Country Health SA Local Health Network

Strategies for Improving Strategies for Improving The Country Patient The Country Patient

JourneyJourney

Pam Pratt

Patient Liaison Network CoordinatorPatient Liaison Network Coordinator

CHSALHN

Patient Journey Initiative

The Patient Journey Initiative aims to

improve the outcomes for people living in

country South Australia needing to access country South Australia needing to access

health services locally, regionally & from

Adelaide-based services

Tip of the iceberg!

Inpatient services

Private hospitals &services

Other Health Services (Allied Health, Dental)

Outpatients – Public & Private

Patient Journey Initiative

The Patient Journey Initiative was established

in 2006 with the following strategies in mind:

> To reduce the number of avoidable referrals

> To improve the journey for people from country S.A.

Patient Journey Initiative

> To decrease the length of time

> To improve discharge planning

> To improve and develop appropriate health services and clinical networks across country South Australia

Key Issues Identified for Action

> Referral systems and processes

> Transport, accommodation and carer support services

> Discharge planning from Adelaide hospitals back to Country S.A.

Key Issues cont.

> The Patient Journey for particular groups of people from Country SA

> Avoiding unnecessary journeys> Avoiding unnecessary journeys

> Availability of health services in country locations

> Informing consumers and carers

Achievements to date include

Patient Liaison Network established

The CHSA Patient Liaison Nurse (PLN) role at

Country hospital sites formally began in 2007

Rural Liaison Nurses at major metropolitan public

hospitals

Patient Liaison Network Forum

Benefits of a Liaison Role

> Coordination

> Linking points of care

> Central Contact

> Improved discharge planning

> Improved understanding

> Improved patient outcomes

Country Health SA Nursing and Midwifery Transfer

Form

(Used when transferring to a metropolitan health unit, another country health unit or residential care

facility)

Achievements to date include

Country Home Link (CHL)

Rapid Intensive Brokerage Scheme (RIBS) Hospital avoidance program

Transitional Care Package (TCP)

Health Literacy Resources

Available on the CHSALHN Web site

Aboriginal Patient JourneyResource

Step Down Services

Enhancement of Step Down services at Port Augusta and Ceduna

Port Augusta Step Down Unit

Patient Liaison Network Coordinator

Provide corporate support services to the

Patient Liaison Network

Metropolitan/Country Patient Flow NetworkMetropolitan/Country Patient Flow Network

Central contact

Referral point

Coordination

Pulmonary Rehab Program

The following locations established

pulmonary rehab programs during 2011:

• Mount Gambier

• Millicent

• South Coast (Victor Harbor)• South Coast (Victor Harbor)

• Mount Barker

• Wallaroo

• Murray Bridge

• Port Augusta

• Port Pirie

• Port Lincoln

• Whyalla

Cardiac Rehabilitation Programs

The following locations have established cardiac rehabilitation programs:

• Mount Gambier

• South Coast (Victor Harbor)

• Mount Barker• Mount Barker

• Wallaroo

• Murray Bridge

• Port Augusta

• Port Pirie

• Port Lincoln

• Whyalla

• Berri

• Gawler

Achievements to date include

GP Plus Services (out of hospital /primary care services)

Better Care FacilitationBetter Care Facilitation

Rehabilitation Services

Cancer Services

Achievements cont.

Alternatives to travelling to access Health

Services

> Telemedicine / IT solutions

> Digital radiology services > Digital radiology services

> Expand advanced care/extended care roles in country SA

Health Diaries

Folder for adults with chronic and/or complex health conditions to use to better manage their health

Patient Journey Communiqué

Patient Journey Storybook

Operational Business Intelligence (OBI)

Dashboard

SA Health completed the work to develop

and implement a near to real time

‘dashboard’ in the areas of inpatients,

emergency departments and elective

surgery across all metropolitan hospitals

Country Patients in Metro

Information available about country

inpatients in metropolitan hospitals

Country patients are ‘flagged’ at broadCountry patients are ‘flagged’ at broad

category level

Access to patient lists/names was restricted

Patient Liaison contacts in country hospitals

Country Patient Lists

Advantages of OBI Dashboard

Quick and easy to use

Improves Communication

Monitor patients Progress

Commence Discharge Planning Home

Decrease occupied Bed Days!!!!

Good News Story

Allied Health workers identified known local clients

Negotiated direct transfer home

Confirmed home assessment and Confirmed home assessment and modifications were completed

Better client outcome

(Clinical Liaison Nurse/ Hospital in the Home

Coordinator, Port Pirie Regional Health Service)

Good News Story

Contacted patient having elective surgery in Metro

Discharge himself against medical advise

Post op complications - staying longerPost op complications - staying longer

Remained for extra days required then discharge

(Patient Liaison Officer, Kangaroo Island Health Service)

OBI Dashboard

The OBI Dashboard has proven to be an

excellent resource for country hospitals to

allow viewing of local patients in metro,

monitoring of their progress and initiating monitoring of their progress and initiating

transfers back

Overnight SA Country Patients in Metropolitan

Hospitals

Total Overnight Country Patients

in Metro28000

Separations

23000

24000

25000

26000

27000

28000

2009 2010 2011 2012 2013

SA Country Patients Transfer Summary

Transfer Summary

3000

3500

4000

4500

0

500

1000

1500

2000

2500

3000

Country to Metro Metro to Country

2009

2010

2011

2012

2013

Right care,

right team,

right time and

right place

QUESTIONS?QUESTIONS?