patient journey through the health system

remote clinic receives outpatient appointment request

INFORMATION CREATION/

UPDATE

PROCESSES

STAFF ROLES

PATIENT NEEDS/

PRACTICE GUIDELINES/

POLICIES

PATIENT MOVEMENT

MEASURE-MENTS

20.RECEIVE RENAL

SERVICES REFERRAL*1A/B

CKD Nurse

- Past Medical Hx- Bloos Results- Medications- HRN/DOB-Correct Name *

Written referral

Verbal referral

21.CREATE/UPDATE

PATIENT FILE

CKD Nurse

22.COMPLETE

REFERRAL TO NEPHROLOGIST

(if GFR <30)

CKD Nurse

Written referral*2

RAM database

Excel S/S

RDU Patient File

23.COMPLETE

REFERRALS TO OTHER SERVICES

CKD Nurse

SW,WDM,Diet,A&A etc

Written referrals??*2

*2: Added to DB? Std letters? What info do they need?

24.MAKE NEPHROLOGY

CLINIC APPT

Ward Clerk

*1A: Length of Referral Validity*1B: Approp Referral Doco Not always received

CARESYS (JCCB)

Excel S/S

25.FAX APPT DETAILS TO HOME CLINIC

Request bloods, Meds (if first

ref)Neph Referral Recent Bloods??

26.RETRIEVE

BIOCHEMISTRY RESULTS

RDU Patient File

JADECARE

WESTERNS*4

*4: Lab Test Feed currently manual

CKD Nurse

RDU Patient File

Hosp File

Or Fax

Ward ClerkCKD Nurse

Written referral

CKD Nurse

clinic organises transport

Nephrologist

INFORMATION CREATION/

UPDATE

PROCESSES

STAFF ROLES

PATIENT NEEDS/

PRACTICE GUIDELINES/

POLICIES

PATIENT MOVEMENT

MEASURE-MENTS

27.COMPLETE PT

REQUEST FORM*5

Community Patient File

PAT Form

PATS

PATS ELIGIBILITY

Escort Permitted?

*5: Long waits, shortage of accom, Pt perception >DNA (educ), Comm

with clinic WHEN??

28.ADVISE PATIENT/RS OF TRANS/ACCOM

DETAILS

CKD Nurse

*6: 2 x clinic/wk (Mon/Thur 1pm-4:30

HIGH DNA

RDU Patient File

Hosp Patient File

JADECARE

30.CONDUCT

NEPHROLOGY CLINIC *6

+

Ward Clerk

31.RECEIVE ADJUNCT

SERVICE APPT TIMES AND ORGANISE

PATIENT TRANSPORT

RDU File

CKD Nurse

RDU File

CKD Nurse

32.FOLLOW-UP BLOOD

REQUESTS

PT Forms

29.PATIENT ARRIVES IN

TOWN

GP/DMO/SpecO/R/P

Nurse/AHW

Nurse/AHW

CKD Nurse

Or Fax

>RenalServP1 NephClinicP1>

journey through renal clinic

INFORMATION CREATION/

UPDATE

PROCESSES

STAFF ROLES

PATIENT NEEDS/

PRACTICE GUIDELINES/

POLICIES

PATIENT MOVEMENT

MEASURE-MENTS

NephrologistCKD Nurse

30.3.DETERMINE NEED

FOR OTHER ADJUNCT SERVICES/

INTERVENTIONS*8A/B/C

*8A:-Dietician -Social Worker-PD - Ultrasound-Iron infusions -Mapping-Bloods -Renal Biopsy-Darwin

NephrologistCKD Nurse

30.1.CONDUCT PATIENT

EXAM

RDU Patient File

Hospital Patient File

CARPA

Interpreter Req?

NephrologistCKD Nurse

30.2.PROVIDE PATIENT

EDUCATION*7A

Existing Education Material*7B

*7A: -Fistula Formation-Dialysis options-Medication/s-Bloods req-Preventative measures-Precautions-Info on future appts *8B:

-Dietician (on call-page)-Social Worker No links curr. est. (on call_page too)-Move clinics to Flynn Dr

NephrologistCKD Nurse

30.4.CONFIRM FOLLOW-UP APPT WITH PATIENT

*9

Nephrologist

30.5.WRITE UP PATIENT

NOTES

Hosp File

30.6.PREPARE REFERRALS

(as per 20.3)

Hosp File

Referrals Letters *10

*7B: Build demo arm

*8C: Transport an issue if move to Flynn Drive

*9:Comm Clinic not currently advised of next appt. Possibly intro patient appt card that patient is told to give to comm clinic?

JADECARE

*10:No std referrals currently

CKD Nurse

RDU Patient File

>RenalServP2 NephClinicP2>

Nephrology Clinic Letter

journey through renal clinic

30.7.SEND CLINIC LETTER

and REFERRALS

Hosp File

Fax/email to Comm Clinic/CKD Nurse/

Other involved services

INFORMATION CREATION/

UPDATE

PROCESSES

STAFF ROLES

PATIENT NEEDS/

PRACTICE GUIDELINES/

POLICIES

PATIENT MOVEMENT

MEASURE-MENTS

CKD Nurse

30.8.WRITE UP CLINIC NOTES & FILE *11

RDU File

*11 Duplicate paperwork

CKD Nurse

30.9.CONFIRM REFERRAL /INTERVENTION APPTS

MADE

Ward ClerkNephrologist

CKD Nurse

RDU File

Or Fax

>NephClinicP1 RenalServP2>

RAM database

Excel S/S

Nephrology Clinic Letter