AcknowledgementsKim Field, Director Primary and Community Health (Sponsor).Alison Zecchin, Director of Nursing and Midwifery, NSAHS (Sponsor and Steering Committee Chair).Gayle Mortimer, Area Director Chronic Disease (Steering Committee).Frances Tolliday, Director of Allied Health (Steering Committee).Linda Wadsworth, Director of Nursing and Midwifery, Primary and Community Health, NSLHD (Steering Committee).Jairo Herrera, Manager, APAC (Steering Committee).Staff and Patients of RNSH, APAC, and Health Contact Centre.

ConclusionGiven the broad scope of our project, change would not have been possible nor sustainable if undertaken in isolation. Fortunately during the course of our project we were able to proactively capitalise on a number of relevant concurrent initiatives. These included:• Accreditation at RNSH, driving best practice in transfer of care processes.• The Whole of Hospital Journey Board Program ensuring effective

communication within the in-patient multidisciplinary teams.• APAC Emergency Department Trial in-reaching to ED to identify patients

better managed at home.

Seamless transitions are only possible when there is a shared commitment between Acute and P&CH for a robust, co-ordinated, and flexible approach to the transfer of care process.

While the positive trends evident across all our objectives are very encouraging, the greater achievement has undoubtedly been the overarching recognition by Executive, both Acute and Community, of the need to work collaboratively in all transfer of care initiatives.

ObjectivesIncrease the identification of potential patients requiring P& CH services at RNSH by 40% by December 2014.

Baseline : use of “Transfer of Care Risk Assessment Tool”-currently 0%.

Implement an improved referral process for the transfer of patient information to P&CH services from RNSH via the

HCC by December 2014. Baseline: use Patient and Staff Satisfaction Survey.

Increase the number of patients being referred to APAC services from RNSH via HCC by 10% before December

2014. Baseline: 1025 patients [2013]- Target: 1127 [2014].

GoalTo streamline access to Primary & Community Health Services (P&CH) for those patients being transferred home from the Royal North Shore Hospital (RNSH) via the Health Contact Centre (HCC).

Diagnostics: Key FindingsPatient Tracking:

• 44% were offered a community service on transfer.• 87% had no Transfer of Care Risk Screen .• 72% of patients had 2 or more co morbidities.• 40% of patients had a discharge diagnosis vastly more complex

than admission diagnosis.

Staff Interviews and Focus Groups:• 88% of staff interviewed unsatisfied with referral process via HCC.

“too many phone calls, time consuming, unprepared for handover, clinical judgement questioned and no feedback.”

• 69% of staff interviewed unaware of the range and availability of Primary Health and Community (P&CH) services.

Patient Surveys:• 73% were very happy with transfer process.• 13% confused by the current transfer process.• 15% may have benefited from a P&CH service if it

had been offered.

Referral Numbers:Significant fluctuation in referral numbers to APAC only over the last 12 months. This was not evidenced in any of the other services mapped.

Tag Along HCC & RNSH:This identified a complex referral process at the HCC complicated by duplication, multiple phone calls and limited technology.

Mapping of Services:This identified that daily multidisciplinary team (MDT) meetings provide the mechanism for generating referrals to P& CH services. Effective referrals often rely on face to face communication with the representatives from individual services who identify potential recipients for their service.

Planning & Implementing Solutions

Seamless Transitions : The Pathway Home

Paula Harman, Melissa Christiansen & Louise BayliffeDischarge Planning CNC, RNSH; APAC, Hospital Liaison, RNSH; Occupational Therapist, RNSH

Case for changeThe current process for the transfer of patient information from RNSH to P&CH via the HCC is time consuming, fragmented and inconsistent, diverting clinical care away from inpatients and increasing the likelihood of an extended length of stay.

MethodClinical Redesign Methodology was utilised throughout the project . The diagnostic process involved extensive stakeholder consultation working closely with patients and staff at the ground level to identify key issues and their root causes.

Data was collected using a variety of methods:

Patient Tracking Staff Interviews Patient Surveys Ward Focus Groups

(n= 276) (n= 25) (n= 15) (n=6)

Tag along with Staff (HCC) Process Mapping Literature Search

Sustaining change

ContactPaula Harman Discharge Planner RNSH Ph: 0422 006 571

Melissa Christiansen APAC: Hospital Liaison RNSH Ph: 0430 126 261

Louise Bayliffe Occupational Therapist Ph: 0413 733 662

Results1. IDENTIFICATION OF POTENTIAL PATIENTS

REQUIRING P&CH SERVICES• Transfer of Care Risk Screening (TCRS)/ Discharge Check List Tools

tested in AAU; 81% pts through AAU are screened for P&CH services using TCRS; 100% pts have completed Discharge Check List.

• Updated Discharge Planning: Transfer of Care Resource ManualHard copy and electronic version now available on allward areas.

• Updated Transfer of Care Patient Information Brochure.

• Development of the APAC LIAISON ROLE to include attendance at daily Board Rounds and the facilitation of referrals to APAC.

2. IMPROVED REFERRAL PROCESS TO P&CH SERVICES VIA HCC

• Negotiated more visible APAC Hospital Liaison role. • Poster “How to Refer to APAC” produced and displayed in all

inpatient areas to simplify and shorten the referral process.• Secured Executive commitment (community and acute) to the

formation of a collaborative working party to improve the transfer of care.

Staff Satisfaction Survey:

33% improvement.

Patient SatisfactionSurvey:

26% improvement

3. INCREASE IN APAC REFERRAL NUMBERS • Early signs encouraging for increase in referral numbers.

ROYAL NORTH SHORE HOSPITAL

PRIMARY &COMMUNITY HEALTH

SERVICES

HEALTH CONTACT CENTRE

50

60

70

80

90

100

Jan Feb March April May June July Aug Sept Oct Nov Dec

Nos

Pts

Adm

itted

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PAC

APAC Admission Numbers from RNSH 2012- 2014

2012

2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun-13 Mar-14

satisfied

unsatisfied

0

10

20

30

40

50

60

70

80

90

100

Jun-13 Mar-14

satisfied

unsatisfied

• High level Executive commitment providing an avenue to escalate issues regarding the transition of care.EXECUTIVE BUY-IN

• Working party that includes key stakeholders from Acute Care, HCC and P&CH services.

• Reports to Executive group.COLLABORATIVE WORKING PARTY

• The collaborative development of tools, policies and procedures that underpin safe and effective transition of care.

COMMUNICATION STRATEGY

• Ongoing education regarding the range and availability of P&CH services

• Directories / info days /electronic resourcesONGOING

EDUCATION

RNSH HCC P&CH

1. Limited knowledge of Acute Staff about P&CH services

• Provide education and resources for staff at RNSH• Redesign and Update Discharge planning; Transfer of Care Manual• Revise and update patient brochure “Planning your Care from Hospital to Home” to be available to all

patients on admission.

2. No mechanism in place to identify “at risk” patients early in admission

• Engage staff in the reintroduction of the TCRS tool into the Nursing admission.• Test use in AAU

3. Fragmented, inconsistent transfer of patient information from Acute toCommunity.

• Meet with managers of services to assist in the development of tools and procedures that will streamline the referral process.

• Develop clear processes and procedures for the transfer of patient information

4. Insufficient collaborative working between RNSH; HCC; APAC

• Present findings of the project to the Executive Managers of RNSH, HCC and P&CH services to ensure high level engagement and commitment to the organisation of a collaborative working party across all areas of health.

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