Keeping Patients at the Centre of Transitions of Care: Translating report findings into action

Dr Lesley Russell, Australian Primary Health Care Research Institute, ANU Dr Paresh Dawda, Australian Primary Health Care Research Institute, ANU Dr Kelly Shaw, KP Health, Tasmania

Outline of Presentation Lesley Russell: Findings of a report done for National Lead Clinicians’ Group.

Paresh Dawda: What does this mean for patients?

Kelly Shaw: A policy and practice perspective.

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The Report

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Patient safety – handover of care between primary and acute care Policy review and analysis Prepared for the National Lead Clinicians Group by the Australian Primary Health Care Research Institute, ANU

Russell l. Doggett J, Dawda P & Wells R. March 2013

http://www.leadclinicians.health.gov.au

Report focus – patients as the one constant PRIMARY &

COMMUNITY-BASED

CARE  

ACUTE CARE   PRIMARY &

COMMUNITY-BASED

CARE  

 

 

General Practice /AMS

-­‐ Specialists

-­‐ Allied Health

-­‐ Mental Health /

Substance Abuse

-­‐ Community Health

Services  

Hospital

Incoming may be

planned or via ED

Outgoing may be via

Transition Care  

General Practice /AMS

-­‐ Specialists

-­‐ Allied Health

-­‐ Mental Health /

Substance Abuse

-­‐ Community Health

services  

Aged Care

-­‐ Community

-­‐ Residential  

Aged Care

-­‐ Community

-­‐ Residential  

Hospital in the Home   Hospital in the Home  

  Rehabilitation  

  Palliative Care  

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Transitions of Care

Clinical aspects of care transfer PLUS

Patient’s needs, preferences, experiences •  Clinical information •  Physical and mental functional status of patient •  Suitability of patient’s home environment •  Availability of carer, family, support system •  Ability to obtain medicines, needed healthcare & social

services / availability of transportation

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Australian Research and Experience Take-out •  Many previous initiatives that can contribute to learning. •  Many current initiatives around coordinated care that are

closely related to this issue. •  Effective communication (giving & receiving) needed. •  Need for shared terminology and communications

systems. •  Time is a key resource; reimbursement is a key issue. •  What are the incentives that will change the behaviours

of all stakeholders?

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International Research and Experience Take-out •  Risk modelling approaches can help identify patients

needing increased oversight during / after transitions of care (UK).

•  ‘Transitions Coach’ can be cost-effective for patients with complex needs (US).

•  Need expanded notion of clinical jurisdictions so there is common ground between primary / acute care (EU).

•  Handovers should be ‘wired’ into healthcare system (EU).

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Key Issues •  How to identify / target high risk patients? •  Where should transition of care manager be located? •  Using transition teams (managed by PHN or LHN?). •  Helping carers / family to be effective advocates. •  Financial / other incentives for hospitals / GPs/

specialists to take an active role in transitions. •  Evaluating reliability in implementation of key elements

and understanding variations in capability, capacity. *What is needed for specific populations?

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Patients’ Stories

Dr Paresh Dawda

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The Key Steps

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Bundle of Interventions

Higher Risk Group

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Interventions (1)

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Interventions (2)

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Anticipate and Build in Reliability

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Tracking

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A High Level Transitional Care Process

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Policy and Practice Perspective

Dr Kelly Shaw

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Patients’ experiences of poor Transitions of Care

•  “falling through the gaps”

•  “being forgotten about”

•  “having to explain yourself to everyone involved in your care”

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What patients want

•  Listened to •  Adequate explanations from health professionals •  Questions answered •  Shared decision making regarding care •  Continuity of care and smooth transitions

between providers

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Barriers to Effective Transitions •  Poor communication

–  Direct communication between clinicians –  Availability of comprehensive discharge summaries

•  Excessive workload and lack of time –  Limited capacity for collaborative care

•  Poor discharge processes –  System factors – lack of guidelines for standardised processes –  Professional factors – unclear role definition –  Patient factors – lack of knowledge / social support –  Social factors – poor service availability

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Tasmanian Response •  Guidelines to support improved transition of patients

across boundaries of care

•  Tasks – Review of peer-reviewed literature (APHCRI) – Analysis of policies, guidelines and protocols – Stakeholder consultation

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Shared Practice Guidelines / Protocols •  Evidence-based

•  Developed through consensus / participation

•  Be explicit about roles and responsibilities of all involved

•  Shared care approaches to diagnosis and management

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Role clarity “An important factor contributing to the challenge of safe care

transition is the lack of a single clinician or clinical entity that has the overarching responsibility for coordination of the patient's care needs across the care continuum, regardless of setting”

•  The role of the GP does not diminish because the patient is in hospital.

•  The role of the specialist does not cease when the patient is out of hospital.

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Improving Role Clarity •  Health care professionals are jointly and individually

accountable for supporting continuity across the boundaries:

–  Supply comprehensive, complete and accurate information to receiving provider.

–  Provide patient with clear instructions about role of varying professionals.

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Routine Communications •  Mechanisms for provider to inform others about the

clinical care received: •  Retrospective •  Provides receiving provider with required information for

continuity of services •  Commonly referral and discharge correspondence

•  Improved with: •  Electronic templates •  Database-generated summaries with structured formats •  Clinical decision support tools – pending results, guidelines •  Pick lists – clear, structured data entry

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Non-Routine Communications •  When provider needs the input or expertise of another to

aid in clinical decision - Commonly telephone

•  Improvements - Provide multiple contact methods - Respond promptly to requests for information - Standardised ‘prompts’ for when non-routine communications required e.g. critical patient events - Structured communication tools (SBAR – situation, briefing, assessment, recommendation)

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Bridging the Routine and Non-Routine •  Processes

–  Plan communication by specifying times for receiving clinician to update referring clinician on patient status;

–  When handing care over to provider, request an update on the patient's condition at intervals appropriate for ensuring patient safety;

–  For patients at higher risk of complications or adverse events, request more frequent updates;

–  Specify the method by which the update should be provided.

•  Roles – liaison nurses / pharmacists •  ICT solutions •  Case conferences

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Admission Process •  Accurate, complete and legible documentation provided

in a timely manner –  Accurate patient identification / protocols –  Detailed record of pre-existing conditions / medications –  Communication between referring and receiving providers

! Clinical status ! Care plan ! Goals of care

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Discharge Process •  Standard screening tools to identify patients at high risk of readmission

with protocols and policies that support the use of tools; •  Formal documented discharge planning process with multidisciplinary

approach; •  Clear role of each multidisciplinary team member identified in the

discharge planning process; •  Designated nurse/physician for discharge planning as contact point; •  Clinical pharmacist for medication reconciliation; •  Patient education: medication/treatment, concept of discharge process; •  Clear process for communication between acute and community

providers; •  Availability of a home care support program to facilitate transition period

from hospital discharge to home if required.

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Referral Process Accurate, complete, legibility referral document communicated in a timely manner:

– Documentation associated with referral process – templates / structured forms

– Multidisciplinary team ‘gatekeeper’ – Electronic referral systems

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Patient and Caregivers / Family •  Education and counselling to improve the patient and

caregivers' understanding and preparation for their self care role in the next care setting;

•  Ensure patients and caregivers do not receive conflicting advice from different practitioners in their preparation for discharge; and

•  Provision of instruction on who to contact in the event of uncertainty.

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Summary •  Effective transitions important for safety / quality •  Can be improved through:

–  Coordination of care –  Shared clinical practice guidelines and protocols –  Role clarity –  Communication – routine and non-routine –  Improvement at transition points

!  Referral processes !  Admission processes !  Discharge processes

–  Preparing patients and caregivers

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