DMU - background

• Commenced in January 2000

• Proactive rather than reactive - Program of ongoing follow-up, monitoring, education and early medical intervention post discharge

• Patients with complex co-morbid conditions

DMU - population• Common co-morbidities:

IHD, CHF, COAD, CRF and DM.

• Acute exacerbations / unstable

• Many problems are non medical:

e.g. social isolation, lack of community supports, poverty, language, illiteracy, housing, access to (specialist) medical care etc.

DMU - population

• Psychiatric illness esp. depression, dementia and ETOH abuse are not uncommon.

• Poly-pharmacy with consequent drug side-effect, awareness and adherence issues are universal (admission).

• Equals readmissions and ED presentations

DMU -Aim

• Improve QOL of patients• Reduce Admissions• Reduce ED presentations• Reduce Length Of Stay (LOS)• Reduce total bed-days

DMU - How?

• Ongoing follow-up & monitoring through

-outpatient specialised clinic reviews

-care coordination activities

-communication with GP

-phone contact

-education and self management

-referrals

• 6 monthly Analysis

DMU - How?

• Overall key is flexible patient review.

• Review time based on complexity/no. of problems.

• Typical review time 30mins as often as required;-even weekly (initially) if necessary.-usually monthly.-discharge when >3-monthly.

• Follow-up of results/referrals/care plans between clinics (role of full-time nurse coordinator & dedicated registrar)

• Care coordinator contact prior to review

Clinics

• Alfred: mon, wed, fri• Caulfield: mon• Sandringham: fortnightly thurs• Inner South: fri

• Eduction classes, library, patient newsletter

DMU - How?

• Utilize allied health/educators: address anxiety, depression, energy conservation, nutrition

• Realize sometimes inpatient Rx is unavoidable.

• Admit at an early stage of disease relapse to;

(i) reduce LOS (“turn-around”)

(ii) maintain performance status (avoid placement).

(iii) Avoid ED by direct admit if possible.

“Self management” DMU style - Past

• Monthly group sessions• Anxiety and depression, energy conservation,

nutrition, relevant topic eg sleeping well• At The Alfred, lunch provided• Greek, Russian• Care co-ordinators invite patients• Patient response• Transport, commitment

Self management DMU style - Now• Psychologist leading group support and

information sessions• “Sick and tired of feeling sick and tired”• Monthly, lunch provided• Not at Alfred (Inner South, Caulfield and

Bentleigh Bayside)• Community health centre staff and DMU staff• Care co-ordinators approach patients• Evaluation

DMU team

• 7 Consultants, Registrar and Residents(renal, general medicine, endocrinology, cardiology, geriatrics, rheumatology, respiratory)

• 4 Nurse Care Coordinators,

• Manager PTE

• Pharmacist

• Allied health educators

• Need: psychologist

Results

Comparative analysis of healthcare utilization of all

patients 6 months pre and post enrolment.

- 6 months prior to enrollment date

- 6 months post enrollment date

- 7-12 months post enrollment date

Each patient acts as own control.

Data analysis is done every six months

Demographic Data*

Male/female % 50.7%/49.3%2 co morbidities 100%1° diagnosis CHF 28%1° diagnosis COAD 30%Lives alone 48%Lives with family/carer 42%Lives in Hostel/NH 8%Lives in supported accom. 2%

*random cohort of 50 patients enrolled last 6 months of 2001.

Outcomes

• 2002-2006 n=1305 patients

• Total admissions reduced by 54%

• 12009 potential beddays saved

• ED presentations reduced by 59%

DM critical factors

• Clinical leadership, enthusiasm, vision

• Team members

• Communication: team meetings, electronic

• Patient telephone contact – care coordinators

• GP liaison

• Education

• Measuring results

The Alfred DMU-Future Directions

• Expand clinics and staffing including psychology

• Increasingly become a community-based service and avoid patients coming to the “physical” Alfred at all.

• Nurse Practitioner ?

• Health coaching

• Assess clinical outcomes in the patient group

• Expand electronic medical record

Acknowledgements

• Dr Marco Bonollo, Renal Consultant, General Physician, DMU leader

• Care Coordinators: Jo Butler, Jo Harris, Belinda Ryan, Fiona Vaular, Juliet Ward

• Drs Laila Rotstein, Solomon Menehem, Harvey Newnham, Livia Rovera-Wall, Annie Fung, Su Hii, Ronald Leong, Yuben Moodley, Juan Aw, DMU Registrars

• Pharmacists Robyn Stell, Susan Fisher

• Community Health Centres allied health

• Inner South, Caulfield, Bentleigh Bayside