Post on 23-Jan-2015
description
Discharge Planning
It’s more than a last minute thing…
Central Adelaide Local Health Network
Patient Centred
SA Health
Patient CentredTeam Work
RespectProfessionalism
> Diverse People groups: England, Italy, Vietnam, India, Greece, Sudan, Afghanistan
> 1.5% Aboriginal and Torres Strait Islander
> Slightly higher percentage of females: males
> Ageing population: > 65
Central Adelaide Local Health Network
SA Health
> Ageing population: > 65 years 17.5%, > 75 years 9.4%
> Western Adelaide has a 5.9% unemployment rate
> 31.6% Single person households in the west
Drivers for Change: Discharge Blockages
• Extended length of stay: patients decondition
• Bed block: decreased access to hospital
services
• Patients not admitted to home wards
• Emergency Department over capacity
• Unnecessary re-admissions
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• Unnecessary re-admissions
• Delayed planning: who to call?
• Lack of accommodation options
• Lack of discharge champions
• Lack of consensus between acute, sub-acute
and community sectors
• Poor communication
• Ownership: who’s responsibility is it?
Discharge Planning Goals
Patient Centred approach
Dignity in Care principles
Best Practice
Improved Outcomes for patientsImproved Outcomes for patients
Improved service access i.e.
the right patient, in the right place,
at the right time.
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10 Dignity in Care Principles> Zero tolerance of all forms of abuse
> Support people with the same respect you would want for yourself or a member of your family
> Treat each person as an individual by offering a personalised service
> Enable people to maintain the maximum possibly level of independence, choice, and control
> Listen and support people to express their needs and
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> Listen and support people to express their needs and wants
> Respect people’s privacy
> Ensure people feel able to complain without fear of retribution
> Engage with family members and carers as care partners
> Assist people to maintain confidence and a positive self esteem
> Act to alleviate people's loneliness and isolation.
In the beginning...
Local
TQEH/Community
SA Health
Regional
CALHN/CAHML
Community
SA Health
A Strategic and Operational Approach
> Outcomes shared with CALHN Executive
> Support to expand the Collaborative Membership
> Terms Of Reference Endorsed
> Reporting line established
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> Reporting line established
> Escalation pathways established
> Operationally Collaborative Action Group: shared goals and achievable outcomes
> Established key workgroups with Measurable Outcomes
Family
Allied Health
Team Approach: Who do We Call?
Medical Team Acute
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Health
Pharmacist
Nursing Acute and Community
Community Health
Providers
PATIENT
Acute and
Primary
Working Collaboratively: Changing Perspective?
> Developing the network & sharing with other services and providers
> Communicating across all sectors and services
> Conducting a gap analysis: what do we have, what do we need?
> Defining shared goals
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> Defining shared goals
> Breaking down the barriers and pre-conceived ideas
> Encouraging conversations, fresh ideas and initiatives
Ways of Working
> Patient centred: Consumer Engagement
> Terms of Reference
> Executive support
> Escalation pathway: Feedback mechanism
> Shared outcomes and goals
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> Shared outcomes and goals
> Equal partnerships
> Open communication
Outcomes
Workgroups: Aged Care, Disability, Hospital Avoidance,
Length of Stay, ED Frequent Presenters
Improved communication at all levels
Improved Education opportunities
Increased knowledge, confidence and communication
Improved pathways and networks
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Improved pathways and networks
Service agreements under development
Patient and Consumer engagement resources
Development of patient
information sheets, posters and brochures to encourage
active
SA Health
active participation in
care.
SA Health
What have learnt?
•Discharge Planning commences at the first patient
encounter: Acute/Sub Acute/Primary Care
•Staff need to be supported to commence the
planning and networking
•Staff should be resourced and have confidence to
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develop and communicate the plan: verbal and written
•Good and comprehensive clinical handover supports
discharge planning and avoids unnecessary
readmission.
•Discharge planning is everyone's responsibility
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