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Home    Resources    Health System Performance    Avoidable Admissions    Healthcare for Older Persons Earlier (HOPE) Strategy

Healthcare for Older Persons Earlier (HOPE) Strategy

Sydney West Area Health Service

Abstract

The HOPE Strategy aims to provide older people, their families and carers with immediate access to skilled clinicians and responsive and appropriate care that is designed to restore and maintain a person’s optimum level of function and independence.

The strategy was developed in response to the increasing numbers of patients presenting to the hospital, particularly via the Emergency Department (ED). It involved the early provision of comprehensive geriatric multidisciplinary assessment to determine the pathological disorder and consequent physiological, psychological and functional impact.

As a result, there have been great improvements in areas such as access block, off stretcher times and triage performance.

Waiting times from triage to treatment time for those aged greater than 75 years has improved from an average of 70 minutes to 21 minutes. This has also contributed to a consistent 3% improvement in Westmead’s Hospital bed occupancy monthly capacity.

 Download the presentation given at the 2008 NSW Health Expo (604 KB).

Aim

To improve service provision to the most vulnerable aged, particularly those with chronic and complex care needs.

Nature of the Problem

A 20% increase in inpatient health care activity in SWAHS is predicted by 2016, largely due to population growth, ageing population and increased prevalence of disease (SWAHS 2006).

Furthermore, a 35% increase in the number of people aged 70 years and above has been estimated from 2001 to 2016 in Sydney West alone. The number of people aged 85 and more will increase by 56% from 2001 to 2016.

The challenge for Sydney West is to manage the demand that this growth will bring. Hence, facilitating a better flow for patients through the ED was identified as a critical step in addressing this growing need and providing better services to older people.

Extent of the Problem

The Emergency Department was being overwhelmed by demand. Much of this increased demand was consequent to an increasing number of elderly presentations, particularly those with complex care needs. This was due to both demographic pressures (population aging) and increased community expectations.

The existing models of care were unable to meet the demand and the system was prone to bouts of crisis. Often the most complex and difficult patients were being assessed and managed by the most junior and inexperienced clinicians.

Patients spent long periods in the ED awaiting initiation of treatment and undergoing assessment to an acceptable stage.

Consequently there were unacceptable delays in entry (OST), assessment and disposition (Access block), inappropriate admissions and discharges, and unpleasant patient journeys.

Strategic Importance

The NSW State Health Plan Strategic Direction 2 states – Create better experiences for people using health services. The HOPE Strategy is aligned with this direction as it is a step forward in redesigning models of clinical care to ensure the elderly patients have a good healthcare experience, good access to care and an efficient service.

It focuses on appropriate care options, hospital avoidance, hospital substitution, ED bypass, direct ward admission, coordination and integration of care.

This simplifies the point of entry to health services, fast track diagnosis and facilitates travel along complex treatment pathways and improves the overall patient journey.

Planning and Implementing Solutions

The HOPE Strategy is designed to provide better health care to the elderly mainly by improving their access to services. This was seen to require a better approximation of patients with the skill mix most suited to satisfying their complex care needs. This skill mix is encapsulated in concept of comprehensive geriatric, multidisciplinary assessment to determine the pathological disorder and consequent physiological, psychological and functional impact.

Direct admission to an area with such a skill mix necessitated a bypassing of the traditional Emergency Department processing role. A 4 bed area was established adjacent to the Emergency Department and staffed by the Geriatric Medicine Department.

HOPE was developed in partnership with residential aged care facilities (RACF) and a range of other service providers. Full executive support was provided and proved critical in successful service rollout.

Whilst an earlier strategy OPERA (Older Persons Evaluation Review and Assessment) aimed to fast track elderly patients through the ED to a specialised ward (an improvement on the old models of care, but still reliant on ED); HOPE bypasses the ED altogether. This has involved:

A schematic representation of the HOPE Strategy is provided below:

Outcomes and Evaluation

Since the opening of the HOPE Strategy at Westmead Hospital:

These have further improved the patient journey by:

All this has contributed to a consistent 3% improvement in the Westmead Hospital bed occupancy rates.

The HOPE Strategy will be monitored on an ongoing basis and continually evaluated to identify areas for improvement. These will also advise how this strategy can be implemented in other areas to reduce length of stay, and access and exit blocks.

Table 1 shows improvement with hospital waiting times from triage to treatment over 75 years old:

Table 2 shows ED performance on access block:

Sustaining Change

This project is integrated into the function of the Geriatric Medicine Department. It has the full support of a dedicated team of clinicians across a full range of disciplines. It has developed strong links with the Emergency Department and other clinical units including Imaging, Pathology, Medicine and surgery. It has strong executive sponsorship which has been critical to its establishment.

Its proven success and appreciation by patients, carers, other health care providers, clinicians and hospital administration have engendered a sense of pride and purpose amongst staff.

Ongoing recruitment will be critical but success will hopefully breed success.

Future Scope

Although HOPE is presently implemented at Westmead Hospital, its application and roll-out across the entire SWAHS is being considered.

HOPE can also be applied to other hospitals across NSW and Nation-wide. Elderly patients bypassing ED has not only improved ED triage performance at Westmead Hospital but also allowed for earlier assessment, diagnosis, treatment and management of elderly patients. By applying this redesign care model, other hospitals can also achieve similar outcomes. This will further reduce the preventable burden on acute health facilities.

References

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