The Sutherland Project

1. The Sutherland Project KATE BONE ABHI Integration Coordinator

2. Background Setting Aim Approach Findings Resources Evaluation ABHI’s Journey ‘A Path For Care Integration’

3. Integrated care refers to "methods and organisations to provide the most cost-effective and caring services to those with the greatest health needs and to ensure continuity of care and co-ordination between different services". J. Integrated care –development issues from an international perspective: models and issues. Healthcare Review , 2(5) March,1998.

4. Background The Sutherland Hospital 320 acute beds, 110 Aged Care 9 ACAU (MAU)

5. Project Objective • Improve communication between health care providers, focusing on the transfer of aged care chronically ill patients between TSH & GP. • Evaluate & develop discharge planning processes. • Develop strategies to increase knowledge and use of GP services available to support patients in their own setting.

6. Approach • Direction & guidance from ABHI Advisory Committee. • Observation & assessment of discharge process. • Surveys & questionnaires. • Develop and implement interventions informed by the data. • Evaluate progress.

7. Findings • Pre-conceived Myths & Views. • Inadequate Discharge Planning processes. • Incomplete Discharge Summaries. • Delayed communication of Discharge Summaries.

8. Myths/Views High proportion of patients re-admitted due to medication errors. High proportion of ‘frequent flyers’ especially from RACF’s All Patients discharge see GP within 3 days Facts & Figures 25% re-admission not related to medication errors. Small percentage of ‘frequent flyers’ 55% patients see GP within timeframe Pre-Conceived Myths & Views

9. Discharge Planning Process Ward View Point • Rushed no EDD used • Reactive process • Risk assessment tools not completed • Not Patient Centred • Multi-system disparate Patients View Point • No planned EDD • Needs not taken into consideration • Unclear information • Information overload • Inadequate medications information

10. Discharge Summaries 2008 100% Hand Written 35% Difficult to read 12% illegible. 15% patients details absent 78% Vague on follow up requirements. 2009 25% Hand Written 75% Typed 12% Difficult to read 6% illegible. 0% patients details absent 92% Vague on follow up requirements.

11. GP Survey 2008 25% illegible following fax 33.3% NOT received 100% NO contact details. >50% satisfied with content. 100% Not notified of death. 25% GPs hesitant to act without medical discharge summary 2009 20% illegible following fax 25% NOT received 25% NO contact details. ? % satisfied with content 100% Not notified of death. 20% GPs hesitant to act without medical discharge summary

12. Discharge Referrals

13. Resources • Basic Care (action) Plan. • Typed Discharge Summary. • Patient Held Record.

14. Basic Care (action) Plan Aim Addressed concerns & problems identified through patent ,carer interviews. Reduce number of complaints ward received following discharge. Approach Outline simple plan of care for the first 48-72 hours following discharge.

15. Typed Discharge Summary Aim Develop typed discharge summary template to addressed problems identified through baseline audit for transfer of data. Approach Through education sessions facilitated by GP highlight the importance of legible discharge summaries.

17. Patient Held Record (Yellow Envelope) Aim • Raise awareness of the need for patients to take active role in their health care issues when transferred to hospital. • To support safe delivery of clinical information when a patient has been discharged home. Approach • Older persons deemed to be high risk of re-admission or with multiple co-morbidities and complex health needs who do not reside within low or high level RACF.

18. Initial Pilot Results Pilot Sites • 2 ILU’s, ED, NSW ambulance, 2 GP Practices, ACAU & aged care wards. Evaluation • written surveys and semi-structured face to-face interviews. Results • (99%) users thought the Envelope provided useful and significant data. • (87%) said it was easy to use. • All interviewees thought the Envelope had raised an awareness of the patients need to have critical clinical information in one place.

20. Challenges • ABHI role is consultative - no “control of or authority” over patients being discharged. • “ABHI person” seen as outsider • Staff on wards stretched and stressed. • High turn over of NUM’s • Lack of designated staff to identify ‘complex patient’ • The Area Health Service

21. Barriers • Difficulty engaging staff & senior clinicians • Turf protection • IT system unable to support proposed changes • Time to change • Change overload • The Area Health Service

22. Evaluation - What worked? • Clinical leader with clear vision and focused goal • Clear direction from Advisory Group • Aged Care CNC dedicated drive the process at executive level. • Being on site in their face • Families, carers, health professionals have welcomed and embraced Patient Held Record (Yellow Envelope).

23. Evaluation - Lessons learnt • Implementation hindered by unstable workforce (high turnover staff). • Prevention message needs to be communicated strongly by both sides • Primarily a nurse driven process of care – • Pre-conceived myths & views. • Communication vital at exec level with Divisions CEO’s

24. Questions