Influencing Demand – Altering
Preload for Canterbury EDs
Dr Greg Hamilton
Planning and Funding
The Problem
• Longer stays driven by three factors
Pre-load
Contractility
community activities to
reduce demand
effective functioning of
ED
• Need system-wide solutions
After-load
services to accept
people from ED –
hospital and community
Outcomes logic - Pre-load
Data Driven Response – Weekly
Dashboard
Patients arriving at ED
ED attendances
ED admission rate
111 calls transported to ED
Managing Acute Demand
• Supported Discharge and CREST
• After Hours and Nurse led telephone triage
• Acute Demand Management Services
Opportunity for People to
Stay Home
CREST
755
17%
18,000
755
clients so
far
2,600
Capacity to
manage
2,600 pa
17% decline in rest home bed days over 2 years
18,000 acute admissions managed in the
community
Ambulance diversion to
primary care as required
CREST Activity
Nurse led telephone triage
Acute Demand Management
Services (ADMS)
• Community-based health services to support patients who can
be safely managed in the community
• Applied during an acute medical episode (up to 5 days)
• When a hospital presentation would otherwise be imminent
• Commenced in 2000 within urban Christchurch to support
extend patient care
Where we have been?
• In 2000, ADMS commenced within urban Christchurch to
support Pegasus practices to extend patient care
• Since October 2007 services expanded to all Canterbury
patients from Kaikoura to Ashburton
• Engagement of general practice
ADMS: a collaborative approach
• Acute community nursing services
• Community observation services
• Timely supported discharge liaison service (hospitalbased)
• Service coordination
• Packages of Care (POC) – general practice
• Rapid diagnostics: radiology and lab services
• Consumables
• 5 hours/1000 patients (post quake)
Who refers to ADMS?
• Any health professional can refer a patient into ADMS
who would otherwise need assessment and/or treatment
within Secondary Care
–
–
–
–
–
–
GP
Practice nurse
Community nurse
Midwife
Ambulance paramedic
Hospital physician or staff nurse (ED and inpatient)
Monthly referrals to ADMS
ADMS referrals
2,000
1,800
1,600
1,400
1,200
1,000
800
600
400
200
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-
Qtr4
2007
Qtr1
Qtr2
Qtr3
2008
Qtr4
Qtr1
Qtr2
Qtr3
2009
Qtr4
Qtr1
Qtr2
Qtr3
2010
Qtr4
Qtr1
Qtr2
Qtr3
2011
Qtr4
ADMS referral monitoring
ADMS Referrals – Variation by
General Practice
Referrals as a Percentage of Enrolled Population
7
6
5
Data
4
Average
2SD limits
3SD limits
3
2
1
0
0
2,000
4,000
6,000
8,000
10,000
12,000
Enrolled Population
Source: Acute Demand Referrals Nov 2009-Oct 2010
Most Common Referrals to ADMS
6000
5000
4000
3000
2000
1000
0
Oct 2007- Jul 2010
ADMS
Post
22 February...
The New
Challenge
• Increased breadth of ADMS services available to high needs patients
• Population determinants of health (especially housing) mean increased risk of
deterioration and hospital attendance
• Proactive management of vulnerable population by general practice – 5
hours/1000 patients
• ADMS re-invigorated with General Practice Teams through Pegasus Education
to increase utilisation
Change in inpatient discharge rates
(2000 – 2009)
22
Acute Medical Discharges
2006/07
1.40
2009/10
1.20
NZ
1.00
0.80
0.60
0.40
0.20
0.00
Canterbury
Auckland Combined
Waitemata
Auckland
Counties
Next Steps
• ADMS Service Level Alliance established - clinical and
service leadership to drive service development and
improvement
– ADMS in residential care
– Stronger linkages with St John
– Community management for COPD
– Service improvement – coordination, problem solving,
trust, acute nursing
• Project Chain – coordinated care management