Innovation Poster Session
HRT1215 – Innovation Awards
Sydney
11th and 12th Oct 2012
Connecting Care in the Community
Presenter: Nicole McDonald, Manager Ongoing
and Complex Care, CCLHD
Central Coast LHD - NSW
The Health Roundtable
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KEY PROBLEM
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Increasing prevalence of chronic disease
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Increasing hospital utilisation associated with complications
of chronic disease and access to primary care.
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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
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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 hospitals
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BASELINE DATA
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The Central Coast area has an aging population, lower socioeconomics, 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.
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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
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437 (36%) from Ever enrolled but no longer
current
•
24% Deceased
•
69% Discharged but not deceased
•
7% Consent to enrol but did not start
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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
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
7 to 42%
overall.
LESSONS LEARNT
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Need capacity to provide a range of service interventions
from intense case management - to health coaching - to
follow-up and monitoring.
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Need access to the range of services that clients need to be
connected to including Allied, Rehab, Community or Medical.
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Need to train staff in chronic disease case management,
provide tools, scripts and protocols to support client
management, and ensure appropriate case load mix.
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Need to support capacity for enrolment and management of
clients through out the range of chronic disease programs.
The Health Roundtable
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