Pamela Pratt, Country Health SA Local Health Network - Strategies for Improving The Country Patient Journey


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Pamela Pratt, Country Health SA Local Health Network 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:

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Pamela Pratt, Country Health SA Local Health Network - Strategies for Improving The Country Patient Journey

  1. 1. Country Health SA Local Health Network Strategies for ImprovingStrategies for Improving The Country PatientThe Country Patient JourneyJourney
  2. 2. Pam Pratt Patient Liaison Network CoordinatorPatient Liaison Network Coordinator CHSALHN
  3. 3. Patient Journey Initiative The Patient Journey Initiative aims to improve the outcomes for people living in country South Australia needing to accesscountry South Australia needing to access health services locally, regionally & from Adelaide-based services
  4. 4. Tip of the iceberg! Inpatient services Private hospitals & services Other Health Services (Allied Health, Dental) Outpatients – Public & Private
  5. 5. Patient Journey Initiative The Patient Journey Initiative was established in 2006 with the following strategies in mind: > To reduce the number of avoidable referrals > To improve the journey for people from country S.A.
  6. 6. Patient Journey Initiative > To decrease the length of time > To improve discharge planning > To improve and develop appropriate health services and clinical networks across country South Australia
  7. 7. Key Issues Identified for Action > Referral systems and processes > Transport, accommodation and carer support services > Discharge planning from Adelaide hospitals back to Country S.A.
  8. 8. Key Issues cont. > The Patient Journey for particular groups of people from Country SA > Avoiding unnecessary journeys> Avoiding unnecessary journeys > Availability of health services in country locations > Informing consumers and carers
  9. 9. Achievements to date include Patient Liaison Network established The CHSA Patient Liaison Nurse (PLN) role at Country hospital sites formally began in 2007 Rural Liaison Nurses at major metropolitan public hospitals Patient Liaison Network Forum
  10. 10. Benefits of a Liaison Role > Coordination > Linking points of care > Central Contact > Improved discharge planning > Improved understanding > Improved patient outcomes
  11. 11. Country Health SA Nursing and Midwifery Transfer Form (Used when transferring to a metropolitan health unit, another country health unit or residential care facility)
  12. 12. Achievements to date include Country Home Link (CHL) Rapid Intensive Brokerage Scheme (RIBS) Hospital avoidance program Transitional Care Package (TCP)
  13. 13. Health Literacy Resources Available on the CHSALHN Web site
  14. 14. Aboriginal Patient Journey Resource
  15. 15. Step Down Services Enhancement of Step Down services at Port Augusta and Ceduna
  16. 16. Port Augusta Step Down Unit
  17. 17. Patient Liaison Network Coordinator Provide corporate support services to the Patient Liaison Network Metropolitan/Country Patient Flow NetworkMetropolitan/Country Patient Flow Network Central contact Referral point Coordination
  18. 18. Pulmonary Rehab Program The following locations established pulmonary rehab programs during 2011: • Mount Gambier • Millicent • South Coast (Victor Harbor)• South Coast (Victor Harbor) • Mount Barker • Wallaroo • Murray Bridge • Port Augusta • Port Pirie • Port Lincoln • Whyalla
  19. 19. Cardiac Rehabilitation Programs The following locations have established cardiac rehabilitation programs: • Mount Gambier • South Coast (Victor Harbor) • Mount Barker• Mount Barker • Wallaroo • Murray Bridge • Port Augusta • Port Pirie • Port Lincoln • Whyalla • Berri • Gawler
  20. 20. Achievements to date include GP Plus Services (out of hospital /primary care services) Better Care FacilitationBetter Care Facilitation Rehabilitation Services Cancer Services
  21. 21. Achievements cont. Alternatives to travelling to access Health Services > Telemedicine / IT solutions > Digital radiology services> Digital radiology services > Expand advanced care/extended care roles in country SA
  22. 22. Health Diaries Folder for adults with chronic and/or complex health conditions to use to better manage their health
  23. 23. Patient Journey Communiqué
  24. 24. Patient Journey Storybook
  25. 25. Operational Business Intelligence (OBI) Dashboard SA Health completed the work to develop and implement a near to real time ‘dashboard’ in the areas of inpatients, emergency departments and elective surgery across all metropolitan hospitals
  26. 26. Country Patients in Metro Information available about country inpatients in metropolitan hospitals Country patients are ‘flagged’ at broadCountry patients are ‘flagged’ at broad category level Access to patient lists/names was restricted Patient Liaison contacts in country hospitals
  27. 27. Country Patient Lists
  28. 28. Advantages of OBI Dashboard  Quick and easy to use  Improves Communication  Monitor patients Progress  Commence Discharge Planning Home  Decrease occupied Bed Days!!!!
  29. 29. Good News Story Allied Health workers identified known local clients Negotiated direct transfer home Confirmed home assessment andConfirmed home assessment and modifications were completed Better client outcome (Clinical Liaison Nurse/ Hospital in the Home Coordinator, Port Pirie Regional Health Service)
  30. 30. Good News Story Contacted patient having elective surgery in Metro Discharge himself against medical advise Post op complications - staying longerPost op complications - staying longer Remained for extra days required then discharge (Patient Liaison Officer, Kangaroo Island Health Service)
  31. 31. OBI Dashboard The OBI Dashboard has proven to be an excellent resource for country hospitals to allow viewing of local patients in metro, monitoring of their progress and initiatingmonitoring of their progress and initiating transfers back
  32. 32. Overnight SA Country Patients in Metropolitan Hospitals Total Overnight Country Patients in Metro 28000 Separations 23000 24000 25000 26000 27000 28000 2009 2010 2011 2012 2013
  33. 33. SA Country Patients Transfer Summary Transfer Summary 3000 3500 4000 4500 0 500 1000 1500 2000 2500 3000 Country to Metro Metro to Country 2009 2010 2011 2012 2013
  34. 34. Right care, right team, right time and right place