Influencing Demand – Altering Preload for Canterbury EDs Dr Greg Hamilton Planning and Funding.

Influencing Demand – Altering Preload for Canterbury EDs

Dr Greg HamiltonPlanning and Funding

The Problem

• Longer stays driven by three factors

• Need system-wide solutions

Pre-loadcommunity activities to

reduce demand

Contractilityeffective functioning of

ED

After-loadservices to accept people from ED –

hospital and community

Outcomes logic - Pre-load

Data Driven Response – Weekly Dashboard

Patients arriving at ED

ED attendances

ED admission rate

111 calls transported to ED

Managing Acute Demand

• Supported Discharge and CREST• After Hours and Nurse led telephone triage• Acute Demand Management Services

Opportunity for People to Stay Home

755

755 clients so

far2,600

Capacity to manage 2,600 pa

CREST

17% 17% decline in rest home bed days over 2 years

18,000 18,000 acute admissions managed in the community

Ambulance diversion to primary care as required

CREST Activity

Nurse led telephone triage

Acute Demand Management Services (ADMS)

• Community-based health services to support patients who can be safely managed in the community

• Applied during an acute medical episode (up to 5 days)

• When a hospital presentation would otherwise be imminent

• Commenced in 2000 within urban Christchurch to support extend patient care

Where we have been?

• In 2000, ADMS commenced within urban Christchurch to support Pegasus practices to extend patient care

• Since October 2007 services expanded to all Canterbury patients from Kaikoura to Ashburton

• Engagement of general practice

ADMS: a collaborative approach

• Acute community nursing services• Community observation services• Timely supported discharge liaison service (hospital-

based)• Service coordination• Packages of Care (POC) – general practice• Rapid diagnostics: radiology and lab services• Consumables• 5 hours/1000 patients (post quake)

Who refers to ADMS?

• Any health professional can refer a patient into ADMS who would otherwise need assessment and/or treatment within Secondary Care– GP– Practice nurse– Community nurse– Midwife– Ambulance paramedic– Hospital physician or staff nurse (ED and inpatient)

Monthly referrals to ADMS

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Nov Dec Jan

Feb

Mar

Apr

May Ju

nJu

lAu

gSe

pO

ctN

ov Dec Jan

Feb

Mar

Apr

May Ju

nJu

lAu

gSe

pO

ctN

ov Dec Jan

Feb

Mar

Apr

May Ju

nJu

lAu

gSe

pO

ctN

ov Dec Jan

Feb

Mar

Apr

May Ju

nJu

lAu

gSe

pO

ctN

ov Dec

Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4

2007 2008 2009 2010 2011

ADMS referrals

ADMS referral monitoring

ADMS Referrals – Variation by General Practice

0 2,000 4,000 6,000 8,000 10,000 12,000 0

1

2

3

4

5

6

7

Data

Average

2SD limits

3SD limits

Enrolled Population

Re

ferr

als

as

a P

erc

en

tag

e o

f En

rolle

d P

op

ula

tion

Source: Acute Demand Referrals Nov 2009-Oct 2010

Most Common Referrals to ADMS

Celluliti

s

Chest P

ain

Asthm

a

DVT Path

way

Abdomin

al Pain

Pneumonia

Shortness

of B

r...

Chest In

fect

ion

COPD

Gast

roente

ritis

0

1000

2000

3000

4000

5000

6000

Oct 2007- Jul 2010

The New ChallengeADMS Post 22 February...• Increased breadth of ADMS services available to high needs patients• Population determinants of health (especially housing) mean increased risk

of deterioration and hospital attendance• Proactive management of vulnerable population by general practice – 5

hours/1000 patients• ADMS re-invigorated with General Practice Teams through Pegasus Education

to increase utilisation

22

Change in inpatient discharge rates (2000 – 2009)

Acute Medical Discharges

Canterbury Auckland Combined

Waitemata Auckland Counties0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40 2006/07

2009/10

NZ

Next Steps

• ADMS Service Level Alliance established - clinical and service leadership to drive service development and improvement– ADMS in residential care– Stronger linkages with St John– Community management for COPD– Service improvement – coordination, problem solving,

trust, acute nursing• Project Chain – coordinated care management