Melbourne Health (Royal Melbourne Hospital ) Developing a discharge model for Diabetes patients

1. Melbourne Health(Royal Melbourne Hospital)Developing a discharge model for Diabetes patients July 2006 & ongoing

2. Access to Diabetes Outpatient Clinic is limited due to high demand & low throughput. Why?

3. Lack of clarity regarding criteria for discharge • Issues of decision making & responsibility (especially for junior medical staff) • Lack of systems to support discharge • Uncertainty about capability of community sector • Limited capacity in the community sector • GP capacity? – decreasing workforce • Patient expectations & preferences

4. DiagnosticsTime (in weeks) to next (review) appointment

5. DiagnosticsWaiting times in clinic

6. Diagnostics Length of stay (years ) in clinic

7. DiagnosticsAudit 2 of current clinic patientsn=63 3 new patients, 59 review 3 patients discharged Frequent reviews (74% < 4 months) Next available new appointment – 10 weeks wait High proportion patients could be partly nurse-managed Medical review of patient records (47) Potential for ~30% patients to be discharged to GP and community care – with care plans

8. Diagnostics Combined results of 3data collections for PFCPatient Condition by Severity

9. DiagnosticsAbility of patient to be managed by nurse specialist

10. Our intervention……. Develop better systems for targeted & effective dischargewith rapid access back into acute if required.

11. Medical Audit 1: n=47

12. DiagnosticsOptimisation Clinic(cont)

13. Discharge Clinic 1(work in progress) Targets people with T2 diabetes • no active complications, or • active complications – stabilised Optimisation intervention (best practice screening & management) Sign off by endocrinologist Allocated discharge appointment slots

14. Discharge Clinic 2(work in progress) Patient identified as ready for discharge - discharge appt made. GP advised by letter. Discharge appointment: • 10 minutes endo, patient & discharge planner • 20-30 minutes patient & planner • Admin time - e-referral, phone etc

15. Discharge Clinic 3(work in progress) Discharge planners – staff from CHS Act as central intake to respective CHSs Patients matched to clinic by area Detailed service directory GPs sent (semi automated) discharge letter (medical) + discharge plan Patients receive copy of care plan Follow up post discharge Coaching function

16. Sustainability issues Joint approach for north west Melbourne? Agreement on levels of care (streams) & pathways – like cancer streams Engagement of GPs – development of shared care models Single point of entry for all diabetes services Need for increased capacity in community Models of care to be supported by patient centred funding.