Timely Quality Care within the Transition Care Program (TCP)

Andrew Perta, Clinical services Director – Rehabilitation Aged And Community Care Director of Nursing and Site Coordination – Caulfield Hospital Janelle Russell, Service Co-ordinator, Transition Care Program

TCP Overview

Alfred Health Transition Care Program commenced in August 2006.

Transition Care program has increased to 68 bed based places. 21 places are located onsite at Caulfield Hospital 47 are located off site under Contracts

Plus 20 Community home based places .

Total of 88 TCP places.

Drivers for change….

• Performance against benchmarks • Demand on inpatient beds across Alfred Health • National Standards • Redesigning Inpatient Rehabilitation Project • Alfred Timely Quality Care • CH redevelopment feasibility study - a ‘model of care’ for the future

Pascal’s Law

• an external pressure applied to a fluid in a closed vessel is uniformly transmitted throughout the fluid

Guiding Concepts for Alfred Health Timely Quality Care

•  The patient should be seen by the most appropriate senior decision maker, as soon as possible along all points in their journey.

•  Trust the referrer •  Accountability & responsibility begins on referral •  Right place, right time, 1st time •  Treat in turn •  Active management of patient’s throughout their

journey •  No tolerance for ‘waiting’

Integration of TCP

• Complex Care • Bed Access • Ward Meetings • Continuum • Location • E-Referral

Stream Options & Partnerships

• Bed based Services – I onsite – 2 offsite

• Best Fit – Medical Complexity – Care Needs – Home location

Methodology

Journey  Board  &  Briefs  

Client  Experience  

Workshop  -­‐  Pa<ent  Mapping  –  Ideal  Pathway  Workshop  -­‐  Shared  Purpose  &  

Principles

Data Collection

E-­‐referral   Workshop  -­‐  Measuring  Success  

Workshop - Shared Purpose

As the Transition Care Program we provide: •  Individualised, client focused, goal directed, collaborative interdisciplinary

care following a hospital admission. We aim to optimise functional capacity and independence facilitating appropriate and timely discharge outcomes within the service scope.

Principles (Ideal State) • Person Centred - in partnership with the patient/client and responsible

person empowering them to make informed decisions • Goal directed – time-framed and realistic • Supportive, safe nurturing environment allowing time for informed decision

making • Consistent approach to care delivery across settings • Smooth transitions across the program

Patient Mapping – Ideal Pathway & Real Pathway

• Referral to Discharge

• Staff

• Medical Record Audit

“Ideal Patient/Client Map”

Smooth  transi<on  Pa<ent/client  is  safe  and  comfortable  

Pa<ent/client’s  plan  is  clarified  

Pa<ent/client  is  involved  in  a  personalised  program  

Pa<ent/client  has  confidence  

in  their  discharge  plan  

Journey Boards & Briefs

• Implementation

• 3 sites

• Evaluation –  Attendance –  Board completion –  Staff Satisfaction –  Other metrics:

>  EDD, DD, time of arrival to first interdisciplinary discussion

Journey Board & Brief Onsite Evaluation

Journey Board & Briefs Evaluation

• Reduced variation between time of arrival and first interdisciplinary discussion of EDD and DD

• Pre Journey Boards 2-22 days, average 10 days • Post Journey Board 0-3 days

Journey Board & Briefs Evaluation

Staff Satisfaction Survey: 8 respondents – 3 Nursing & 5 Allied Health

• 88% (n=7) agreed or strongly agreed that the Journey Board & Briefs improve communication within the care team.

• 63% (n=5) agreed or strongly agreed that the Journey Boards & Briefs assist/support the clinical handover process.

• Comments suggested that the Journey Board provided a good snapshot & 1 brief per week might be enough.

Electronic - Referral

Staged roll out organisation wide resulting in:

•  Improved organisational communication • Greater interdisciplinary collaboration •  Improved quality of referral • Collection of KPI’s and monitoring of service efficiencies • Positive user feedback

Phase 2 • ACAS link

Client Experience

Marjorie is a recent TCP client who spend 11 weeks 4 days in bed based care offsite. She had been living independently at home by herself and has no husband or children. She has a very supportive sister, niece & nephew. Marjorie spent months in hospital due to a number of complications and underwent a BKA.

It was a very difficult decision for Marjorie to make when considering her long term discharge options and she believed:

• The amount of time she spent with TCP was appropriate so that she could make the right decision to go to low level care and feel very comfortable with her discharge plan.

• That staff involved her in decisions about her discharge plan and her family and home situation was taken in to account.

• Nursing & Medical input met care expectations • Physio Input – needed more given she was accustomed to twice per day • Home visit – provided clarity about her decision in that she would not cope at

home

Where to from here…

• Patient Mapping Detail Completion • Metric refinement • Dashboard – reporting

QUESTIONS?!