Amanda Humphreys - Sir Charles Gairdner Hospital - How I Became a Juggler: Managing the Needs and Demands of all Stakeholders on the Pathway to Transition Care

Sir Charles Gairdner and Osborne Park Health Care Group:

Committed staff, clever researchers – caring for patients

How I became a juggler

Managing the needs and demands of

all stakeholders on the pathway to

Transition Care

Amanda Humphreys, NMHS Transition Care Central Coordinator

TCP in WA

Residential and restorative

pathways

Metropolitan:

Residential and community programs

Rural:

the Great Southern, the Midwest and the

South West. TCP Community services are

available.

TCP in WA

Residential and restorative pathways

Metropolitan and rural There are three rural

areas in which TCP is delivered; the Great

Southern, the Midwest and the South West.

In these areas, TCP Community services

are available.

Residential and community programs

Central Coordination

Model of TCP Management

Pre 2011

The new way

Process

Responsibility

The stakeholders

The patient

Their family and significant others

The referring hospital

The treating team

The area health service

The TCP providers

The Department of Health

Government

The TCP Central Coordinators

The TCP patient in the system

The patient

Family/carers

Treating team

Referring hospital

Area Health service

TCP Providers

WA Dept of Health

Government

Patients

Core values care based on:

Respect

Choice and empowerment

Equality and access

Emotional support

Information

Involvement of carers and families

Patient involvement in health policy

Patients

“I wanted to know someone would help me get better to get home”

“I know they don’t want me to stay in hospital any longer then I have to. They need the beds for sick people”

“I want to go home but I know I probably can’t and I need time”

Family and carers

Expectations

Concerns and needs

Impact of consumerism

Treating Team

Professional assessments and opinions

Direct patient care imperatives

Hospital demands:

Sir Charles Gairdner Hospital

NEAT:

Admitted, transferred or discharged

within four hours

Impact on patient flow

ABF

Funding based on patient activity

DRGs and impact on patient flow

The Budget

North Metropolitan Health Service

Perth metro : NMHS & SMHS

Hospital medical and surgical services to adults @ SCGH, OPH, Swan Districts, Kalamunda and Joondalup hospitals

1749 beds, 3000 m2, 1 million=40% of State

TCP Providers

Organisational demands and goals: NMHS

= 2 organisations

Reputation and credibility

Budgets

Managing resources in patient care

Health Department of WA

Contractual requirements and constraints

Herding cats

Interplay with Providers and TC

Coordinators

Government

Steering the ship: National guidelines

Policy on ageing

State versus Federal in implementation

Juggling the system: becoming

comfortable with discomfort

Central Coordinator

Patient and family

Health system

TCP Providers

Juggling skill set

Teamwork

Communication

Leadership

Conflict resolution and negotiation

Systems Theory

Managing external pressures

Aged Care Reform impact

Contractual lag and constraints

Location, accessibility and satisfaction

Strategies

Information, information, information

Listening, the lost art

Collaborative problem solving

Chocolates and strategic thinking

Education Working Party

Process mapping – identification of

education needs

Representation of perspectives

Survey

EWP Survey: True or False

The good ones

Handovers are essential when transferring a

patient to TC (TRUE)

Both residential and community based TC is

available (TRUE)

Patients/families receive a "TC Fact Sheet" from

the hospital Social Worker when discussing TCP

as an option (TRUE)

All patients admitted to TCP will be discharged to

a residential aged care facility (FALSE)

Highest incorrects

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

rehabilitation Nursing handov at anytime

IV antibiotics are NOTeligible

functioning is expectedto decline

Incorrects

Highest Not sures

29.20%

29.40%

29.60%

29.80%

30.00%

30.20%

30.40%

30.60%

30.80%

31.00%

TCP fees must be paidregardless of economic

circumstances

Nursing handovers may beprovided to the TCP facility atany time after the referral is

made

All TCP facilities have singlerooms with ensuites

Not Sure

EWP Survey: We Like

44.0%

46.0%

48.0%

50.0%

52.0%

54.0%

56.0%

58.0%

60.0%

Brochure Group Education Profession specific educationsession

We Like

EWP Survey: The Top Three

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

Health site education includingcase studies

Website Profession specific educationsessions

The Top Three

EWP Survey: No, thanks

62.0%

64.0%

66.0%

68.0%

70.0%

72.0%

74.0%

76.0%

78.0%

80.0%

82.0%

84.0%

DVD Podcast

A Definite No

From Here to eternity…

Change is constant

Electronic referral and database system

Contracts and relocations

Budgets

More of the same, less of the same