Geri-Connect
AN INNOVATIVE APPROACH TO CLINICAL SERVICE DELIVERY
… or how a region
Introduced a new disruptive, clinical service model
supported by technology into Residential Aged Care
Facilities (RACF) which:
Polypharmacy by up to 17%
falls by up to 43%
waiting times by two months
access to clinical services by 90%
new revenue
And kept going….. !!!
About Us
Loddon Mallee Region
Acute Beds
25%
Sub-Acute beds
1%
Aged Care
67%
TCP
3%
others
4%
Regional Bed Profile
Problem – Unmet Demand
Yes
5%
No
95%
RACF Patients with Geriatric
Medical input into care plans2-3 month wait for a
Geriatrician Outpatient
Review
Decline in GP’s wanting to
visit RACFs
Where we started
Health Service 1st Priority 2nd Priority 3rd Priority
Echuca Regional Health Pain Management Geriatrician Services Cancer Services
Swan Hill District Health Geriatrician Services Fractures Clinic
Cohuna District Health Service Geriatrician Services Pre-Surgical Consultations Skin Disorder
Inglewood District Health Service Geriatrician Services Mental Health
Kyabram District Health Service Geriatrician Services Huntington's Disease Orthopaedics
Heathcote Health Geriatrician Services Mental Health Social Worker
Boort District Health Service Geriatrician Services Aged Care Mental Health
Kerang District Health Geriatrician Services Urgent Care Urgent Mental Health
Kyneton District Health Service Trauma Support Geriatrician Services Urgent Mental Health
Rochester and Elmore District Health Geriatrician Services Fractures Clinic
Maryborough District Health Geriatrician Services
Castlemaine Health Geriatrician Services Rehab Support Urgent Care
Robinvale District Health Service Geriatrician Services Trauma Support
GP Services into Aged
Care
Solution
Vision
A self-sustaining specialist Geriatrician virtual service hub to improve equity & quality of care provided to older adults across regional Victoria
Scope
Initial scope of implementing a service into 15 public health service Residential Aged Care Facilities across the Loddon Mallee Region.
What we had to do it with
No Geriatricians No money
Pillars for a sustainable clinical service model
Recurrent funding source
Ability
Technical and Financial Resource
WorkforceDesireClinical
(Market)
Technology
ConceptSustainable
Service Model
Pillars for a sustainable clinical service model
Recurrent funding source
Ability
Technical and Financial Resource
WorkforceDesireClinical
(Market)
Technology
ConceptSustainable
Service Model
Pillars for a sustainable clinical service model
Recurrent funding source
Ability
Technical and Financial Resource
WorkforceDesireClinical
(Market)
Technology
ConceptSustainable
Service Model
Financial
Kick start funding required to
accelerate the program
(provided by Better Care
Victoria
Financially stable
proposition
Scalability
proposition
Implementation/Change Management Approach
Service
Specialist engages and develops ongoing relationship
with GP
Ongoing conversations
Referral Sent
Consultation held
Specialist letter sent
to GP
Care Plan implementted
Triaged
yes
No
GC Clinical Nursing
Coordinator educated
Nursing staff on the value of a Geriatric Service (how and when to
engage)
Point of care nurses
engage with Patients and Families to
identify suitable
residents
Nursing Staff complete Referrals
Discuss/engage with the
GP
Copy of Specialist
letter sent to RACF
approved
No Yes
Addressing risks
Risk Did it eventuate?
GPs won’t refer to the service No
Not all Regional Health Services participate in the service Yes
Unable to recruit sufficient clinical staff
(Consultants & Registrars)
No
RACF Staff will not support the program Yes
MBS items for telehealth no longer supported Not yet!
Poor Technology acceptance No
What did we end up delivering?
Initial Scope:
15 Loddon Mallee (Vic) region public health service RACFs
RACFs = Residential Aged Care Facilities
Innovative
What has been the result
A new disruptive, clinical service model supported by
technology/connectivity into Residential Aged Care
Facilities (RACF) which:
Polypharmacy by up to 17%
falls by up to 43%
waiting times by two months
growth of access to clinical services by 90%
new funding
Diffusion / Integration
in to Regional Health
Service provision
Looking Forward……
2019 onwards: Increased Access, Scope & Evaluation of Outcomes
Loddon Mallee 2017- Hume 2019- 2019 on
Stage 1 Stage 2 Stage 3 The Future
Stages 2 and 3
• Increased scope of service
• Virtual Medicine services to regional and remote health services
Overall VISION:Telehealth enabled shared platform NOT a telehealth service
In CareAt Home
Geri-Connect
Chronic Disease
Management
Aged care
Dementia• Diagnosis• support
RACFsSmall Rural
Hospitals
Common Telehealth, Tele-monitoring & Technology Platform
Stage 1Stage 2 & 3
Where we started… and where we are now
Health Service 1st Priority 2nd Priority 3rd Priority
Echuca Regional Health Pain Management Geriatrician Services Cancer Services
Swan Hill District Health Geriatrician Services Fractures Clinic
Cohuna District Health Service Geriatrician Services Pre-Surgical Consultations Skin Disorder
Inglewood District Health Service Geriatrician Services Mental Health
Kyabram District Health Service Geriatrician Services Huntington's Disease Orthopaedics
Heathcote Health Geriatrician Services Mental Health Social Worker
Boort District Health Service Geriatrician Services Aged Care Mental Health
Kerang District Health Geriatrician Services Urgent Care Urgent Mental Health
Kyneton District Health Service Trauma Support Geriatrician Services Urgent Mental Health
Rochester and Elmore District Health Geriatrician Services Fractures Clinic
Maryborough District Health Geriatrician Services
Castlemaine Health Geriatrician Services Rehab Support Urgent Care
Robinvale District Health Service Geriatrician Services Trauma Support
GP Services into Aged
Care
Health Service 1st Priority 2nd Priority 3rd Priority
Echuca Regional Health Pain Management Geriatrician Services Cancer Services
Swan Hill District Health Geriatrician Services Fractures Clinic
Cohuna District Health Service Geriatrician Services Pre-Surgical Consultations Skin Disorder
Inglewood District Health Service Geriatrician Services Mental Health
Kyabram District Health Service Geriatrician Services Huntington's Disease Orthopaedics
Heathcote Health Geriatrician Services Mental Health Social Worker
Boort District Health Service Geriatrician Services Aged Care Mental Health
Kerang District Health Geriatrician Services Urgent Care Urgent Mental Health
Kyneton District Health Service Trauma Support Geriatrician Services Urgent Mental Health
Rochester and Elmore District Health Geriatrician Services Fractures Clinic
Maryborough District Health Geriatrician Services
Castlemaine Health Geriatrician Services Rehab Support Urgent Care
Robinvale District Health Service Geriatrician Services Trauma Support
GP Services into Aged
Care
Health Service 1st Priority 2nd Priority 3rd Priority
Echuca Regional Health Pain Management Geriatrician Services Cancer Services
Swan Hill District Health Geriatrician Services Fractures Clinic
Cohuna District Health Service Geriatrician Services Pre-Surgical Consultations Skin Disorder
Inglewood District Health Service Geriatrician Services Mental Health
Kyabram District Health Service Geriatrician Services Huntington's Disease Orthopaedics
Heathcote Health Geriatrician Services Mental Health Social Worker
Boort District Health Service Geriatrician Services Aged Care Mental Health
Kerang District Health Geriatrician Services Urgent Care Urgent Mental Health
Kyneton District Health Service Trauma Support Geriatrician Services Urgent Mental Health
Rochester and Elmore District Health Geriatrician Services Fractures Clinic
Maryborough District Health Geriatrician Services
Castlemaine Health Geriatrician Services Rehab Support Urgent Care
Robinvale District Health Service Geriatrician Services Trauma Support
GP Services into Aged
Care
Plus more
Tele - ICU
Endocrinology
Tele Paediatrics Aged Care
Assessments
(ACAS)
Transition
Care (TCP)
Assessment
Tele Palliative Care CDAMS Clinic
Mental Health
MDT’s
Oncology MDT’s
>250 Telehealth
Consultations,
Assessments or
MDT’s per
month
Opportunity:
Development of a
Virtual Hospital and Ambulatory Outreach
services
eConsults
Tele - ICU
Multi-Disciplinary
Teams
Inpatient / Hospital Outpatient / Community
Consultations
Remote Monitoring
Foundations
Mental Heath
Tele - Stroke
UCC Support
Hospital in the Home
Assessments
E-Advice
In Hospital telemetry
Remote Patient Monitoring
Electronic Patient Record
Quality Programs
Sepsis Program
Community Health System
Loddon Mallee Virtual Hospital Architecture
eCredentialling
Ongoing Development
Clinical Service Foundation
Educational Outreach, Feedback and upskilling- Staff and community
Continuous Evaluation, QI & Research
Geri-Connect
Questions?
Authors:
Assoc Prof Marc Budge [email protected]
Jackie Plunkett [email protected]
Spares
Assessment and
Prevention
Electronic Health Record
Personal Health Record
‘Home’ monitoring
andSelf
Management
Information Connectivity / Sharing
Service Management
Evidence Base and Pathways
Co
ord
inate
d D
evelo
pm
en
t
Fu
nd
ing
Marc Budge
2009
Stage 3: Development of a comprehensive,
Ambulatory and Outreach Health Service…. for Older Adults
7. Awaited Outcome: Connect @ HomeCurrent BCV Innovation project Bid: April 2019
Connect@Home:• To optimise the management and outcomes of people with
chronic disease and other acute illnesses through remote monitoring of patients;
• directing clinical resources to patients in a more effective and timely manner;
• Hospital in the Home (HITH), Commonwealth Home Support Program (CHSP), Hospital Admission Risk Program (HARP), Home and Community Care Program for Younger People (HACC PYP) programs, and a shared relationship with the client’s local GP.
• The intention of remote health monitoring is the seamless transition of clients and client clinical information throughout the care continuum seamlessly. PRELUDE TO ->
Assessment and
Prevention
Electronic patient Record
My Health Record
‘Home’ monitoring
andSelf
Management
Information Connectivity / Sharing
Service Management
Evidence Base and Pathways
Co
ord
inate
d D
evelo
pm
en
t
Fu
nd
ing
Marc Budge
2009
Keeping it all together
https://www.kingsfund.org.uk/publications/making-sense-integrated-care-systems
https://www.kingsfund.org.uk/sites/default/files/2018-09/Year-of-integrated-care-systems-reviewing-journey-so-far-full-report.pdf