metro North Hospital and Health Service How has PACS used the Acuity Tool? The acuity tool has enabled the Service to: • Capture client acuity scores on admission and discharge • Analyse and compare acuity scores from admission and discharge In the future the tool will assist with: • Determining capacity and flow processes • Predict workload allocation accurately
  29. 29. Metro North Hospital and Health Service Case Study - Molly
  30. 30. Metro North Hospital and Health Service Molly • Molly 93 year old female • Presented to ED after fall – large skin tear on leg, bruising and black eye • MMSE 23/30 • History - Parkinson’s, multiple falls in past 3/12, family noticing changes and concerned • Lives alone, has no services and resistant to services • High risk of representation/readmission to ED • Referred for medication supervision, wound care, home safety assessment, mobility assessment
  31. 31. Metro North Hospital and Health Service Molly cont… • Home had numerous trip hazards • Not using previously prescribed mobility aids (stick and frame) • Unsure of medications and their use - non adherence to medication regime • Family supportive – not wanting to be a burden on them • Required support with personal hygiene • MST score = 3 (irregular eating patterns)
  32. 32. Metro North Hospital and Health Service
  33. 33. Metro North Hospital and Health Service Clinical Indicators Psychosocial Indicators Environmental Indicators CN4 Multiple S&S requiring MD intervention PS3 Minimal adherence to care plan – does not accept advice for safety or use prescribed walking aids Q3 Substantial improvements required for safety Admission Score 4 Admission Score 3 Admission Score 3 Total Admission Acuity Score = 10 Complexity Score = Moderate Priority Score = 4
  34. 34. Metro North Hospital and Health Service Molly cont… Over 2 week journey Molly had assistance with: • Showering and wound care • Medication review and education – Webster pack • OT and PT intervention – education on use of frame and stick – modifications to bathroom • Dietitian review of weight loss and education – high protein drinks • SW assisted with family and client education in relation to future care needs • Liaison with GP re Molly’s care needs and MMSE score (Molly refused referral to Memory Clinic) • Agreed to some community supports: – NGO for ongoing nursing support and personal care – Meals on Wheels
  35. 35. Metro North Hospital and Health Service
  36. 36. Metro North Hospital and Health Service Clinical Indicators Psychosocial Indicators Environmental Indicators CN3 Multiple S&S requiring support from one discipline (or minor interventions from other disciplines) PS2 Mostly cooperative and adhering to care plan – may occasionally forget medication Q3 Minimal modifications required for safety A = 4 D = 3 A = 3 D = 2 A = 3 D = 2 Total Admission = 10 Complexity = Moderate Priority = 4 Total Discharge = 7 Complexity = Fair Priority = 3
  37. 37. Metro North Hospital and Health Service Evaluation • Data capture commenced April 1, 2014 • Only those patients who had completed their journey of care (and had a discharge acuity score recorded) by June 30, 2014 were included in sample. • Sample size = 765
  38. 38. Metro North Hospital and Health Service Characteristics Number Total sample size 765 Female 445 (58%) Male 320 (42%) Age range 24 - 102 Average age 74 years Range of Acuity scores 3 - 12 Mean Acuity score on admission 6 Mean Acuity score on discharge 4 Demographics
  39. 39. Metro North Hospital and Health Service Comparison of Admission and Discharge Acuity Scores. N=765 0 20 40 60 80 100 120 140 160 180 3 4 5 6 7 8 9 10 11 12 Acuity Score NumberofClients Admission Acuity Discharge Acuity
  40. 40. Metro North Hospital and Health Service Grouped Acuity Scores on Admission and Discharge 472 (62%) 595 (78%) 293 (38%) 169 (22%) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Admission Discharge NumberofClients Acuity Score 7-12 Acuity Score 3-6
  41. 41. Metro North Hospital and Health Service Acuity > 7 by Age Group on Admission and Discharge 109 (63%) 152 (64%) 32 (62%) 65 (37%) 85 (36%) 20 (38%) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 24-60 61-80 81-102 Age Group Percentage Discharge Admission
  42. 42. Metro North Hospital and Health Service Lesson’s Learned • Sub drivers not always clear for all disciplines (including wound clinic) – requires further work • Repeat reliability and validity studies within the post acute setting • Engagement from staff of the process and the tool has been positive
  43. 43. Metro North Hospital and Health Service Recommendations • Conduct further research on the reliability and validity of the tool • Apply the tool to E-Referral process – which will enable discharge planners to assess acuity and drive a priority response from the acute setting • Electronic solution to enable the ‘live’ display of team and discipline acuity scores (assist in resource distribution)
  44. 44. Metro North Hospital and Health Service Thank You

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