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Ann-Maree Redden delivered the presentation at 2014 Hospital in the Home Conference. The 2014 Hospital in the Home Conference included practical presentations such as Medico Legal Issues, Public Private Partnership Driving HITH Growth, HITH implementation, Clinical Redesign and Impact on Clinical Governance & Performance, Advanced Care Planning and more. For more information about the event, please visit: http://www.informa.com.au/HITHconference14
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Barwon Health HITH Model change Ann-Maree Redden
Barwon Health
• Largest regional healthcare provider in Victoria
• Incorporates – acute , sub-acute and primary care services
• Regional challenges – increasing demand, ageing population &
chronic illness
• Regional area – large geographical region - urban, coastal &
rural communities
• HITH in the region – program long established – commenced at
The Geelong Hospital in 1994
• Service model - major change 2004 – service integration of
HITH, PAC & HACC access – commencement of brokered
service model
Barwon Health HITH 2010 – what we had?
• Nursing led program
• Integrated service –HITH, Post Acute Care and
direct HACC liaison role
• Dilution of focus on HITH within the model
• No direct medical oversight of HITH program
• Perception from TGH medical staff of HITH being
difficult to access
• Limited direct access for GP referral
• Lack of organizational protocols to drive HITH option
What changed?
• Department of Health –Victoria – HITH review
– 2010
• Regional population growth with increasing
demand on health service
• DoH Victoria – BH Statement of priorities –
2011 – 2012
Service redesign approach - What did we do?
• Data, Data, Data and more data!
• Service mapping
• Surveys – TGH medical staff
• Time and motion studies
• Presentations to senior medical staff
• Health service visits – review of established models
• Challenges of comparison with other health service models
• Morphed into higher level redesign – acute to home with
supports redesign project, and much bigger service redesign
that still resulted in HITH being part of integrated model with its
own challenges
• Development of roles – medical lead, impact on nursing model
HITH medical lead
• Strategic position to identify and develop growth in
collaboration with the acute clinical units
• To improve the interface between the acute inpatient
teams and HITH by joint development of new and
existing HITH DRG’s
• To develop the interface with the community GP’s
through the development of shared clinical guidelines
and governance
HITH medical lead
• Development of role
• What we needed?
• Medical leadership
• Medical engagement
- TGH medical staff – Clinical Heads role
- Residential in reach medical staff
- Regional GP’s
• Development of confidence in service from medical / surgical
teams within health service
• Clinical governance – increased focus on patient safety and
outcomes
Timelines
• Initial review of service
• Executive decision making in relation to
medical lead
• Recruitment/ commencement of lead
• Negotiation / implementation of new medical
model – what was going to be the model?
• Introduction and development of HITH junior
medical roles
HITH – Junior medical roles
• Registrar and resident roles – high level of rotation – building
knowledge and capacity across health service
• Daily management of HITH patient group
• Increased HITH clinic reviews
• Decreased ED returns for HITH patients
• Impact for nursing team -
- Access to medical staff
- Efficiencies in dosing (single dosing point vs 5-10 teams)
- Direct out of hours medical referral
- Medical on-call for nursing re patients
Nursing roles & service model
• Clinical co-ordination team at TGH
• Clinical co-ordination model - nursing FTE –
proposed vs actual requirements
• Significant increase in HITH clinic contacts
• Increased patient turnover
• Impact of and on brokered direct care model in
community
• Increased total activity to broker to community
nursing teams
• Shift from BD to TDS dosing for a range of patients
• Communication and education re new / revised
protocols
HITH clinic
• From a 3 x weekly clinic – HITH clinic operational 7 days
• Significant impact on multiple HITH ,measures and patient
outcomes
- Timely and responsive medical review
- Reduced LOS
- Reduced rate of unplanned returns to ED (in/out of HITH
hours)
- Capacity for medical outreach service
- Capacity to respond to direct referrals from GP’s
HITH clinic nursing contacts
PaRT – Planning & Referral Team role
• Integrated ward model – identification , initial assessment,
consent, enrolment
• Ward PaRT
- patient care types generally more complex
- higher level of variability
- increased challenge in maintaining skill set
• ED PaRT
- high level of coverage (8am – 9pm)
- simple & high volume HITH care types
Pharmacy role and development
• Project role – to develop warfarin dosing protocol
• Impact on LOS for patients on HITH for warfarin
management
• Growth in FTE (0.2 to 0.8 FTE)
• Dedicated pharmacy role for HITH – supply,
counselling
• Outcome for patients – access to counselling
Protocol development
• Formalized existing treatment types
• Simple infections
• Complex infections
• DVT/PE
• Hyperemesis gravidarum
• New developments
• Febrile neutropenia
• Acute infective gastroenteritis
• Periarticular catheter management
• Drain tube management referral protocols
Barwon Health HITH separations and admissions –
average monthly
Internal measures
Proportion of separations – J64A&B
Same day flag (All)
Vic DRG (Multiple Items)
Proportion of
Separations Separations (with
HiTH Bed Days)
Average LOS
(with HiTH Bed
Days) HiTH Bed Days
BHCurrentYear
2013-14 38% 166 3.8 521
PreviousYears
2012-13 29% 145 5.2 593
2011-12 12% 60 5.4 229
2010-11 13% 63 4.3 225
ALOS data
ALOS data
Fluctuating demand
Marketing
Marketing
• BH website
• Quality of care magazine
• Poster campaign
• GP newsletter & mailout
• GP health pathways
IT support & development
• Barwon Health – well developed clinical / patient management
systems – just too many of them
• HITH interface between acute and community – using multiple
systems
• High level support from business analysts & clinical
development teams
• Development
- electronic referral for medical staff
- direct referral link from the Emergency Department
system
- transfer to e – referral system for all patients on an acute
to home pathway (including HITH)
What we have learnt?
• Don’t underestimate the complexity of HITH
patients and planning for their care
• Be prepared for the flow on level of change
across operations – eg. HITH clinic
operations
• True value of multidisciplinary integration
became more evident
• Ensure making real gains for health service –
access to good data to ensure real
substitution
Clinical governance
• Dedicated responsibility for ongoing patient
care
• Senior medical oversight
• Protocol driven care types
• Focus on unplanned returns – overall
increase
• Broader perspective to incident management
Organisitation focus and its impact
• CEO support
- Focus at staff forums
- Push with executive leadership teams
- Support from executive leadership teams
- whole of executive approach
Ongoing challenges - operational
• Variability in patient numbers
• Integrated and live IT solutions
• Nursing FTE and resources to support model of care
• Clinical space
Ongoing challenges - strategic
• Ongoing engagement of surgical services
• DoH guidelines in relation to HITH
• Continued focus on real substitution
• In-house model of care – i.e structural separation
• Brokered model of care – community nursing
Future opportunities
• Surgical services – focus on real
substitution opportunities
• Chemotherapy services development
• Infusion service development
• HITH as a transition service – cultural
shift
Patient journeys