Streamlined Care Pathways A healthy Tasmania – a team approach

1. Streamlined Care PathwaysA healthy Tasmania – a team approach Rosie Beardsley, ManagerStreamlined Care Pathways Program

2. Talking Points – Guidelines to Transitional Care

3. Background • In 2012 the Commonwealth funded theTasmanian Health Assistance Package(THAP) in recognition of the need for: • “…urgent steps to head offa crisis caused by Tasmania’s older population, higher rates of chronicdisease and state healthsystem constraints.”

4. Key initiatives

5. The Streamlined Care Pathways Program • Four-year program governed by TML to: • Improve transitional care of people with chronic/complex illness between acute, primary and aged care sectors • Capacity build and system redesign to improve transitions and reduce avoidable hospital readmissions • Improve practices and processes that already exist – not add another layer to an already complicated system

6. Where to start? • Develop an evidence base • We engaged with the Australian Primary Health Care Research Institute, Menzies Research Institute Tasmania and KP Health to: • Analyse existing sub-acute pathways in Tasmania • Identify gaps and inefficiencies impacting post-hospital care • Support the establishment of an evidence base across the post-hospital patient pathways • Teamwork

7. The findings • The research revealed that a range of factors contribute to poor-quality care transitions, including: • Poor communication between hospital and community service providers • Lack of guidelines for a standardised discharge process and/or care pathway within a facility • Poor role definition and accountability for transition planning and care • Low awareness by staff of patients’ social needs

8. “Patients who are recipients of sub-acute care generally have multiple chronic conditions that are complex toself-manage. The majority of their care in Tasmania isreceived in the community from a network of generalistproviders whose individual care roles are poorly coordinatedand who often do not have access to information aboutthe patient's care needs, goals and wishes from otherproviders delivering care to the patient.” • - Australian Primary Health Care Research InstituteSub-acute care in Tasmania, 2014

9. A consumers perspective • “Everything's going along okay. Then you go into hospital. You never know when or for how long. But when you get out you have to fill everyone in on what happened. It seems like they never know what happened in there.”

10. The issues • General practice is the centre of usual care. Acute hospitalisations are not unexpected by the person living with chronic illness but are viewed as disruptive to usual care. • The experience of transitions between the community and hospital is characterised by fragmentation, with poor coordination and communication across the acute/community divide. • People, their families and their caregivers desire better communication, planning and coordination to improve their care.

11. The provider perspective • “Multi-disciplinary or inter-disciplinary.We don’t do it properly. We all do our little bitin a silo and don’t really work with the personworking beside us. If you don’t discuss ittogether, it’s not really multi-disciplinary.”

12. The issues • A desire for more holistic care pathways for sub-acute care that combine health and healthcare planning into a more integrated service coordination model. • Greater access to providers whose roles include coordination of care and / or discharge planning. • Improved role definition of providers in the sub-acute service system so that it’s clear who is accountable for each element of planning and coordination. • Teamwork

13. A way forward: Talking Points – Guidelines for Transitional Care • Guidelines developed to: • Provide health professionals across the sector with direction on what is required to improve the transition process. • Shift the culture from a service-driven model of transition care to a person-centred model • Support an integrated approach across the healthcare team – including hospitals, community & consumers

14. The five talking points • A person and their family and/or carers are involved in the transition plan • A shared accountabilityfor a person-centred approach to care • Timely, appropriate, routine and non-routine communication between providers involved in a person’s care • Sharing of high-quality documentationbetween providers, regardless of setting • Coordinated, evidence-based, person-centred care across care boundaries

15. Talking Points • To be launched in September 2014 and implemented using team-based learning.

16. Some practical solutions • To address the gaps in care, we need: • Shared practice guidelines and protocols • Agreed strategies to bridge routine and non-routine communication • Improved hospital discharge pathways and process • Improved quality of discharge summaries • Teamwork

17. A call to action To realise the recommendations of the research, we needto: • Incorporate research findings into development of patient pathways • Work together to implement practical solutions to improve the service system • Work together across the acute, sub-acute, primary health and aged care service systems to create a sustainable whole-of-system approach to service redesign • Talk to one another Teamwork

18. The result: person-centred care

19. THANK YOUTML Gratefully acknowledges the support of: The Australian Government Department of HealthDr Lesley Russell & Associate Professor Terry Findlay - Australian Primary Health Care Research InstituteDepartment of Health & Human ServicesTasmanian Health OrganisationsAssociate Professor Tania Winzenberg - Menzies Research Institute TasmaniaDr Kelly Shaw - KP HealthThe consumers, their families and carers, and stakeholders who shared their knowledge and experiences