Kim Fraser, Metro North Hospital and Health Service, Queensland - Acuity Measurement of the Post-Acute Client- Enabling Prioritisation for Service Response

Metro North Hospital and Health Service

Acuity Measurement of the

Post Acute Client:

Enabling Prioritisation for

Service Response

Kim Fraser

Nursing Director

Post Acute Care Service

Sub Acute and Ambulatory Service

Metro North Hospital and Health

Service


Metro North Hospital

and Health Service

• 850,000 population

• 4,157 square kilometres

• Brisbane River to north of Kilcoy

• Rural, regional and tertiary hospitals

• Acute, post acute, subacute, rehabilitation, aged care, oncology, palliative care, psychiatric, women’s and newborn services.


Objectives of Presentation

• Overview Post Acute Care Service

• Background

• Description of the Acuity Tool

• Rationale for use of Acuity tool

• Case study

• Results of initial implementation

• Recommendations


Brief Overview PACS

• 7 day per week post acute

hospital avoidance

• ED or admitted patient.

• Short term MD interventions

to address immediate care

needs

• Rapid response


PACS • Service linkages

• High risk for representation / readmission

• Support acute facilities in meeting NEAT / NEST

• Average 620 referrals per month


PACS

• Average LOS 14 days

• Average Age 80-89 years

• 55% Female

• Average will require 2.5 disciplines

• Inpatient DRG: – Hip replacement with complexity

– COPD

– Rehabilitation

– Patient > 64 years with injuries


Background • 2013 underwent extensive service

redesign

• From HACC and Chronic Disease service

to a rapid response post acute service

• Review of national and international

literature on PAC models identified the

value of acuity measures


Background cont…

• Literature review identified:

– no published evidence (Aust)

– 2 published acuity tools (UK and

Nth America)

– UK tool lacked reliability;

resource intensive; not

developed for the

MD team


Case Management Acuity Tool

• Developed by Hubber, D.L. and Craig,

K. (2007) for use within a telephonic

chronic disease case management

health service

• Captures the evidence base of case

management activities and measures

case management outcomes


Acuity Tool Development

• Literature review

• Gap analysis

• Clinical experts monitored development and testing of the tool, concepts, scores, differentials and their operating principles

• Pilot phase testing (n = 3,000) – interrater reliability testing and content validity

• (β) testing for content and appropriateness

• Representative sampling size testing

• Expert panel reviews


Why the Need for an

Acuity Tool?

• Providers of clinical services are required to demonstrate value.

• What benefits are achieved beyond the traditional measurements of cost savings or cost avoidance?

• How do we measure, compare and then evaluate interventions as to their effectiveness and cost?


Acuity Tool

The Acuity Tool:

• Quantifies a client’s complexity (or acuity).

• Links duration, quality, quantity and volumes of

health care interventions required.

• Provides a quantifiable indicator of

measurement which can be applied across care

points in time from admission to discharge.

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What does the CM-Acuity Tool

Measure?

• Dosage

• Acuity


Dosage

• Dosage – two main variables:

– The activities carried out by the provider in

the delivery of the intervention

– The amount of time these activities take

• These variables do not capture the

complexity of interventions or

complexity of client needs


Dosage cont…

• The four essential elements of

intervention dose are:

– Amount

– Frequency

– Duration

– Breadth (Huber et al., 2003)

• Too much or too little of a dose may

result in harm; inefficiency and

ineffectiveness


Acuity

• Defined as severity of illness or client condition that indicates the need for intensity of the interventions

• Acuity links duration, quality, quantity and volume to key points of service delivery.

• Intensity is a term related to acuity that represents the amount of care and complexity of care needed by the patient.

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Case Management – Acuity Tool©

• The Acuity Tool©: contains indicator,

drivers and subdriver categories. The

three indicators take the form of:

• Clinical Indicators

• Psychosocial indicators

• Environmental indicators


Acuity Tool

• April 2014 – permission from author to

implement tool with minor modifications.

• Tool within Australian context renamed:

• Concise Acuity Tool for Australian

Healthcare©





Inc

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sin

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om

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y


2 1 2 5


2 1 2 5


Acuity

Score

Complexity

Score

Priority

Score

3-4 Basic 1

5-6 Good 2

7-8 Fair 3

9-10 Moderate 4

11-12 Highest 5


Initial Implementation

• Ease of use

• Quick to use (approximately 1-3 minutes)

• High clinician engagement

• Ability to predict workload capacity

• Ability to predict patient flow problems

• High scores reflect high complexity

• High scores reflect high risk for rehospitalisation

• Sub-drivers not sensitive enough for some disciplines


Test Inter-rater Reliability

• 32 inpatients (RBWH) were assessed prior to

discharge

• 29 patients assessed on admission to PACS

• Minimal divergence of scores (from hospital

to home)

• Higher the score the higher the complexity

and the higher the risk of

representation/readmission


How has PACS used the Acuity

Tool?

The acuity tool has enabled the Service to:

• Capture client acuity scores on admission

and discharge

• Analyse and compare acuity scores from

admission and discharge

In the future the tool will assist with:

• Determining capacity and flow processes

• Predict workload allocation accurately


Case Study - Molly


Molly • Molly 93 year old female

• Presented to ED after fall – large skin tear on leg, bruising and black eye

• MMSE 23/30

• History - Parkinson’s, multiple falls in past 3/12, family noticing changes and concerned

• Lives alone, has no services and resistant to services

• High risk of representation/readmission to ED

• Referred for medication supervision, wound care, home safety assessment, mobility assessment


Molly cont…

• Home had numerous trip hazards

• Not using previously prescribed mobility aids (stick and frame)

• Unsure of medications and their use - non adherence to medication regime

• Family supportive – not wanting to be a burden on them

• Required support with personal hygiene

• MST score = 3 (irregular eating patterns)



Clinical

Indicators

Psychosocial

Indicators

Environmental

Indicators

CN4

Multiple S&S

requiring MD

intervention

PS3

Minimal adherence

to care plan – does

not accept advice

for safety or use

prescribed walking

aids

Q3

Substantial

improvements

required for safety

Admission Score

4

Admission Score

3

Admission Score

3

Total Admission Acuity Score = 10

Complexity Score = Moderate

Priority Score = 4


Molly cont… Over 2 week journey Molly had assistance with:

• Showering and wound care

• Medication review and education – Webster pack

• OT and PT intervention – education on use of frame and stick – modifications to bathroom

• Dietitian review of weight loss and education – high protein drinks

• SW assisted with family and client education in relation to future care needs

• Liaison with GP re Molly’s care needs and MMSE score (Molly refused referral to Memory Clinic)

• Agreed to some community supports: – NGO for ongoing nursing support and personal care

– Meals on Wheels



Clinical

Indicators

Psychosocial

Indicators

Environmental

Indicators

CN3

Multiple S&S

requiring support

from one discipline

(or minor

interventions from

other disciplines)

PS2

Mostly cooperative

and adhering to

care plan – may

occasionally forget

medication

Q3

Minimal

modifications

required for safety

A = 4 D = 3 A = 3 D = 2 A = 3 D = 2

Total Admission = 10

Complexity = Moderate

Priority = 4

Total Discharge = 7

Complexity = Fair

Priority = 3


Evaluation

• Data capture commenced April 1, 2014

• Only those patients who had completed

their journey of care (and had a

discharge acuity score recorded) by

June 30, 2014 were included in sample.

• Sample size = 765

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Characteristics Number

Total sample size 765

Female 445

(58%)

Male 320

(42%)

Age range 24 - 102

Average age 74 years

Range of Acuity scores 3 - 12

Mean Acuity score on admission 6

Mean Acuity score on discharge 4

Demographics


Comparison of Admission and Discharge Acuity Scores.

N=765

0

20

40

60

80

100

120

140

160

180

3 4 5 6 7 8 9 10 11 12

Acuity Score

Nu

mb

er o

f C

lien

ts

Admission Acuity

Discharge Acuity


Grouped Acuity Scores on Admission and Discharge

472

(62%)

595

(78%)

293

(38%)

169

(22%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Admission Discharge

Nu

mb

er o

f C

lien

ts

Acuity Score 7-12

Acuity Score 3-6


Acuity > 7 by Age Group on Admission and Discharge

109

(63%)

152

(64%)

32

(62%)

65

(37%)

85

(36%)

20

(38%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

24-60 61-80 81-102

Age Group

Percen

tag

e

Discharge

Admission


Lesson’s Learned

• Sub drivers not always clear for all

disciplines (including wound clinic) –

requires further work

• Repeat reliability and validity studies

within the post acute setting

• Engagement from staff of the process

and the tool has been positive


Recommendations

• Conduct further research on the reliability and validity of the tool

• Apply the tool to E-Referral process – which will enable discharge planners to assess acuity and drive a priority response from the acute setting

• Electronic solution to enable the ‘live’ display of team and discipline acuity scores (assist in resource distribution)


Thank You

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Kim Fraser, Metro North Hospital and Health Service, Queensland - Acuity Measurement of the Post-Acute Client- Enabling Prioritisation for Service Response

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