Alternatives to Acute Hospital – APAC/GP Shared Care
Northern Sydney Central Coast Area Health Service
Abstract
The Northern Beaches (NBs) APAC/GP Shared Care model was initiated in 2006/2007 in response to increasing demand on Emergency Departments (EDs) and the growing number of elderly patients, with ambulatory sensitive conditions, being admitted to hospital.
In the traditional APAC continuum of care, from hospital to community, General Practitioners (GPs) do not have the ability to refer directly to APAC or to retain responsibility throughout their patient’s illness.
The NBs APAC/GP Shared Care Program has enabled people using public health services to experience a care option, in their own home, that is underpinned by primary health care principles. Redesign of the APAC service to include GP direct referral optimises the patient journey and experience, reflecting better access to care.
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Aim
To provide safe, effective alternative treatment locations, other than the Northern Beaches acute hospitals, for patients with ambulatory sensitive conditions, in partnership with GPs.
Nature of the Problem
- There is a growing demand for services from NBs acute hospitals with an increase in EDs attendances.
- Patients prefer to be treated at home or in RACFs rather than being admitted to hospital.
- The number of nursing home residents being admitted to hospitals is increasing. The resultant risk of iatrogenic complications is high and many return in a worse state following a hospital admission. (Caplan, G. et al 2006).
- Service options did not support GPs treating patients requiring intense short term clinical management while retaining responsibility throughout their patient’s illness regardless of location.
Extent of the problem
There were 1750 presentations with 6 of the APAC/GP Shared Care Targeted diagnosis, to NBs Emergency Departments in 2006. Of these 1404 ie 80% were admitted to a ward from ED, accounting for 9399 bed days. (See Table 1)
Prior to the introduction of the NBs APAC/GP Shared Care program, there were 520 patients (selected DRGs 06/07) referred from NBs Hospitals to the APAC services.
In 2006 there were 576 patients who attended EDs on the NBs for follow up APAC review, contributing to the increase in ED activity.
Table 1
Patients prefer to be treated at home or in a Residential Aged Care Facilities (RACF) rather than travelling by ambulance, waiting in Emergency Departments and subsequently being admitted to hospital.
RACF Directors of Nursing have strongly indicated that they prefer to keep their patients in their facility where possible and are incorporating this type of care into the Advanced Care Planning Directives.
Strategic Importance
The APAC/ GP Shared Care Program enables people using public health services to experience an option of care underpinned by primary health care principles.
The redesign of the APAC service to include a GP direct referral optimises the patient’s journey and experience, reflecting better access to care. Elderly patients remain in their own environment thus diminishing the risks associated with acute hospital admission.
This program brings together key stakeholders from public, private and non government organisations, navigates relationships including funding and bridges gaps in service in order to treat patients requiring intense short term clinical management in the community.
Planning and Implementing Solutions
A review was undertaken of patient data relating to referrals to APAC from the NBs Manly and Mona Vale hospitals, including EDs with ambulatory care sensitive conditions. Reviewing five DRGs – deep vein thrombosis, pneumonia/chest infection, cellulitis, chronic pulmonary disease and urinary tract infections, 520 patients were identified as referred from NB Hospitals to APAC between July 2006 and April 2007.
The recommendations from the Independent Evaluation of the Central Coast APAC/GP Shared Care project, together with the patient & carer surveys results were also considered.
Preliminary meetings were held with the NBHS Executive, ED Medical Directors and the Manly Warringah Division of General Practice to ensure support for the venture.
A Steering Committee was established to engage key stakeholders and promote inter-service collaboration. Members included of Medical Directors pof the NBs EDs, Manly and Mona Vale Directors of Nursing & Midwifery, representatives from - Manly Warringah Division of General Practice, Alliance of NSW Divisions, Northern Beaches GPs, Residential Aged Care Facilities (RACFs), Community Pharmacists and Community Health services.
Orientation and promotional forums were held for GPs, RACFs and Patients/Carers
Clinical governance was determined and the Medical and legal responsibilities were identified and communicated.
Recruitment of GPs and RACFs to register to participate in the APAC/GP Shared Care program was undertaken through group and individual site visits, as wsa the recruitment of Community Pharmacists to support and resource GPs.
Clinical Guidelines and protocols were developed in collaboration with relevant stakeholders and were endorsed by local pharmacy committees.
A process negotiated with anaesthetists for fast tracking of minor procedures eg Insertion of PICC lines, without hospital admission, when required.
Outcomes and Evaluation
The NBs APAC/GP Shared Care Program was launched on the 15th May 2007
As at 30th April 2008:
- 64 GP’s have registered to participate, representing 62% of all NBs GPs.
- 20 RACFs have signed up to support the program for their residents and
- 21 Community Pharmacies are helping to support and resource the program.
- 146 NBs patients have been directly referred by GPs to the Shared Care program. 110 acute and 36 post acute patients.
- 13% of referrals were for residents of RACFs
- The admission rate in this cohort from APAC to Hospital was 4%
- The top 6 NSW Health targeted DRGs, ie Cellulitis, Community Acquired Pneumonia, Chronic Obstructive Airway Disease, Urinary Tract Infection, and Deep Vein Thrombosis, accounted for 130 patients. These APAC/GP non admitted episodes of care represent 611 acute bed days saved.
- The NBs APAC/GP collaboration has diverted 23% of 06/07 DRG cohort who historically would have presented to hospital EDs.
- Expression of interest (EOI) have been received from NSCCAHS GP Network - Northside Divisions, for implementation in 2008
- EOIs received from Sydney West Health, ACT Health, and Queensland Health to replicate the program in these areas.
Sustaining Change
The NBs APAC/GP Shared Care initiative is guided and supported by a stakeholder advisory committee to enable program evolution, clinical support and consumer satisfaction. Members include GP, Community Pharmacy, ED Clinican, RACF, APAC and NB Executive representatives.
Ease of access to the program is sustained via a single point of access for GPs, and simple referral and operational processes.
Empowerment of staff in RACFS and GP Practices is sustained through regular workshops, education sessions, and ongoing clinical support.
The clinical governance strategies of the program include clinical protocols, file audits and incident /compliment management.
Future Scope
There is increasing activity and demand for services in all EDs across NSW Health. This initiative offers a viable, replicable, community based alternative for the treatment of ambulatory sensitive conditions in partnership with GPs.
Protocols and evidence based clinical guidelines have been developed in collaboration with GPs, and medico legal responsibilities have been clearly identified.
There is ongoing enhancement of diagnoses targeted eg dehydration and remodeling of service delivery eg 1st dose IV antibiotics by credentialed APAC RNs and imminent integration of program resources onto GP secure email messaging.
The model is available on the ARCHI and APAC websites. The Community Acute/Post Acute Care incorporates the APAC/GP Shared Care Model on ARCHI.
Reference
Caplan, G. et al 2006: Advance care planning and hospital in the nursing home. Age and Ageing: 35:581-585
Contact
This project was entered in the 2008 NSW Health Awards, Strengthen Primary Health and Continuing Care in the Community category.
