Business Case for Significant Change - Together...• The Diabetes Educators, Discharge Planner, Occupational therapist and Cardiac Rehabilitation Clinical Nurse, Dietician, Physiotherapist

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Business Case for Significant Change Integrated Care Model: Division of Medicine

1. Purpose of Business Case

Implement an Integrated Care Model and associated leadership structure, aligning the existing Hospital avoidance teams into one service within one model of care.

The Integrated Care Service (Medical Division) is proposing change in accordance with government policy and relevant industrial obligations.

Wide Bay Hospital and Health Service Population Profile

WBHHS has a population of approximately 214,000. The demographic profile details a large number the population are aging and live in isolation, and a disproportionate prevalence of people experiencing profound or severe disability (Primary Health Network 2017, Wide Bay Hospital and Health Service 2018). Compared with the Queensland average, the Wide bay also has very high rates of unemployment, socioeconomic disadvantage, mental health problems with risky behaviour and lifestyles carrying significant health care consequences. According to the Primary Health Network (PHN), Local Government Area profile (2017). The Wide Bay also has significantly higher percentage of adults with obesity, diabetes, asthma, arthritis and heart disease than the Queensland average. Those who have one chronic condition are highly likely to have multiple co-morbidities. Wide bay region’s population demographic and epidemiology portrays significant challenges for the current state and future demand of health service delivery (Wide Bay Hospital and Health Service 2018).

Table 1 The current state – Chronic Disease Patient Profile (Deloitte 2018)

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2. Background In response to the current and predicted population demographic, burden of chronic conditions within our communities and the Wide Bay Hospital and Health Service Strategic Plan 2015-2019, the Medical Division and Deloitte’s completed a review of the existing hospital avoidance services in September 2018. The review reinforced that the WBHHS has among the highest rate of potentially preventable hospitalisations (PPHs) in Queensland due to the relatively disproportionate elderly population and persons diagnosed chronic conditions mentioned previously. Alone, chronic conditions accounted for 7509 admissions and 22,040 bed days across Wide Bay in 2018. These are often compounded by psychosocial and socioeconomic issues (Wide Bay Hospital and Health Service 2018). Diagram 2 demonstrates the impact of chronic disease within our communities and bed optimisation opportunities.

Diagram 2. The current state – Chronic Disease Patient Profile (Deloitte 2018)

3. Challenges The outcomes of the Deloitte’s review and consultations highlighted existing gaps in the coordination of care, siloed service delivery in response to funding and provider-centred models, historical disease focused approaches, with duplication of capabilities. Additionally, it was also identified that General Practitioners lacked alternative pathways to the Emergency Department for those patients who required urgent (not emergency) care (see Diagram 3).

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Diagram 3. The current state of an urgent patient episode (Deloitte 2018)

• Presentation to an emergency department which is effectively the only care option in an acute episode after hours, and the only real alternative for GP care within standard business hours.

• If a General Practitioner (GP) seeks urgent specialist referral their only timely option is to refer patients to the emergency department.

• QAS only has the DEM as a point of patient care and with this, no existing ability for diversion with timely review and follow-up.

• The current model provides sporadic, disjointed and often siloed service across the WBHHS population. This can cause duplication, inefficiencies, consumer confusion and dissatisfaction.

• Services offering case management capability are reactive with timely delays in processing referrals.

• Patients often fall through the gap once discharged from an episode of care because of complex health care systems, health literacy levels, biopsychosocial and economic factors.

• Communication and engagement across health care systems is limited due to multiple Information Technology solutions and siloed roles between health systems.

While the Deloitte’s Integrated Care review highlighted opportunities to improve the health and wellbeing and health care journey for patients, this integrated model creates an innovative way of conducting business across the patient chronic disease journey. With the supporting leadership structure and Executive sponsorship, this model will create meaningful system improvements, engagement and a culture change which will encourage and pioneer integration within teams, across streams, specialties and systems. This will be exhibited through improved communication, transparency of information, streamlined processes, efficiencies, and improved staff and patient satisfaction… where ‘Care comes first… through patients’ eyes’. In response, a design process of the model was undertaken and included:

• Initial consultations with WBHHS clinicians on existing service needs and issues

• Data analysis to support model design

• Design workshops involving a broad range of WBHHS clinicians and stakeholders

• Validation of a model with WBHHS clinical leadership groups

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4. Current Leadership structure

The current Integrated Care Service reporting structure is a consequence of historical positions and structures which have resulted in small and siloed sub teams. WBHHS Human Resources (HR) acknowledged the current leadership structure was unsustainable and inefficient with the Operations Director having over 40 direct reports and misalignment of existing leadership roles due the eclectics of professional and service delivery models. It was recommended that realignment of existing leadership positions be consistent with an integrated approach.

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5. Proposed Integrated Care Service realignment

In line with the 2017 WBHHS HR recommendations and the proposed Integrated Care Model, the below diagram graphically represents the proposed realignment with emphasis on Chronic Disease and Rehabilitation functionality when clustering roles and leadership.

Chronic Disease

Rehabilitation

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6. Proposed Leadership structure.

Significant change is proposed for the three leadership roles indicated below. The details and impact of these changes are outlined below. These leadership positions have been realigned in appreciation of subordinate roles and functions, while ensuring operational accountability is manageable, effective, efficient and sustainable. Furthermore, this design hopes to unify core team objectives and standards in line with the Integrated Care Model and Integrated Care Service ethos.

1. 2. 3.

4.

.

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1) 1.0 (FTE) Nurse Unit Manager Community Hospital Interface Program Bundaberg Hospital (30481564)

History: This position is a legacy dual role position that has encompassed a small CHIP and Diabetes teams without integration with broader Chronic Disease clinicians sitting under other teams. As this position manages a multi-disciplinary team, it is proposed that this position remain a dual role.

New Title: Nurse Unit Manager / Team Leader Integrated Care – Bundaberg

Benefit:

• This is in line with the proposed Nurse Unit Manager / Team Leader of Integrated Care – Fraser Coast

• Integration of existing chronic disease and hospital avoidance clinicians in line with the proposed Integrated Care Services Model

• Operational management 26.38 (FTE)

• Cost neutral - Nurse Grade 7

Impact:

• This position is currently vacant

• Clinical Nurse Consultant – Respiratory will report operationally to this position, rather than the Operations Director for Integrated Care Services

• Nurse Navigators will report to this role operationally, rather than the Nurse Unit Manager Nurse Navigator Service

• This position will report to the Operations Director Integrated Care Service

• Nurse Unit Manager professional management through Nursing Director - Division of Medicine Bundaberg and Hervey Bay

• Allied Health Team Leader professional management through Executive Director of Allied Health

• Professional management of all other positions within this structure will be through the respective discipline Director

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2) 1.0 (FTE) Clinical Nurse Consultant - Hospital to Community (32001697) History: This is a historical position with line management function and accountabilities that are indicative of a Nurse Unit Manager role description rather than Clinical Nurse Consultant specialty. As this is a position manages a multi-disciplinary team, it is proposed that this position be made into a dual role. It is therefore proposed that this role is changed to:

New Title: Nurse Unit Manager / Team Leader Integrated Care - Fraser Coast

Benefit:

• This is in line with the Nurse Unit Manager / Team Leader of Integrated Care – Bundaberg

• Integration of existing chronic disease and hospital avoidance clinicians in line with the proposed Integrated Care Services Model

• Management of 24.9 (FTE)

• Cost neutral - Nurse Grade 7

Impact:

• This position is currently vacant

• The Diabetes Educators, Discharge Planner, Occupational therapist and Cardiac Rehabilitation Clinical Nurse, Dietician, Physiotherapist will now report operationally to this role, rather than the Operations Director for Integrated Care Services

• Nurse Navigators will report to this role operationally, rather than the Nurse Unit Manager Nurse Navigator Service

• This position will report to the Operations Director Integrated Care Service

• Nurse Unit Manager professional management through Nursing Director - Division of Medicine Bundaberg and Hervey Bay

• Allied Health Team Leader professional management through Executive Director of Allied Health

• Professional management of all other positions within this structure will be through the respective discipline Director

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3) 1.0 (FTE) Team Leader Transition Care Bundaberg (NG7: 30490219 / HP5: 32032257)

History: This is a legacy position which has historicallly managed the Transition Care Program (TCP) team at Bundaberg which has led to a differing TCP processes and standards across the district rather than a coordinated approach.

New title: Team Leader Transition Care WBHHS NG7/HP5

Benefit

• Health service wide position

• Integration of rehabilitation clinicians in line with the proposed Integrated Care Service Model

• Management of 22.1 (FTE)

• Cost neutral - NG7/ HP5

Impact:

• This position is currently vacant

• The Equipment Officer, Admin Officer, Occupational Therapist, Clinical Nurse Case managers, Physiotherapist currently within the Transition Care Program team in Bundaberg team will report to this position rather than the Nurse Unit Manager Community Hospital Interface Program

• Admin Officer, Occupational Therapist, Clinical Nurse Case managers, Physiotherapist currently within the Transition Care Program team in Fraser Coast team will report to this position rather than the Operations Director Integrated Care Services

• Speech Pathologist, Cardiac Rehabilitation CN, Social Worker on the Fraser Coast will report to this role, rather than the Operations Director of Integrated care Service

• This position will report to the Operations Director Integrated Care Service

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• Nurse Unit Manager professional management through Nursing Director - Division of Medicine Bundaberg and Hervey Bay

• Allied Health Team Leader professional management through Executive Director of Allied Health

• Professional management of all other positions within this structure will be through the respective discipline Director

4) Nurse Unit Manager Nurse Navigator Service (32041986)

History: This position was created at the commencement of the Nurse Navigator Service and the current operation lead for the Nurse Navigator Team across the Wide Bay district.

New Title: Nurse Navigator Integrated Care Quality and Innovation (WBHHS) Benefit:

• Support Operations Director

• Clinical lead role for Integrated Care Services including Nurse Navigator Service

• Integrated care Model implementation and embedment and lead

• Change Management

• Ongoing quality improvement and innovation within the Integrated Care Service and Nurse Navigator Service

• Maintains Service delivery standards and KPI’s

• Responsible for local and OCNMO reporting and clinical state-wide representation for Nurse Navigation

• Cost Neutral – Nurse Grade 7

Impact:

• This position is currently vacant

• Professional management through Nursing Director – Division of Medicine Bundaberg and Hervey Bay

• Position reports to Operations Director for Integrated care Services

7. Positions Within the Redesign Without Change

1.0 FTE Team Leader Aged Care Assessment Team (HP5 - 30484431)

1.0 FTE Clinical Nurse Consultant Complex Care (NRG 7 - 32006469)

1.0 FTE Nurse Practitioner Heart Failure FC (NRG8 – 30493624)

1.0 FTE Nurse Navigator / Nurse Practitioner Heart Failure BBH (NRG8 – 32053513)

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8. Proposed Reporting Lines (changes in italic) Where there are current substantively vacant roles, these roles will be filled through an advertised open merit process

Operations Director Integrated Care

Position number

Position title Classification Incumbent

32001697 NUM / Team Leader Integrated Care FC

NRG7 Vacant

30490219/ 32032257

Team Leader TCP NRG7/HP5 Vacant

30484431 Team leader ACAT NRG7/HP5 Vacant

32041986 OR 30494228

Nurse Navigator Integrated Care Quality and Innovation

NRG7 Vacant

30481564 NUM / Team Leader Integrated Care BBH

NRG7 Vacant

32006469 CNC Complex Care NRG7 Pauline Blaney

30493624 Nurse Practitioner Heart Failure

NRG8 Kalvyn Judge

32053513 Nurse Navigator - Nurse Practitioner Heart Failure

NRG8 Vacant

32048516 Clinical Support officer AO3 Temp (Katie Russell-Green)

NUM / Team Leader Integrated Care (Bundaberg)

Position number

Position title Classification Incumbent

32002707 CNC Respiratory NRG7 Maxine Barker

32017181 Clinical Nurse Diabetes Education

NRG6 Tracey Devine Antoinette Hollett Marie MacDougall

32042259 Nurse Navigator

NRG7 Naomea Caville Di Gee Fay Clark Angela Wotherspoon Rachael Spanner Peta Thompson Gillian Wilkie Caroline Facer Will increase to a total of 10 FTE

32017180 Registered Nurse Diabetes Education

NRG5 Anita Smith Antoinette Hollett

30488791 Admin Officer AO3 Diane Donnarumma

30491580 OSO Personal Care (casual)

OO3 Vacant

30490798 OSO Personal Care Worker

OO3 Catherine O’Donnell

30490852 CNC Discharge Manager NG7 Vacant

30477314 Clinical Nurse CHIP NRG6 Carol Banks

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Allison Coe Jane Cutler Angela Ellis Barbara Fulton Jacqueline Gordon Vanessa Kroon Susan Livingston Cecilia Morrison Kathryn Young Wendy Graham

32054580 Registered Nurse (casual)

Susan Ambrose

30491025 Senior Occupational Therapist

HP4 Seona Areaiiti

30490944 Senior Pharmacist HP4 Tracey Watson

30490186 Admin Officer CHIP AO3 Sharon Small

32054307 Diabetes Educator NRG5 Vacant

NUM/Team Leader Integrated Care (Fraser Coast)

Position number

Position title Classification Incumbent

30475721 Clinical Nurse Adult Health (HBH discharge planner)

NRG6 Vacant (temp filled)

32042259 Nurse Navigator NRG7 Kristen James Maxine Rose Catherine Birkett Karen Brandt Gillian Lang Liza Watkins Glen Bovey Caroline Kerr Will increase to a total of 10

32013068 Combine these three Pos Ids

Clinical Nurse Hospital to Community (HITH)

NRG6 Therese Peck

30473622 Clinical Nurse Hospital to Community (HITH)

NRG6 Carol Burns Adelle McCallion

30468445 Clinical Nurse Hospital to Community (HITH)

NRG6 Clare Fowler Kim Machen Tracey Simmons

30494228 CN Pt Flow Coordinator NRG6 Vacant

32006562 CN Discharge Planner NRG6 Vacant (temp filled)

32042646 CN Supportive Therapies

NRG6 Ann Orr

32042492 RN Supportive Therapies

NRG5 Jan Bond

30468447 Clinical Nurse (casual) NRG6 Vacant

30468413 Clinical Nurse Diabetes NRG6 Lisa Doyle

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Educator

32003101 HP Senior Diabetes Educator

HP4 Karin Lategan

32005484 Senior Social Worker HP4 Rebecca Torkington

32054389 Supportive Therapies (Casual)

NRG5 Paul Cantrell Joanne Proudley Mary Osmak Sarah Wren Sarah Leak Tamara Tabulo Bianca Wilkie Michelle Hebblewhite Maxine Henderson

30485788 Senior Dietitian HP4 Melanie Englezakis

30480483 Senior Physiotherapist HP4 Catherine Wood

Team Leader Transition Care (WBHHS) (NG7: 30490219 / HP5: 32032257)

Position number

Position title Classification Incumbent

30479817 Clinical Nurse Case Manager

NRG6 Eileen Franklyn Beverley Goldenstein Marlene Lang

30490555 Therapy Assistant OO3 Angela Beddows Vickie Schurmann

30468422 Senior Physiotherapist

HP4 Vacant

32022745 Senior Occupational Therapist

HP4 Ramakanth Iluri

32000147 Case Manager TCP HP3 Gillian Richter

32032186 Physiotherapist HP3 Emelyn Jovic

32006537 Speech Pathologist HP3 Quaneta Greenwood

32027328 Therapy Assistant OO3 Narelle Maclean Jacqueline McDermott Kerri Samuels Hayley Steffan Vacant 0.64 Kellie Williams

32029463 Therapy Assistant (casual)

OO3 Vacant

32006531 Operational Service Officer (Equipment)

OO3 David Allen

32000772 Combine 32000772 and 32018610

Clinical Nurse Case Manager

NG6 Tanya Moroney Ann Todd Tania Tognolini

32018610 Clinical Nurse TC BU NRG6 Sheryll Habermann

30481199 Senior Occupational Therapist

HP4 Mikaela Hawkins

32010760 Senior Physiotherapist HP4 Brandy Johnson

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30481198 Admin officer TCP AO3 Suzanne Larsen Kaylene Zunker

30468392 CN Cardiac Rehab NRG6 Philip Wells

Team Leader ACAT (WBHHS)

32045199

Clinical Nurse ACAT BU NRG6 Rachael Herkes Kylie Wilson Marianne Bugg

30468433 Clinical Nurse ACAT HB NRG6 Kathryn Davis Caroline Lowe

30482917 Clinical Nurse ACAT (Casual)

NRG6 Karen Black

30497461 Senior Occupational Therapist

HP4 Kelley Hickey

30468432 Senior Social Worker HP4 Jason Dally Amanda Gorry

30478982 HP ACAT Relief (Casual)

HP3 Vacant

9. Financials These are existing funded positions, subsequently is cost neutral with current staffing model.

10. Other Significant Re-Alignment

1.0 FTE CNC Cannulation BBH (32012762) History: Role is purely proceduralist and fits more with an inpatient model rather than a hospital avoidance model. 95% of current workload is inpatient based. Benefit:

• Alignment with inpatient teams as per indicative work requirement

• Sustainable service model through upskilling and succession planning

• Senior role working in line with Advanced Practice Nursing Framework providing education and upskilling Nursing staff across the WBHHS district including to Integrated Care CN’s.

• Nursing Director Division of Medicine consulted and endorsed Impact:

• Re-align to ND Medicine/NUM MCDU

• Permanent incumbent – Stephen Sinclair

• Significant change management process required 1.0 FTE HP4 Social Work (30491081) and 1.0 FTE HP4 Physiotherapist (30491027) See Appendix A ‘Physiotherapy and Social Work Brief’.

11. Recommendation It is recommended that this Integrated Care Model and Leadership re-alignment are endorsed and implemented as outline above.

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12. Next Steps The following steps will be followed:

Date Activity 8th August 2019 Executive approval and sponsorship

Week commencing 2nd September 2019

Correspondence with relevant unions to present Proposed Business Case for Change

Week Commencing 2nd September 2019

Meet directly with affected staff

Week Commencing 9th September 2019

Meet directly with indirect staff

Week Commencing 16th September 2019

Meet with individual affected staff upon request

Week commencing 23rd September 2019

Collate feedback

Week commencing 30th September 2019

Analyse feedback and adapt model and re-alignment

Week commencing 7th October 2019

Further period of consultation

Week commencing 21st October 2019

Implementation Phase

13. Supporting Employees through Change We appreciate this may be a difficult time for affected employees. The following support activities are offered to support staff.

• encouragement to contact the Employee Assistance Service (EAS) on 1300 687 321. This confidential service can be accessed through self-referral to Converge International, the external EAP service provider. Services are available 24 hours a day, seven days a week, and 365 days a year, at no cost. Counselling services are available face to face or by telephone. Additional information available at: http://qheps.health.qld.gov.au/eap/

14. Feedback contacts Stakeholders are invited to provide feedback by the 27th September 2019 regarding the business case. Feedback may be provided to the following officers by email, phone or face to face: Kristen James: Integrated Care Lead Email: [email protected] Peter Wood: General Manager Division of Medicine Email: [email protected]

15. Research Opportunities The Integrated Care Service will investigate opportunities for research that demonstrates which the model’s outcomes and achievements to local, national and international audiences. The success of this model stands to put WBHHS on the global map for innovation in health and research in the field of Person-centred, Integrated health care strategies.

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16. References Commonwealth of Australia, 2009, ‘Emergency Triage Education Kit’, Canberra, [online] 23rd May 2019 https://www.health.gov.au/internet/main/publishing.nsf/Content/387970CE723E2BD8CA257BF0001DC49F/$File/Triage%20Quick%20Reference%20Guide.pdf

Deloitte, 2018, ‘WBHHS Integrated Care Service Project: Integrated Care Services Model-Solutions Design Report’, Brisbane QLD PHN, 15/16, ‘Local Government Area Profiles: Wide Bay’, https://www.ourphn.org.au/wp-content/uploads/2017/03/LGA-profiles_Wide-Bay-final.pdf, [online] 21st June 2019 Wide Bay Hospital and Health Service, 2017 ‘Wide Bay Hospital and Health Service Strategic Plan 2015-2019 (reviewed and Updated 2017)’ Bundaberg, Queensland, [online] https://www.health.qld.gov.au/__data/assets/pdf_file/0022/157441/strategic-plan-2015-2019.pdf 21st June 2019 Wide Bay Hospital and Health Service, 2018, ‘Care Comes First…Through Patient’s Eyes, Strategic Plan 2018-2022, Bundaberg, Queensland, www.health.qld/gov.au/widebay WHO 2016, ‘Framework on Integrated, people-centred Health Services’, World Health Organisation, Report, Sixty-Ninth World Health Assembly Provisional Agenda item 6.1, [online] http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf?ua=1, 14th June 2019

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Appendix A: – Physiotherapy and Social Work Brief Proposal That the General Manager of Medicine approve a consultation in relation to reviewing the reporting lines of the CHIP Physiotherapist, Social Worker and Pharmacist:

Urgency Routine – proposed model of care and reporting line review as there are opportunities for efficiencies

Key issues

• The Social Work and Physiotherapy workload within CHIP is primarily servicing the Emergency Department (ED) at Bundaberg Hospital, rather than CHIP outreach to homes. A growing demand over the past 10 years has resulted in 60% of their work now being done within the ED department.

• The challenge with the model is that if the Social Worker or Physio is off site providing a community intervention, then there is no rapid service for Emergency Department which impede patient flow and subsequently impact the NEAT targets.

• Having single disciplines within the CHIP team (Social Work, Physiotherapy) has resulted in having no workforce capacity to cover emergent leave and often require agency locums to backfill planned leave. This leaves the allied health service provision in ED at risk as we have no sustainable options to cover leave.

Background

An Allied Health service within the CHIP team has provided hospital avoidance and outreach to home services for 15 years. The workload also included service provision for the Emergency department and Hospital in the Home Service. The Allied Health component provided is within CHIP is: - Physiotherapy - Social Work - Occupational Therapy

The Physiotherapy and Social Work statewide models highlight that the inpatient teams manage the Emergency Department caseload as they are always on site and can prioritise within the broader acute workload. Bundaberg Hospital is the only service in Queensland (for a medium sized hospital) where the Physio and Social Work Emergency Department interventions are provided by Community Interface clinicians. Following a workload review, the emergency department caseload comprises approximately 60% of the Physio and Social Work caseload. On the Fraser Coast Emergency Department interventions are provided by the acute Allied Health departments, so it is timely to review the model for these two disciplines. Occupational Therapy (OT) services are not commonly provided within EDs in hospitals the size of Bundaberg. Which is shown in the activity reports (only 3 patients in a 12 month period in Bundaberg ED). The OT role within CHIP provides hospital avoidance interventions

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in patients home, providing 300 home visits in a 6 month period. Following a workload review 98% of the caseload is community based, this role also supports the Transition Care OT position (so there is a more sustainable workforce). Subsequently no change is proposed to this position.

Consultation Operations Director Integrated Care A/Director of Allied Health Bundaberg General Manager Division of Medicine General Manager Family and Community

Financial implications There are no financial risks – it is proposed that 2FTE within establishment may move to an alternate organisational unit.

Legal implications 1. There are no legal implications

Impact The Physiotherapy and Social Work roles will be supporting the Emergency Department, bolstered by the GEDI service. Integrated Care service model will not be impacted. Reporting line changes for Social Work and Physiotherapy from CHIP to Allied Health

Recommendation Approve the reporting re-alignment of the CHIP Physiotherapist and Social Worker to the Allied Health Department