Transitioning the Transition Care Program

• Johanna Hayes

• Northern Health, Victoria

• Johanna.Hayes@nh.org.au

May 2013

What I want to share with you today

• Describe TCP in Victoria and Northern Health (NH)

• In house model set up and external set up

• How to get optimal outcomes for our clients by contract management with external sites

• Jury is still out on which is better, recommend thorough evaluation

Victoria TCP

Entry points:

• 13% Acute – Length of Stay (LOS) is 4 days

• 58% subacute

- Geriatric Evaluation Units (GEM) LOS is 22 days

- Rehabilitation LOS is 20 days

• Restorative Care (will be GEM in July 2013) LOS 30 days

• All metro and large regional hospitals have this model, smaller Health

Services may not have full GEM or Rehab model

Other Home based services:

• Post Acute Care (PAG) -30 days home support inc therapy

• Rehab in the Home (RITH) therapy as required

• Hospital in the Home (HITH) – nursing and medical follow-up

Northern Health TCP

• Health Service – 300 Acute beds, 2 subacute sites plus 1 residential care

facility on site

• Growth corridor- old and young migrants

• TCP has been considered important and valued in providing appropriate care at end of hospital stay, reducing LOS for GEM, and well liked by clients. Able to admit clients with varied and complex needs including young disability.

Model: Residential Bed Based (BB) 24 beds Community Home Based

(HB) 43 Restorative Care (RC) 8 beds

NH TCP Model - current

1.0 Manager 1.8 Clinical Coordinator (previously 1 NUM) 2 Admin

1.9 EFT Care Coordinator

0.3 EFT Geriatrician

Therapists – 0.5 EFT OT

– 1.0 EFT PT

– 1 EFT AHA

– Speech/Dietetics/Podiatry on demand

Med Resident for in-house

43 Home Based

• 4.3 EFT Care Coordinator

• 0.1 Geriatrician

• Therapists – 1 EFT OT

– 1.0 PT

– 1.3 AHA

• Broker other disciplines ($)

24 Bed Based

In-house Model (2009, 2010)

• Executive Decision (March 2009) move to acute GEM

model and 18 beds available at BECC GEM ward

• Opportunity to move, issues with quality at residential care, low occupancy (76%), hard to admit to

• Increased demand and increase from 12 to 18 • Occupancy of 99%

• 2010 - increase beds on other side of catchment by 6

beds

Logistics

• Environmental audit

• Money for redevelopment and equipment

• Steering committee

• Communication key- manage uncertainty about losing jobs in TCP and ward SW

• Consultation important – existing NUM, Dementia Consultants, TCP, Medical (but where were the clients in this)

• Define roles – DON/NUM/TCP Manager etc

Benefits of in-house model

High Satisfaction from clients Well integrated into subacute core business Clients able to be reviewed by medical, Allied health within 24 hours Close control • issues with falls around toileting and out of commodes • Flexible 7 days/week admission and discharges • Medical instability • Staff performance and training • Implement positive changes • Avoid hospital admissions for HB

To tell the whole truth....

• More expensive model

• Impacted directly with Nurse EBA – strike

• Less engagement with HB TCP- same site but different building

• Difficult to get full payment from clients, move from one bed to another and have to pay $42/day plus medications

• Duplication of documentation (NFR / drug charts)

• Change in model from GEM – educate and reinforce

How we made it work

• Involvement in team activities - “team stepps” with GEM ward

• Shared our philosophy with nurses- clients out of bed, activities, importance of keeping on trying

• Showcase what we can do

• Manage what can change -Drug charts (7 week rather than 7 day)

• Allied health follow thru from GEM

• Built new partnerships (volunteer coordinator)

Key partnerships to have

• Nursing- DON and NUMS • Acute/subacute admission manager • Medical • Allied Health • Executive • Volunteer coordinator • Engineering and gardening • Ancillary services • Communications • Residential care facilities • Better Care for Older People (BCOP) project • Dementia Consultant, Diabetes nurse and continence

educators

Successes??

• Demonstrated good outcomes and satisfaction

• Publicise these in health service communication

• Did not look at LOS or discharge destination as definition of good outcome (get data)

• Look at GEM LOS in line with other initiatives

Moving out 2012 - summary

1. Communicate internally and understand that ward was grieving about the change

2. Availability of local beds with reputation for good care and interest in new model – contract discussions begin

3. Contract management

4. Commence Dept approval (2-3 months)

5. Close the ward

6. Open new beds over 2 week period

What we looked for

• Availability and reputation

• Interest and ability to manage new model

• Location in the catchment -split

• Quality of care (hard to measure )

• Do people look happy here?

• GP- how often do they visit

• Space

• Meet TCP criteria for home like

Important to communicate this and sell to staff and key stakeholders

How to achieve good contract management

1. Know what you want, discuss this and document in contract

2. Acknowledge to both parties that may not have everything written in contract and how will we manage this (eg height adjustable equipment)

3. Ensure you and your key staff know the contract

4. Meet regularly with other party

Achieving Departmental regulations

• Can take up to three months so be frank with all parties of this time frame and be ready to operate

• Have the key party responsible for the documentation and give them timelines (1 week is sufficient)

• Can take up to 3 months - we achieved in 2

How to make the external model work

• Engage own staff and communicate the model

• Engage facility staff (clinical coordinator critical) and communicate the model

• Establish clear admission/discharge/incident reporting

• Visit 1-2 weekly for clinical coordinators/ other staff

• Communicate with clients and refers about what to expect

• Get wireless access to your own electronic notes (citrix)

• Inform internal and external staff (GP) about admissions/discharges

Key issues with external model

• Facility may not meet clients/family expectations/standards

• Gaps in facility staff knowledge, clients more acute than permanent clients and difficult to change

• Not notified in timely manner of incidents

• Keeping track of equipment

• No weekend admissions

• GP hard to control quality

• Risk is will be seen as separate to

core business of health service

THE FUTURE

• Review and evaluate data – incidents, satisfaction, admission and discharge status

• Continue to engage key stakeholders

• Focus on quality and streamlining processes

• Communicate success and manage incidents/failures

• Be ready for the next waves of change