Barwon Health HITH Model change Ann-Maree Redden

Barwon Health

• Largest regional healthcare provider in Victoria

• Incorporates – acute , sub-acute and primary care services

• Regional challenges – increasing demand, ageing population &

chronic illness

• Regional area – large geographical region - urban, coastal &

rural communities

• HITH in the region – program long established – commenced at

The Geelong Hospital in 1994

• Service model - major change 2004 – service integration of

HITH, PAC & HACC access – commencement of brokered

service model

Barwon Health HITH 2010 – what we had?

• Nursing led program

• Integrated service –HITH, Post Acute Care and

direct HACC liaison role

• Dilution of focus on HITH within the model

• No direct medical oversight of HITH program

• Perception from TGH medical staff of HITH being

difficult to access

• Limited direct access for GP referral

• Lack of organizational protocols to drive HITH option

What changed?

• Department of Health –Victoria – HITH review

– 2010

• Regional population growth with increasing

demand on health service

• DoH Victoria – BH Statement of priorities –

2011 – 2012

Service redesign approach - What did we do?

• Data, Data, Data and more data!

• Service mapping

• Surveys – TGH medical staff

• Time and motion studies

• Presentations to senior medical staff

• Health service visits – review of established models

• Challenges of comparison with other health service models

• Morphed into higher level redesign – acute to home with

supports redesign project, and much bigger service redesign

that still resulted in HITH being part of integrated model with its

own challenges

• Development of roles – medical lead, impact on nursing model

HITH medical lead

• Strategic position to identify and develop growth in

collaboration with the acute clinical units

• To improve the interface between the acute inpatient

teams and HITH by joint development of new and

existing HITH DRG’s

• To develop the interface with the community GP’s

through the development of shared clinical guidelines

and governance

HITH medical lead

• Development of role

• What we needed?

• Medical leadership

• Medical engagement

- TGH medical staff – Clinical Heads role

- Residential in reach medical staff

- Regional GP’s

• Development of confidence in service from medical / surgical

teams within health service

• Clinical governance – increased focus on patient safety and

outcomes

Timelines

• Initial review of service

• Executive decision making in relation to

medical lead

• Recruitment/ commencement of lead

• Negotiation / implementation of new medical

model – what was going to be the model?

• Introduction and development of HITH junior

medical roles

HITH – Junior medical roles

• Registrar and resident roles – high level of rotation – building

knowledge and capacity across health service

• Daily management of HITH patient group

• Increased HITH clinic reviews

• Decreased ED returns for HITH patients

• Impact for nursing team -

- Access to medical staff

- Efficiencies in dosing (single dosing point vs 5-10 teams)

- Direct out of hours medical referral

- Medical on-call for nursing re patients

Nursing roles & service model

• Clinical co-ordination team at TGH

• Clinical co-ordination model - nursing FTE –

proposed vs actual requirements

• Significant increase in HITH clinic contacts

• Increased patient turnover

• Impact of and on brokered direct care model in

community

• Increased total activity to broker to community

nursing teams

• Shift from BD to TDS dosing for a range of patients

• Communication and education re new / revised

protocols

HITH clinic

• From a 3 x weekly clinic – HITH clinic operational 7 days

• Significant impact on multiple HITH ,measures and patient

outcomes

- Timely and responsive medical review

- Reduced LOS

- Reduced rate of unplanned returns to ED (in/out of HITH

hours)

- Capacity for medical outreach service

- Capacity to respond to direct referrals from GP’s

HITH clinic nursing contacts

PaRT – Planning & Referral Team role

• Integrated ward model – identification , initial assessment,

consent, enrolment

• Ward PaRT

- patient care types generally more complex

- higher level of variability

- increased challenge in maintaining skill set

• ED PaRT

- high level of coverage (8am – 9pm)

- simple & high volume HITH care types

Pharmacy role and development

• Project role – to develop warfarin dosing protocol

• Impact on LOS for patients on HITH for warfarin

management

• Growth in FTE (0.2 to 0.8 FTE)

• Dedicated pharmacy role for HITH – supply,

counselling

• Outcome for patients – access to counselling

Protocol development

• Formalized existing treatment types

• Simple infections

• Complex infections

• DVT/PE

• Hyperemesis gravidarum

• New developments

• Febrile neutropenia

• Acute infective gastroenteritis

• Periarticular catheter management

• Drain tube management referral protocols

Barwon Health HITH separations and admissions –

average monthly

Internal measures

Proportion of separations – J64A&B

Same day flag (All)

Vic DRG (Multiple Items)

Proportion of

Separations Separations (with

HiTH Bed Days)

Average LOS

(with HiTH Bed

Days) HiTH Bed Days

BHCurrentYear

2013-14 38% 166 3.8 521

PreviousYears

2012-13 29% 145 5.2 593

2011-12 12% 60 5.4 229

2010-11 13% 63 4.3 225

ALOS data

ALOS data

Fluctuating demand

Marketing

Marketing

• BH website

• Quality of care magazine

• Poster campaign

• GP newsletter & mailout

• GP health pathways

IT support & development

• Barwon Health – well developed clinical / patient management

systems – just too many of them

• HITH interface between acute and community – using multiple

systems

• High level support from business analysts & clinical

development teams

• Development

- electronic referral for medical staff

- direct referral link from the Emergency Department

system

- transfer to e – referral system for all patients on an acute

to home pathway (including HITH)

What we have learnt?

• Don’t underestimate the complexity of HITH

patients and planning for their care

• Be prepared for the flow on level of change

across operations – eg. HITH clinic

operations

• True value of multidisciplinary integration

became more evident

• Ensure making real gains for health service –

access to good data to ensure real

substitution

Clinical governance

• Dedicated responsibility for ongoing patient

care

• Senior medical oversight

• Protocol driven care types

• Focus on unplanned returns – overall

increase

• Broader perspective to incident management

Organisitation focus and its impact

• CEO support

- Focus at staff forums

- Push with executive leadership teams

- Support from executive leadership teams

- whole of executive approach

Ongoing challenges - operational

• Variability in patient numbers

• Integrated and live IT solutions

• Nursing FTE and resources to support model of care

• Clinical space

Ongoing challenges - strategic

• Ongoing engagement of surgical services

• DoH guidelines in relation to HITH

• Continued focus on real substitution

• In-house model of care – i.e structural separation

• Brokered model of care – community nursing

Future opportunities

• Surgical services – focus on real

substitution opportunities

• Chemotherapy services development

• Infusion service development

• HITH as a transition service – cultural

shift

Patient journeys