Transcript Care Coordination decreases hospital reliance

Innovation Poster Session
HRT1215 – Innovation Awards
Sydney
11th and 12th Oct 2012
Care Coordination decreases hospital
reliance-Case Study
Presenter: Alison Austen
Central Coast LHD NSW
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KEY PROBLEM
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Implementing NSW Connecting Care Program to target
patients with chronic disease at high risk of admission.
Identify patients with frequent admission via 3rd admission
Flag and direct referrals.
Patients often have low capacity to prioritise health and poor
self management.
Lack of coordinated care between services.
Lower level triage categories in ED and Frequent unplanned
admissions to Hospital impacting on patient flow.
Central Coast has a low ratio of GP FTEs per population,
which are lower than the recommended national levels.
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AIM OF THIS INNOVATION
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Minimise unplanned hospital admissions/ ED presentations
Establish Shared Care Plans and increase quality GP
involvement
Coordinate patient care
Organise Specialist review as appropriate
Confirm Diagnosis –Improve patient disease knowledge
Increase medication compliance
Provide a process of monitoring to identify exacerbations
Reduce pressure on Emergency and hospital admissions
Supporting Transfer of Care policy
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BASELINE DATA
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Male 59 yrs
Multiple presentations to A&E and
Hospital admissions
2010 - 9 A&E LOS 3 to 9 hrs and 2
admissions 3 & 4 days
2011 - 7 A&E LOS 1 to 14 hrs and 1
admission over night
Short of Breath - ? Asthma
Direct referral from Continuing Care
Nurses
Minimal GP contact
Smoker
 Tobacco since aged 13years
 Cannabis $100 F/n since 30yrs
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Influenced by residents at Dpt
Housing complex
On parole
Not contactable by phone
Previously attended Smoking
Cessation clinic once
? capacity to change
Client aware of problems with
short term memory
MMSE – 24/30
ACE – 78/100
HAD – Anxiety 12/21
Depression 8/21
K 10 - 29
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KEY CHANGES IMPLEMENTED
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Enrolled into Connecting Care program February 2012 for
case management
14 home Visits, 3 GP visits, 2 specialist visits, and multiple
phone case management with other service providers.
GP contact
Respiratory Physician/ non charge clinic
Memory assessment prior to behaviour change
Referral for Neuropsychologist assessment
Neurologist review
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OUTCOMES SO FAR
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1 ED presentation since enrolment in 2012 – compared to 16 ED
presentations over the previous two years.
Diagnosis confirmed-COPD not Asthma and Medications adjusted
Neuropsychologist review - Client recommended for (financial)
guardianship
Neurologist review - MRI this week to investigate vascular
dementia
Referral to Complex Care Allied Health Social Work for assistance
with appointing public trustee for Power of Attorney
Improve social support – example Neighbors, and Parole.
Planned smoking cessation
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LESSONS LEARNT
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The need to assess clients capacity & motivation to change
Necessity of one to one holistic assessment preferably in
home environment
Continuous long term reinforcement of instructions–clients
may not have capacity to initiate instructions given-health
coaching
Benefits of accessing specialist services - case study examplehome memory assessment
Importance of communication with other services eg
Medical, Community - case study example - Parole office
High risk clients need one to one input though supported
case management
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