kim fraser, metro north hospital and health service, queensland - acuity measurement of the...
DESCRIPTION
Kim Fraser, Nursing Director, Post-Acute Care Service, Subacute and Ambulatory Services, Metro North Hospital and Health Service, Queensland delivered the presentation at the 2014 Discharge Planning Conference. The 2014 Discharge Planning Conference - Assisting health services to adopt an integrated and consumer directed approach to discharge planning. For more information about the event, please visit: http://bit.ly/dischargeplan14TRANSCRIPT
Metro North Hospital and Health Service
Acuity Measurement of the
Post Acute Client:
Enabling Prioritisation for
Service Response
Kim Fraser
Nursing Director
Post Acute Care Service
Sub Acute and Ambulatory Service
Metro North Hospital and Health
Service
Metro North Hospital and Health Service
Metro North Hospital
and Health Service
• 850,000 population
• 4,157 square kilometres
• Brisbane River to north of Kilcoy
• Rural, regional and tertiary hospitals
• Acute, post acute, subacute, rehabilitation, aged care, oncology, palliative care, psychiatric, women’s and newborn services.
Metro North Hospital and Health Service
Objectives of Presentation
• Overview Post Acute Care Service
• Background
• Description of the Acuity Tool
• Rationale for use of Acuity tool
• Case study
• Results of initial implementation
• Recommendations
Metro North Hospital and Health Service
Brief Overview PACS
• 7 day per week post acute
hospital avoidance
• ED or admitted patient.
• Short term MD interventions
to address immediate care
needs
• Rapid response
Metro North Hospital and Health Service
PACS • Service linkages
• High risk for representation / readmission
• Support acute facilities in meeting NEAT / NEST
• Average 620 referrals per month
Metro North Hospital and Health Service
PACS
• Average LOS 14 days
• Average Age 80-89 years
• 55% Female
• Average will require 2.5 disciplines
• Inpatient DRG: – Hip replacement with complexity
– COPD
– Rehabilitation
– Patient > 64 years with injuries
Metro North Hospital and Health Service
Background • 2013 underwent extensive service
redesign
• From HACC and Chronic Disease service
to a rapid response post acute service
• Review of national and international
literature on PAC models identified the
value of acuity measures
Metro North Hospital and Health Service
Background cont…
• Literature review identified:
– no published evidence (Aust)
– 2 published acuity tools (UK and
Nth America)
– UK tool lacked reliability;
resource intensive; not
developed for the
MD team
Metro North Hospital and Health Service
Case Management Acuity Tool
• Developed by Hubber, D.L. and Craig,
K. (2007) for use within a telephonic
chronic disease case management
health service
• Captures the evidence base of case
management activities and measures
case management outcomes
Metro North Hospital and Health Service
Acuity Tool Development
• Literature review
• Gap analysis
• Clinical experts monitored development and testing of the tool, concepts, scores, differentials and their operating principles
• Pilot phase testing (n = 3,000) – interrater reliability testing and content validity
• (β) testing for content and appropriateness
• Representative sampling size testing
• Expert panel reviews
Metro North Hospital and Health Service
Why the Need for an
Acuity Tool?
• Providers of clinical services are required to demonstrate value.
• What benefits are achieved beyond the traditional measurements of cost savings or cost avoidance?
• How do we measure, compare and then evaluate interventions as to their effectiveness and cost?
Metro North Hospital and Health Service
Acuity Tool
The Acuity Tool:
• Quantifies a client’s complexity (or acuity).
• Links duration, quality, quantity and volumes of
health care interventions required.
• Provides a quantifiable indicator of
measurement which can be applied across care
points in time from admission to discharge.
Metro North Hospital and Health Service
What does the CM-Acuity Tool
Measure?
• Dosage
• Acuity
Metro North Hospital and Health Service
Dosage
• Dosage – two main variables:
– The activities carried out by the provider in
the delivery of the intervention
– The amount of time these activities take
• These variables do not capture the
complexity of interventions or
complexity of client needs
Metro North Hospital and Health Service
Dosage cont…
• The four essential elements of
intervention dose are:
– Amount
– Frequency
– Duration
– Breadth (Huber et al., 2003)
• Too much or too little of a dose may
result in harm; inefficiency and
ineffectiveness
Metro North Hospital and Health Service
Acuity
• Defined as severity of illness or client condition that indicates the need for intensity of the interventions
• Acuity links duration, quality, quantity and volume to key points of service delivery.
• Intensity is a term related to acuity that represents the amount of care and complexity of care needed by the patient.
Metro North Hospital and Health Service
Case Management – Acuity Tool©
• The Acuity Tool©: contains indicator,
drivers and subdriver categories. The
three indicators take the form of:
• Clinical Indicators
• Psychosocial indicators
• Environmental indicators
Metro North Hospital and Health Service
Acuity Tool
• April 2014 – permission from author to
implement tool with minor modifications.
• Tool within Australian context renamed:
• Concise Acuity Tool for Australian
Healthcare©
Metro North Hospital and Health Service
Metro North Hospital and Health Service
Metro North Hospital and Health Service
Metro North Hospital and Health Service
Inc
rea
sin
g C
om
ple
xit
y
Metro North Hospital and Health Service
2 1 2 5
Metro North Hospital and Health Service
2 1 2 5
Metro North Hospital and Health Service
Acuity
Score
Complexity
Score
Priority
Score
3-4 Basic 1
5-6 Good 2
7-8 Fair 3
9-10 Moderate 4
11-12 Highest 5
Metro North Hospital and Health Service
Initial Implementation
• Ease of use
• Quick to use (approximately 1-3 minutes)
• High clinician engagement
• Ability to predict workload capacity
• Ability to predict patient flow problems
• High scores reflect high complexity
• High scores reflect high risk for rehospitalisation
• Sub-drivers not sensitive enough for some disciplines
Metro North Hospital and Health Service
Test Inter-rater Reliability
• 32 inpatients (RBWH) were assessed prior to
discharge
• 29 patients assessed on admission to PACS
• Minimal divergence of scores (from hospital
to home)
• Higher the score the higher the complexity
and the higher the risk of
representation/readmission
Metro North Hospital and Health Service
How has PACS used the Acuity
Tool?
The acuity tool has enabled the Service to:
• Capture client acuity scores on admission
and discharge
• Analyse and compare acuity scores from
admission and discharge
In the future the tool will assist with:
• Determining capacity and flow processes
• Predict workload allocation accurately
Metro North Hospital and Health Service
Case Study - Molly
Metro North Hospital and Health Service
Molly • Molly 93 year old female
• Presented to ED after fall – large skin tear on leg, bruising and black eye
• MMSE 23/30
• History - Parkinson’s, multiple falls in past 3/12, family noticing changes and concerned
• Lives alone, has no services and resistant to services
• High risk of representation/readmission to ED
• Referred for medication supervision, wound care, home safety assessment, mobility assessment
Metro North Hospital and Health Service
Molly cont…
• Home had numerous trip hazards
• Not using previously prescribed mobility aids (stick and frame)
• Unsure of medications and their use - non adherence to medication regime
• Family supportive – not wanting to be a burden on them
• Required support with personal hygiene
• MST score = 3 (irregular eating patterns)
Metro North Hospital and Health Service
Metro North Hospital and Health Service
Clinical
Indicators
Psychosocial
Indicators
Environmental
Indicators
CN4
Multiple S&S
requiring MD
intervention
PS3
Minimal adherence
to care plan – does
not accept advice
for safety or use
prescribed walking
aids
Q3
Substantial
improvements
required for safety
Admission Score
4
Admission Score
3
Admission Score
3
Total Admission Acuity Score = 10
Complexity Score = Moderate
Priority Score = 4
Metro North Hospital and Health Service
Molly cont… Over 2 week journey Molly had assistance with:
• Showering and wound care
• Medication review and education – Webster pack
• OT and PT intervention – education on use of frame and stick – modifications to bathroom
• Dietitian review of weight loss and education – high protein drinks
• SW assisted with family and client education in relation to future care needs
• Liaison with GP re Molly’s care needs and MMSE score (Molly refused referral to Memory Clinic)
• Agreed to some community supports: – NGO for ongoing nursing support and personal care
– Meals on Wheels
Metro North Hospital and Health Service
Metro North Hospital and Health Service
Clinical
Indicators
Psychosocial
Indicators
Environmental
Indicators
CN3
Multiple S&S
requiring support
from one discipline
(or minor
interventions from
other disciplines)
PS2
Mostly cooperative
and adhering to
care plan – may
occasionally forget
medication
Q3
Minimal
modifications
required for safety
A = 4 D = 3 A = 3 D = 2 A = 3 D = 2
Total Admission = 10
Complexity = Moderate
Priority = 4
Total Discharge = 7
Complexity = Fair
Priority = 3
Metro North Hospital and Health Service
Evaluation
• Data capture commenced April 1, 2014
• Only those patients who had completed
their journey of care (and had a
discharge acuity score recorded) by
June 30, 2014 were included in sample.
• Sample size = 765
Metro North Hospital and Health Service
Characteristics Number
Total sample size 765
Female 445
(58%)
Male 320
(42%)
Age range 24 - 102
Average age 74 years
Range of Acuity scores 3 - 12
Mean Acuity score on admission 6
Mean Acuity score on discharge 4
Demographics
Metro North Hospital and Health Service
Comparison of Admission and Discharge Acuity Scores.
N=765
0
20
40
60
80
100
120
140
160
180
3 4 5 6 7 8 9 10 11 12
Acuity Score
Nu
mb
er o
f C
lien
ts
Admission Acuity
Discharge Acuity
Metro North Hospital and Health Service
Grouped Acuity Scores on Admission and Discharge
472
(62%)
595
(78%)
293
(38%)
169
(22%)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Admission Discharge
Nu
mb
er o
f C
lien
ts
Acuity Score 7-12
Acuity Score 3-6
Metro North Hospital and Health Service
Acuity > 7 by Age Group on Admission and Discharge
109
(63%)
152
(64%)
32
(62%)
65
(37%)
85
(36%)
20
(38%)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
24-60 61-80 81-102
Age Group
Percen
tag
e
Discharge
Admission
Metro North Hospital and Health Service
Lesson’s Learned
• Sub drivers not always clear for all
disciplines (including wound clinic) –
requires further work
• Repeat reliability and validity studies
within the post acute setting
• Engagement from staff of the process
and the tool has been positive
Metro North Hospital and Health Service
Recommendations
• Conduct further research on the reliability and validity of the tool
• Apply the tool to E-Referral process – which will enable discharge planners to assess acuity and drive a priority response from the acute setting
• Electronic solution to enable the ‘live’ display of team and discipline acuity scores (assist in resource distribution)
Metro North Hospital and Health Service
Thank You