The Health Roundtable

Connecting Care in the Community

Presenter: Nicole McDonald, Manager Ongoing and Complex Care, CCLHD

Central Coast LHD - NSW

Innovation Poster SessionHRT1215 – Innovation AwardsSydney 11th and 12th Oct 2012

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The Health Roundtable

KEY PROBLEM

Increasing prevalence of chronic disease Increasing hospital utilisation associated with

complications of chronic disease and access to primary care.

Recommendation of Garling Inquiry - in response to hospital utilisation by chronic, complex and elderly patients – people with multiple health and social issues

Key strategy driving NSW Health Efficiency Plan - hospital avoidance program.

Implementation of the NSW Chronic Disease Management Program (Connecting Care in the Community)

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AIM OF THIS INNOVATION

Improve the health system’s capacity to respond to the needs of people with chronic diseases with proactive identification, assessment, enrolment and monitoring.

Provide integrated, patient focused care - addressing clinical and non clinical functional deficits.

Increase service continuity and build strong support for multidisciplinary care, care planning and care coordination.

Increase client capacity for self management and improve the quality of life of people with chronic diseases with support to their carers and families

Reduce the progression and complications of chronic disease

Reduce unplanned and avoidable admissions to hospitals3

The Health Roundtable

BASELINE DATA

The Central Coast area has an aging population, lower socio-economics, low education attainment and high reliance on public health care.

A low ratio of GP FTEs per population, which are lower than the recommended national levels.

Only half of chronic condition patients are referred to community services.

Chronic condition patients have low rates of referral to, and completion of rehabilitation.

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KEY CHANGES IMPLEMENTED

Central Coast Ongoing & Complex Care

Model of Care

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KEY CHANGES IMPLEMENTED

Established a Care Coordination Team to provide case management and coaching for complex high risk clients.

Established an Complex Care Allied Health team to provide and support client interventions.

Integrated Connecting Care with capacity to enroll patients across all of the Chronic Disease Management Programs.

Trained all Chronic Disease staff in the Health Coaching through HCA.

Developed an algorithm into EMR for identification of eligible patients on their 3rd admission.

Developed referral pathways for General Practice and 48hr Follow-up. 6

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OUTCOMES SO FAR Patient Profile Connecting Care

ICIS Snapshot June 2012 from Complex Care, Respiratory and Diabetes

1640 patients identified as suitable for enrollment

1207 (74%) patients consented and enrolled Ever

433 (26%) Suitable but not consented• 86% Declined (Self Managing, RACF,

Other appropriate Services)• 6% Deceased on follow-up• 7% Moved out of area / Unable to contact

1207 patients consented and enrolled Ever Male 52% Female 48% Average Age - 70yrs (Range 16yrs – 98yrs)

42% of Patients have Multiple Conditions• 1 condition 58%• 2 condition 14%• 3 condition 12%• 4 condition 8%• 5 condition 2%• Not recorded 6%

770 (64%) Patients Still Current • 58% Coaching• 38% Case management• 4% Tele-monitoring

40% of current patients have care plans shared with GP

Average Length of Enrolment for current patients - 361days

Average Length of Enrolment for discharged patients - 213days

437 (36%) from Ever enrolled but no longer current• 24% Deceased• 69% Discharged but not deceased• 7% Consent to enrol but did not start

Aboriginal Clients slightly younger 60yrs compared to overall 70year and more females enrolled 62% compared to 48% overall.

Clients enrolled with Complex Care slightly older 74yrs compared to 70years overall and more likely to have multiple conditions 62% compared to 42% overall.

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LESSONS LEARNT

Need capacity to provide a range of service interventions from intense case management - to health coaching - to follow-up and monitoring.

Need access to the range of services that clients need to be connected to including Allied, Rehab, Community or Medical.

Need to train staff in chronic disease case management, provide tools, scripts and protocols to support client management, and ensure appropriate case load mix.

Need to support capacity for enrolment and management of clients through out the range of chronic disease programs. 8