An alternative model of care was needed at Port Macquarie Base Hospital (PMBH) to address sustained growth in Emergency Department (ED) presentations, highly variable waiting times for triage category 4 & 5 patients and the unnecessary admission of patients suitable for treatment in the home. A comprehensive consultation process culminated with the establishment of the Express Community Care Centre (ECCC) in August 2007.

The ECCC integrates a revamped ED 'fast-track' system with medical governance for the existing Community Acute Post Acute Care Service (CAPACs) in an alternative clinical setting. The combined effect of these initiatives has been to reduce variation in ED waiting times for non-urgent patients while significantly increasing home-based treatment options for patients from selected hospital avoidance DRGs.

To improve the patient experience through reduced variability in wait times for non-urgent ED presentations and increased access to home-based care options.

A sustained upward trend in ED presentations at PMBH associated with high variability in wait times for non-urgent patients meant patients were enduring waiting time 'blow-outs'.

In addition, the existing practice of admitting patients suitable for home-based care was contrary to evidence-based practice. Research shows patients treated at home experience higher levels of satisfaction (Lemlin J. et al 2007) and are less likely to experience medical complications (Leff B. et al 2005) than patients treated in hospital. Three particular patient groups - cellulitis, venous thrombosis and respiratory infection - were identified as having potential for increased rates of home-based care.

Analysis of PMBH ED Performance Reports showed a 13% increase in total presentations from 2005/06 to 2006/07, with triage 4 & 5 patients accounting for more than half of all presentations.

Table 1: Triage 4 & 5 and Total Emergency Department Presentations - Port Macquarie Base Hospital

ED Performance control charts from January 2006 to June 2007 showed growth in ED activity was associated with high variability in waiting times for non-urgent patients.

Table 2: Control Chart - Month by Month Waiting Time by Triage Category Performance (Triage Category 4 & 5) - Port Macquarie Base Hospital NB – no data available for the period prior to Jan 2006.

Health Information Exchange (HIE) data analysis for avoidable admissions found patients who could otherwise have been safely treated at home spent  1391 days in PMBH during 2005/06. Of these, 805 (58%) were attributed to cellulitis (J64B), venous thrombosis (F63B) and respiratory infection (E62C).

Further consultation with staff, patient/carers, GPs and service partners identified:

• Limited scope for further application of 'fast-track' principles within the existing ED environment.
• Lack of alternative care options to hospitalisation.
• Limitations of the existing CAPACs due to absence of dedicated medical governance.

This project directly supports three Strategic Directions of the State Health Plan:

Strategic Direction 2: Create better experiences for people using health services is supported through:

• reduced variability in the timeliness of access to care
• expansion of appropriate care options.

Strategic Direction 4: Build regional and other partnerships for health is promoted through enhanced partnerships with GPs via direct referral to CAPACS via the ECCC.

Strategic Direction 5: Make smart choices about the costs and benefits of health services is advanced by generating health service efficiency through hospital avoidance.

A working party was established in March 2007 and met weekly to develop, plan and implement solutions to the identified problems. The group resolved to establish a means of targeting the three selected DRGs for early identification and referral from the ED or hospital ward to home-based care. This was achieved by integrating the existing 'fast-track' system with medical governance for CAPACS in an alternative clinical setting. A 'virtual facility', called the Port Macquarie Multi-Function Centre (PMMFC), was created in Cerner to facilitate data capture for activity in the new facility, separate to PMBH inpatient activity.

A site at PMBH was identified for the establishment of this facility, known as the Express Community Care Centre (ECCC). Executive approval was granted for minor capital works and staffing enhancements. Central to this new model of care was the creation of the ECCC Career Medical Officer (CMO) role, achieved by converting and relocating the existing 'fast-track' CMO position in the ED.

The ECCC commenced operation (9am-5pm, 7 days) in August 2007. The two key functions of the unit in the context of this submission are:

1. 'Fast-track' treatment of non-urgent patients
   Triage 4 and 5 patients are diverted from ED to the ECCC for treatment by a Nurse Practitioner or the ECCC CMO where appropriate.
2. Medical Governance and review for CAPACs
   The ECCC CMO identifies, assesses and refers patients suitable for treatment by CAPACs. This role includes provision of medical review and clinical governance for the service, enhancing its scope and efficiency. GPs are able to refer directly to this service.

Further efficiencies not elaborated on in this submission have been achieved through the integration within the ECCC of day-only treatments and an Aged Care Nurse Practitioner role, incorporating an outreach service to Residential Aged Care Facilities (RACF).

ED Waiting Times

Analysis of ED Performance control charts for Triage category 4 and 5 patients reveals a reduction in waiting time variability since the opening of the ECCC.

Table 3: Control Chart - Month by Month Waiting Time by Triage Category Performance (Triage Category 4 & 5) - Port Macquarie Base Hospital

This finding is supported by a series of patient interviews in which respondents who had attended the ECCC reported positive experiences and reduced waiting times compared to their previous attendances at the ED.

'Les' commented, "I only had to wait about 15mins down there. It would have been much longer if it had to be done in the emergency department. I have been through the ED dozens of times so I know the department well".

Expanded Patient Treatment Options

The implementation of the ECCC has seen a marked increase in the proportion of patients with cellulitis, venous thrombosis or respiratory infection who have been referred from the ECCC for home-based treatment via CAPACS.

Table 4
DRG description	PMBH seps 2007	ECCC seps 2007	PMBH seps 2008	ECCC seps 2008	Proportion of patients via ECCC - 2007	Proportion of patients via ECCC - 2008
J64B Cellulitis	159	33	68	63	17.2%	48.1%
E62C respiratory infections/ Inflammations W/O cc	107	5	44	16	4.5%	26.7%
F63B venous Thrombosis W/O catastrophic or severe CC	20	10	9	15	33.3%	62.5%

Conversely, there has been a sustained downward trend in the proportion of these patients being admitted to hospital.

 

Table 5: Selected DRGs (E62, F63B, J64B) - Port Macquarie Base Hospital and Multi-Function Centre 2006-2008

The importance of this achievement is reinforced by patient interviews, where home-based treatment was associated with high patient satisfaction.

'Simone' was typical of the patients interviewed - "They gave me a choice to go into hospital or stay at home and everything was explained to me. I was happier being at home with my books, my dog, my own bed and my own food. I think a lot of people would prefer it that way".

A range of strategies are in place to ensure the sustainability of the ECCC.

Staffing of the centre is recurrently funded and CAPACs has received a 1.4FTE enhancement to manage growing demand generated by the ECCC. Plans for further expansion of the service are currently before the NCAHS Executive. Policies and procedures for clinical governance and service delivery are in place to ensure ongoing operation is not affected by staff turnover. Monthly reports on ECCC activity are generated and monitored by the PMBH Executive to identify potential support needs.

The ECCC has successfully integrated acute, community and primary care services in a way that could be replicated in hospitals across Australia. The centre has been resourced primarily from existing hospital staffing and many of its policies and procedures have been adapted for application across the NCAHS. Delegations from other networks in the NCAHS have visited the ECCC with a view to developing similar programs. The facility has also attracted interest from the Greater Southern Area Health Service.

• Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK, Greenough WB 3rd, Guido S, Langston C, Frick KD, Steinwachs, D, Burton JR 2005, Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Annals of Internal Medicine, vol 143(11), pp798-808.
• Lemelin J, Hogg WE, Dahrouge S, Armstrong CD, Martin CM, Zhang W, Dusseault JA, Parsons-Nicota J, Saginur R, Viner G 2007, Patient, informal caregiver and care provider acceptance of a hospital in the home program in Ontario, Canada. BMC Health Services Research, vol 7, p130.