Central Network Respiratory Coordinated Care Program Innovation Presenter: Benjamin Kwan

1. Innovation Poster Session HRT1215 – Innovation Awards Sydney 11th and 12th Oct 2012 Central Network Respiratory Coordinated Care Program InnovationPresenter: Benjamin Kwan Staff specialist respiratory and sleep medicine St George and Sutherland hospital network. Medical director of SESLHD central network RCCP (respiratory coordinated care program):

2. INTRODUCTION SESLHD Central Network Respiratory Coordinated Care Program (RCCP) is a collaborative approach between respiratory physicians, nurses, physiotherapists, social workers, community services personnel and GPs. 9Team members undertake regular home visits to improve management of chronic obstructive pulmonary disease (COPD) in community. Monthly average of 375 chronic participants with a mean age of 76.2 years

3. KEY PROBLEM Increased number of patient presentations to Emergency Department Increased infective and non infective exacerbations Access to medical services Inadequate nursing and physiotherapist resources to meet growing community demand. Recurrent presentations and prolonged hospital stay for COPD patients who are outside ENABLE NSW “Domiciliary Home O2” criteria

4. AIM OF THIS INNOVATION Reduce hospital admission and readmission rates Reduce direct COPD presentations to Emergency Departments across SESLHD (STG & TSH Hospitals) Improve access to hospital medical specialist service Improve accuracy of stage of disease and management Optimise participants’ respiratory condition to help them live as independently as possible in their home Provide extra supplementary medical support to the community team

5. Solutions designCurrent and New systems – RCCP • Dedicated Adv/Basic trainee attached to RCCP • Early identification of RCCP patient to RCCP • Early identification of respiratory patients to resp. Team & RCCP • Streamlined oxygen prescribing process • Hospital oxygen lending pool • Appropriate referral to RCCP • Sustained TSH RCCP patient load ratio of 1:125 RCCP Triage Assessment Diagnostics to transfer to ward Ward D/C Community Self Management • Med registrar home visit • GP, ED and Specialist referrals to Clinic • Appropriate discharge via RCCP • Utilisation of GOLD standard Private Clinic Rapid Access Clinic Measurement of success i Access • Proactive clinic referral if no GP access within 5 days after dc Qualitative Benefits ii LOS iii vi No. of Admissions Quality of care in hospital iv No. of Readmissions (28 & 56 days) vii Quality of care in the community v viii No. of Presentations Increased RCCP capacity

6. BASELINE DATA Describe the issue or preferably show baseline measures e.g. rate of this problem over time prior to the innovation Mean National admissions per patient per year for COPD = 1.35 (2010/2011) Mean National hospital bed days length of stay for COPD – 6.7 (2010/2011) The 2011 National mean number of bed days for the 375 chronic RCCP pts is 3391 hospital bed days (1.35 x 375 x 6.7 OR average of 283 bed days per MONTH)

7. KEY CHANGES IMPLEMENTED Allocation of a medical registrar to attend home visit with RCCP staff Newly established Rapid Access Respiratory outpatient clinic COPD patients assessed by RCCP to require further medical input will either be referred directly to the weekly respiratory outpatient clinic or assessed on one of the weekly medical registrar accompanied home visit. Clinic and registrar home visit days are spaced apart (Tues / Thurs) to provide a more continuous medical input throughout the working week. GPs are notified of review outcome either by clinic letter or via direct phone call.

8. KEY CHANGES IMPLEMENTED Provision of Home O2to COPD patients who are borderline outside of ENABLE criteria i.e. P02 56-70mmHg in addition to 2 hospital admissions in the previous 12 months This group made up 6% of cohort but contributed to 12% of total admissions over 2010-2011. Those fitting with the above criteria has hospital funded hospital for 12 months with regular medical review and monitored by RCCP.

9. OUTCOMES SO FAR As from January to September 2012 inclusive, the provision of the aforementioned innovations have; reduced admission ratesfor 5 pts outside of Enable 02 criteria (Pre: 12 admissions, post: 2 admissions) Based on 375 patients Current admission rates per/pt/yr in this timeframe = 0.33 admissions/pt [126 pts] (National mean 1.35 adm/pt) Current number of bed days = 87.5 bed days per month, i.e,. January to September(National mean of 283 bed days per month) 25% of patients [based on 240 patients] seen in the clinic between 2011-12 were referred directly from RCCP or ED bypassing admission with only 1 admitted directed from clinic.

10. LESSONS LEARNT Model of care has a direct and significant effect in minimising the burden on the acute sector and preventing access block,. Innovations circumvent hospital admissions are cost efficient, when compared to the cost of ED presentations and hospital length of stay. Increased medical support improved disease diagnosis and management Allows outpatient management of chronic diseases, thus enabling patient to remain as independent as possible in their familiar environment

11. Nick Spiliopoulos (NUM of RCCP) Dr Elizabeth Clark Ms Mary Dunford Central Network RCCP staffs Central Network Department of Respiratory and Sleep Medicine Central Network Executives LEAD design team (from KPMG) Acknowledgement and Thanks

12. QUESTIONS? THANK YOU!