Phase Three – Solutions Design Sydney South West Area Health Service CCCC C HRONIC AND C OMPLEX C ARE C OLLABORATION C AND C OORDINATION.

Phase Three – Solutions Design

Sydney South West Area Health ServiceCCHRONIC AND CCOMPLEX CCARE CCOLLABORATION

AND CCOORDINATION

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Scope of the Project

Patients with multiple chronic & complex conditions (identified diagnoses)

Patients who can be safely managed in the community setting.

Patients presenting to Concord and Canterbury hospitals on more than 2

occasions in a calendar year.

Patients over the age of 16 years .

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Avoidable Admissions (the defined 8 DRGs)

• Community Acquired Pneumonia (E62C).

• Chronic Obstructive Pulmonary Disease.

• (E65B) Bronchitis and Asthma (E69C).

• Deep Venous Thrombosis (F63B).

• Acute Non-Surgical Pain (musculotendinous) (I71C).

• Cellulitis (J64B).

• Urinary Tract Infections (L63C).

• Red Blood Cell Disorders and Transfusions (Q61C).

• Respiratory chronic conditions

• Cardiac chronic conditions

• Coronary artery disease.

• Hypertension.

• Diabetes

Chronic & complex condition disease groups

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Engagement of GPs

• Invitation to participate in Working Parties & interviews

• Presented the GPC Division

• Survey via GP Division

– What works well?

– Gaps?

– Would you like to be involved?

• Newsletters

Most Prominent Issues Identified by Patients and Staff

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16

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Most Prominent Issues Identified by Patients and Staff

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Diagnostic themes identified

• Communication

• End of Life / Advance Care planning

• Discharge planning

• Self Management

• Duplication & fragmentation of coordination

• Case management

• Team work

• Lack of single point of contact

• Managing exacerbation in the community – medical governance

• Information systems & info sharing

• Referral processes

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Diagnostic Report – April 2010

Sydney South West Area Health ServiceCCHRONIC AND CCOMPLEX CCARE CCOLLABORATION AND CCOORDINATION

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Patient journey – the current journey

Hospital presentation

Discharge / Transfer of care

Community Care

Self Management

Deterioration / Acute Exacerbation

Health Review

Coordination of Care

Case ManagementHospital care

Patient journey – the desired journey

Deterioration

Hospital presentation

Discharge / Transfer of care

Community Care

Self Management

Deterioration / Acute Exacerbation

Health Review

Coordination of Care

Case ManagementHospital care

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Solutions • Expansion of CERNER to include Patient Care Plans• Flagging of C&CC patients in the EMR / CERNER• GP access to CERNER, sharing medical care & pt action plans• Single point of contact• Hospital in the Home / Ambulatory Care – rapid assessment/

community treatment• Care plans• Patient held file• Case Management of High Risk Patients• Improved discharge processes• Increased self management• Advance Care Plan• Electronic Service Directory• Discharge follow-up

What next

We

are

here

•Finalising Solution Design report•Implementation Working Parties•Recommendations•Cost Benefit Analysis

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Project Team & Contact Details

For further information or to contribute to the Solutions, please contact the Project Team:

Sue Schasser [email protected]

Debbie McNamara [email protected]

Peter Reisinger [email protected]