This project was entered in the Baxter 2005 NSW Health Awards, Continuity of Care category.

Entries from the Baxter 2005 NSW Health Awards - full list.

Author

William McClean, Community Health Central Coast Health, NSCCAHS 

Abstract

The ability of our health care system to provide, efficient and effective acute and subacute care is challenged by increasing numbers of patients awaiting placement in Residential Aged Care Facilities (RACF). Accenture, a global management-consulting firm was commissioned by NSW Minister for Health Morris Iemma to manage the Access Block Improvement Project (ABIP). Access block is the prolonged wait for an inpatient hospital bed after emergency department treatment. The Central Coast Aged Care Assessment Team (ACAT), working closely with Accenture, involved Central Coast Residential Aged Care Facilities (RACF) and the four hospital sites within Central Coast Health Service in identifying problems associated with the management of elderly patients awaiting RACF placement. Results show a dramatic decrease in the number of patients awaiting placement in RACF, greatly improved usage of the subacute care areas; improved partnerships with RACF: and an accurate up to date database.

Aim

The Aged Residential Care Consultancy Service will ensure each patient has effective, efficient transition through healthcare environments by implementing case management and developing integrated seamless relationships between inpatient and RACF.

Background

The Residential Placement Service (RPS) was created in 1997 to assist with placement of patients to RACF. In 1997 the daily average number of patients awaiting RACF placement was 20. In 2005 the daily average had increased to 57 (see Fig.1). In 2005 patients awaiting RACF placement consumed over 20000 bed days. There was limited case management of patients, meaning patient and carer needs were met. Prior to the ABIP, the RPS had identified key areas that may have had a negative impact on access block. Working collaboratively with Accenture and key stakeholders within the inpatient setting the existing RPS was redesigned and a detailed Process Model was engineered to identify a patient pathway from presentation through to placement in a RACF.

Methodology

In the diagnostic phase Accenture initially interviewed departments within the acute system at Gosford Hospital. These interviews provided an excellent opportunity for the RPS to demonstrate the limitations within the existing residential placement model. The interviews led to the formation of a working party with key stakeholders, including nursing, allied health, senior management and the consultant project services. Within this process clear roles and responsibilities for each discipline were identified. Intensive case management was introduced to ensure efficient and effective discharges; to improve length of stay in all inpatient areas; and to improve the interface between RPS, the multidisciplinary team and RACF partners. An alternative model was developed and assessed for effectiveness and adopted by the working party as being the preferred model to enact the changes required to improve the patient flow and improve the efficiency of residential aged care placement from the hospital system. Through a consultative, collaborative approach, Accenture identified the need to allocate additional funding to enhance the performance of the existing residential placement model. The allocation of this funding resulted in the redesign of the existing model and the creation of the Aged Residential Care Consultancy Service (ARCCS) to replace the RPS.

Planning and Implementation

The end-to-end residential aged care admission to discharge process was mapped and then redesigned by the project team. Patients were to be actively streamed from the acute facility into sub-acute facilities, where case management activities would be focussed. The allocation of additional funding facilitated an increase in staffing of 2.4 FTE. With this additional resource two case manager and one Liaison Nurse positions were created. Roles and responsibilities of staff involved in the process were clarified. The definition of case management as defined by The Case Management Society of Australia was adopted by ARCCS. The case managers, utilising this definition, were responsible for the screening of referrals, assessing discharge risks, planning care, evaluating service and acting as patient advocates in the patients’ journey to residential care. It was also created to provide ongoing, individualised service delivery following patients’ comprehensive Commonwealth ACAT assessment in the hospital system. This involves direct liaison with patients, their families, the in-patient setting and the RACF to provide a seamless transition from hospital to the RACF. Care planning meetings would be conducted in the sub-acute facilities with representatives from the ARCCS to ensure patients’ readiness for residential aged care.

Outcome and Evaluation

The ABIP developed key performance indicators (KPI) for ARCCS. These KPI are recorded on a data base and from these indicators ARCCS have been able to measure improvements in selected key areas. The daily average number of patients awaiting placement in RACF in CCHS hospitals has decreased from 57 to approx 20. The percentage of patients awaiting RACF in sub- acute hospital is now 82% compared to acute hospital at 18%. The numbers of patients referred for residential placement has decreased as shown in Figure 1. The average number of days from referral to placement of patient in RACF has decreased 62.5% as shown in Figure 2. Estimated bedday savings in 2004 was 9825 or 26.9 bed equivalents. The RPS completed a RACF satisfaction survey in 2004 and this will be used as a baseline measurement. Initial feedback suggests that the introduction of the role of case manager has strengthened the liaison between hospital and RACF. This role provides a complete patient Care Guide relevant to the Resident Classification Scale (RCS) and provides an access point and support mechanism to the RACF for information. ARCCS have prepared a patient / family satisfaction questionnaire to evaluate service.

Future Scope

The remarkable success of ARCCS has demonstrated the benefits of intensively case managing patients awaiting RACF placement. However those patients awaiting RACF placement are nursed in acute or sub acute hospital beds. The development and implementation of an “Awaiting Residential Care” model of nursing care within a Transitional Care Unit is considered by ARCCS as the future direction for continued improvement. The ARCCS model for RACF placement has proven to be instrumental in the reduction of access block. As access block is a problem in most hospital systems, the ARCCS model could be used successfully in any Area Health organisation.