Innovation Poster Session
HRT1215 – Innovation Awards
Sydney
11th and 12th Oct 2012
Central Network Respiratory
Coordinated Care Program Innovation
Presenter: Benjamin Kwan
Staff specialist respiratory and sleep medicine St George and Sutherland hospital network.
Medical director of SESLHD central network RCCP (respiratory coordinated care program):
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INTRODUCTION
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SESLHD Central Network Respiratory Coordinated Care
Program (RCCP) is a collaborative approach between
respiratory physicians, nurses, physiotherapists, social
workers, community services personnel and GPs.
9 Team members undertake regular home visits to improve
management of chronic obstructive pulmonary disease
(COPD) in community.
Monthly average of 375 chronic participants with a mean age
of 76.2 years
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KEY PROBLEM
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Increased number of patient presentations to Emergency
Department
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Increased infective and non infective exacerbations
Access to medical services
Inadequate nursing and physiotherapist resources to meet
growing community demand.
Recurrent presentations and prolonged hospital stay for
COPD patients who are outside ENABLE NSW “Domiciliary
Home O2” criteria
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AIM OF THIS INNOVATION
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Reduce hospital admission and readmission rates
Reduce direct COPD presentations to Emergency
Departments across SESLHD (STG & TSH Hospitals)
Improve access to hospital medical specialist service
Improve accuracy of stage of disease and management
Optimise participants’ respiratory condition to help
them live as independently as possible in their home
Provide extra supplementary medical support to the
community team
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Solutions design
Current and New systems – RCCP
•Dedicated Adv/Basic trainee
•Early identification of RCCP
attached to RCCP
patient to RCCP
•Early identification of respiratory
•Streamlined oxygen prescribing process
•Hospital oxygen lending pool
patients to resp. Team & RCCP
•Appropriate
referral to RCCP
•Sustained TSH RCCP patient
load ratio of 1:125
RCCP
Triage
Diagnostics to
Assessment transfer to ward
Ward
D/C
Community
Self
Management
•GP, ED and
•Appropriate
•Med registrar
Specialist
referrals to Clinic
discharge via RCCP
home visit
•Utilisation of GOLD standard
Measurement of
success
i
Access
ii
LOS
iii
No. of Admissions
No. of Readmissions (28 & 56
days)
iv
v
Private
Clinic
No. of Presentations
Qualitative
Benefits
Quality of care in hospital
vi
vii
vii
i
Quality of care in the
community
Increased RCCP capacity
Rapid
Access
Clinic
•Proactive clinic referral if no GP
access within 5 days after dc
BASELINE DATA
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Describe the issue or preferably show baseline measures e.g.
rate of this problem over time prior to the innovation
Mean National admissions per patient per year for COPD =
1.35 (2010/2011)
Mean National hospital bed days length of stay for COPD – 6.7
(2010/2011)
The 2011 National mean number of bed days for the 375
chronic RCCP pts is 3391 hospital bed days (1.35 x 375 x 6.7
OR average of 283 bed days per MONTH)
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KEY CHANGES IMPLEMENTED
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Allocation of a medical registrar to attend home visit with
RCCP staff
Newly established Rapid Access Respiratory outpatient clinic
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COPD patients assessed by RCCP to require further medical input
will either be referred directly to the weekly respiratory outpatient
clinic or assessed on one of the weekly medical registrar
accompanied home visit.
Clinic and registrar home visit days are spaced apart (Tues / Thurs)
to provide a more continuous medical input throughout the
working week.
GPs are notified of review outcome either by clinic letter or via
direct phone call.
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KEY CHANGES IMPLEMENTED
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Provision of Home O2 to COPD patients who are borderline
outside of ENABLE criteria i.e. P02 56-70mmHg in addition to
2 hospital admissions in the previous 12 months
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This group made up 6% of cohort but contributed to 12% of total
admissions over 2010-2011.
Those fitting with the above criteria has hospital funded hospital
for 12 months with regular medical review and monitored by
RCCP.
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OUTCOMES SO FAR
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As from January to September 2012 inclusive, the provision
of the aforementioned innovations have; reduced admission rates
for 5 pts outside of Enable 02 criteria (Pre: 12 admissions, post: 2
admissions)
Based on 375 patients
Current admission rates per/pt/yr in this timeframe = 0.33
admissions/pt [126 pts] (National mean 1.35 adm/pt)
Current number of bed days = 87.5 bed days per month, i.e,.
January to September(National mean of 283 bed days per month)
25% of patients [based on 240 patients] seen in the clinic between
2011-12 were referred directly from RCCP or ED bypassing
admission with only 1 admitted directed from clinic.
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LESSONS LEARNT
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Model of care has a direct and significant effect in minimising
the burden on the acute sector and preventing access block,.
Innovations circumvent hospital admissions are cost efficient,
when compared to the cost of ED presentations and hospital
length of stay.
Increased medical support improved disease diagnosis and
management
Allows outpatient management of chronic diseases, thus
enabling patient to remain as independent as possible in their
familiar environment
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Acknowledgement and Thanks
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Nick Spiliopoulos (NUM of RCCP)
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Dr Elizabeth Clark
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Ms Mary Dunford
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Central Network RCCP staffs
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Central Network Department of Respiratory and Sleep Medicine
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Central Network Executives
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LEAD design team (from KPMG)
QUESTIONS?
THANK YOU!
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