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Kim Fraser, Nursing Director Post-Acute Care Service, Metro North Hospital and Health Service delivered this presentation at the inaugural Developing a 7 Day Health Service Conference. By moving to whole of system 7 day a week health delivery, public and private hospitals, social care and support services, and healthcare organisations can improve patient care, safety, and outcomes. The event examined different models for offering a 7 day a week patient-focused service. For more information about the annual event, please visit the conference website http://www.healthcareconferences.com.au/sevendayhealth.
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Engaging with Community Health Services to Strengthen Avoidance Strategies and Reduce Hospital LOS: Moving to a Post Acute 7 Day Model Kim FraserNursing DirectorPost Acute Care Service
Sub Acute and Ambulatory Services
Journey to Post Acute 7 day Model
• Comparison of old and new model
• Imperatives for change• Developing and
implementing the new model of care
• Benefits and challenges of new model
• Lessons learnt
Metro North Hospital and Health Service
• 850,000 population• 4157 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.
Context of Change
• Primary Health Care Service funded by both HACC and State. Provided assessment and care coordination services.
Change to …
• Post Acute Care Service which provides State funded services to patients discharged from hospital or diverted from ED.
Seismic Shift
• Moving from a 15 year unchanged model of care
• Skilled and valued staff in old model of care
• Old model no longer met changing health imperatives
• Skills and service model required drastic overhaul
• Profound change
Old and New Models OLD
Post Acute Care Service
• Referrals hospital only
• Frail aged / chronic disease / all ages
• Intervention based
• No wait list and rapid response
• Average 2 week LOS - Time Limited care journeys
• 4 MD teams (100 FTE)
• Home and clinic model
• 7 day a week model
•Team managed flow processes
NEW
Primary Health Care Service
• Referrals community / hospital
• Frail aged and disabled / chronic disease
• Assessment and care coordination
• Lengthy wait lists
• Longer term care
• 9 MD teams (200 FTE)
• Home visiting model
• Monday to Friday
• Clinician managed case loads
Understanding Why
• National Health Reform• Understand current state• Describe potential future
state• Communicate early in the
planned change process• Engage with staff and
discipline leads• Engage with Unions
Engagement with Partners
• Determining who are the partners
• Understanding and sharing key coordination imperatives for each partner
• Reinforcing a partnership approach – we work together!
Analysing Current State
• Review and analyse components of service delivery
• Determine improvement strategies
• Releasing time to care • Improve client flow• Determine effectiveness
of improvement strategies
Findings
• Extensive case loads• Concept of hovering• Existing definition of complex
client too sensitive• Long wait list• Access block• Inability to respond to referrals
as per priority response framework
Moving from Access Block
To Efficient Patient Flow
Focus of Flow
• Whilst still operating from old model of care
• Expectations of service that staff will manage caseloads and focus on timely discharge
• Became part of everyday language
• Ongoing audits
Increasing Internal Capacity• By reviewing and analysing components
of service delivery the Service was able to:– Achieve greater face-to-face activity – Improve client flow– Decrease wait times– Improve responsiveness to high
priority clients
Key Elements to Change
1. Engage Staff
& stakeholders
2. Service Profile
3. Clear Staff Roles
4. Journeys of Care
• Multiple forums• All levels of management• Range of communication strategies
• Define aim, objectives• Budget• Skill mix• Care journeys• Location and hours etc
• Develop & assign R&R• Duty Statements• Engagement• Performance & Dev. Plan
• Discipline developed• Time Limited• Measurable
Key Elements to Change
5. Role of Team
6. Skill Development
7. Monitoring and reporting capacity
8. Stakeholder and consumer feedback
• Huddles• Rapid pace• Strong coordination• Journey Boards
• Skill gap analysis• Implement required training• Just-in-time• Procedures & Instructions
• Based on FTE• Trial and error• Staff feedback
• Formal and informal processes• Staff participation in solutions
Partnering with Stakeholders
Pre-acute Inpatient Acute Post Acute
Continuum of Care
Patient; GP;
Family/Carer
Patient; medical team; nursing; allied health; discharge planners; family/carer
Patient; Family/Carer; PACS MD Team; GP
• Preventative Care
• Prevent unnecessary ED / hospital pres.
• Disease Prevention
• LOS management
• Inpatient utilisation management
• Reduce readmissions
• Partner with long term care providers
• Standardise care
• Reduce readmissions
Stakeholders
Involved:
Care Coordination Imperatives:
Referral Management: Reduce the Blockages
• Focused on what the stakeholders required
• Seven day a week model• Minimum of information required to
produce referral• Increase skill mix (clinician)• Electronic referrals• Future electronic referral system to
enable mobile technology at the bedside
Attitude Adjustment
• Partnership with acute hospitals – we are one of the same
• Be open to (and act on) feedback
• Continuum of care• Patients who are well enough
to go home should be home• NEVER SAY NO
Demand for Service
Demand for Service April 2013 to Sept 2013
925
11331044
12881335
1589
0
200
400
600
800
1000
1200
1400
1600
1800
Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13
Num
ber o
f Ref
erra
ls
Seven-Day Rostering
• Requires skill development
• Awareness of Awards
• Union agreement
• Time for managing and maintaining roster
• Building casual positions to support planned and unplanned leave
Seven-Day Rostering
• Staff involvement by: – Allowing plenty of lead in
time– Scheduling time to hear
concerns and respond to those concerns
– Support Union involvement– Where possible self
rostering approach
Getting the Skill Mix Right
• Establishment of a Coordinating Nurse Role for each shift
• Formalising the role with documented responsibilities
• Expectation of all clinical nurses to undertake task
Back up Support
• Nurse Unit Manager rotation on-call
• Nursing Director on-call
Benefits of New Model
• Team work
• Strong acceptance from partners
• Strong patient focus
• Accountability
• Adherence to LOS
• Skill development
Challenges of New Model
• Pace of work rapid
• Workload management
• Resources must match demand
• Social impacts of 7 day roster on some staff
• Recruitment of appropriately skilled staff
Lessons Learnt
• Influencing culture has been difficult – however, NEAT and NEST targets became an engagement factor between acute and post acute services
• If staff have participated in engagement processes, outcomes improve.
• Relationship building does not stop – requires energy and commitment
• Not everyone will be happy with new model
• Expect staff change over – enables recruitment of right skill mix
Lessons Learnt
• Line Manager expertise• Change management• Communication and team
engagement skills• Monitoring, supporting and
coaching• Line Manager support • Messages need to be
heard multiple times
Lessons Learnt
Questions?