Rehab@Home Princess Alexandra Hospital 2019 Service Model · • Rehab@Home Access team (nursing...

Rehab@Home

Princess Alexandra Hospital

2019 Service Model

Business Case for Change: Amalgamation of CARS, TCP and Rapid Response, Metro South@Home

July 2019

Business Case: Rehab@Home, Metro South@Home, Metro South Health

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Contents

1. Purpose of Business Case ................................................... 3

2. Background ........................................................................... 3

3. Reason for change ............................................................... 4

4. Details of Proposed Change ................................................ 5 Table 1 – Option 1 - No change (not supported by MSH Executive) ................................. Table 2 – Option 2 - Amalgamated Rehab@Home Services (Recommended) ................. Referral Pathway ............................................................................................................... 7 Patient Journey ................................................................................................................. 8

5. Recommendation .......................................................................................................... 9

6. Next Steps ............................................................................. 9

7. Supporting Employees through Change ............................ 9

8. Feedback contacts ............................................................. 10

9. References .......................................................................... 10

10. Signature Page .................................................................... 11

11. Attachments ........................................................................ 12

Attachment 1 - Current Organizational Structure .................................................. 12 Attachment 2 - Proposed Interim Organisational Structure ................................... 13 Attachment 3 - Proposed Future Organisational Structure .................................... 14 Attachment 4 - Current Professional Structure ...................................................... 15 Attachment 5 - Proposed Professional Structure .................................................. 16


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1. Purpose of Business Case

This document provides an overview of the business case for the proposed reorganisation of the Transition Care Program(TCP), Rapid Response at Home(RR@S) and Community Adult Rehabilitation Service(CARS) within Metro South Health@Home. The proposal represents Phase 2 of the Metro South Rehab@Home reform process, with Phase 1 being the creation and implementation of the Director, Rehab@Home position. It is intended to support consultation in relation to the proposed changes and invites feedback from affected employees and relevant unions on these proposed changes. Metro South Health@Home is proposing change in accordance with government policy and relevant industrial obligations.

2. Background

The current and expected future short fall in MSH acute and subacute inpatient beds has led to a focus on hospital avoidance and substitution strategies and an increased reliance on community services. Improving access to and integration of community-based aged care and rehabilitation services across the continuum of care was identified as a short-term priority in the MSH Aged Care and Rehabilitation Services Health Service Plan 2013-2022. In addition, given the current pressures on the health care system, it is imperative to focus on the provision of care that is preventative, integrated, proactive and based closer to the patient’s home, avoiding high-cost, reactive and hospital bed-based care. In early 2019 Phase 1 of the Rehab@Home model was implemented with the establishment of a new Health Practitioner position of Director Rehab@Home, with operational responsibility for the 107.8 FTE allied health, nursing, and operational staff for TCP, CARS and Rapid Response@Home (excludes allied health in RR@H – the current Allied Health operational and professional reporting lines were retained subject to Phase 2). This business case for change reflects Phase 2 of the Rehab@Home model. Objectives:

1) Establish a single point of referral for MSH into the new Rehab@Home Service (including clear eligibility criteria),

2) Further align MSH@H to organisational priorities and governance structures, 3) Amalgamation of Rehab@Home services to a single service model, to improve clinical

and operational effectiveness and efficiency 4) Establish clear communication and engagement protocols, and 5) Establish clear metrics and reporting frameworks 6) Optimise revenue for service activity

Additionally, in July 2017, Metro South HHS executives and district stakeholders agreed on a set of five principles to optimise MSH@H model of care. These principles will form the foundational principles of Rehab@Home and are defined as:

1) Easy to use 2) Caring and responsive 3) Consistent and reliable 4) Effective and efficient 5) Innovative


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The changes proposed will be cost neutral, utilising existing budgets for Transition Care Program, Rapid Response @Home Service and Community Adult Rehabilitation Service. Future service improvements will be funded through optimisation of the Transition Care Program and Commonwealth revenue achieved through this additional activity, significant reduction in outsourced service provision and re-investment of any operational efficiencies gained through implementation of the new service model.

3. Reason for change

A significant body of work has been undertaken to review and optimise the delivery of community care in Metro South HHS including a Diagnostic Report in 2015 and a draft Solution Design Report in 2016. This work supported the establishment of a single Rehab@Home service and resulted in the establishment of the Director Rehab@Home position as Phase 1 of the redesign process. This business case outlines Phase 2 of this process, the amalgamation of TCP, CARS and Rapid Response service. The purpose of the Rehab@Home model is to ensure that patients receive high quality, evidence-based care close to, or in their own home. The benefits of healthcare delivery by integrated “same service” teams are evidence based, include better continuity and consistency of care through holistic discussion, better planning, enhanced problem-solving and reduced ambiguity between team members (Mickan, 2000). The current Rehab@Home service delivery model comprises three separate services operating across five different locations: Redland Hospital, Eight Mile Plains CHC, Logan CHC, Browns Plains CHC and Beenleigh CHC. These services have separate workforce, service profiles and operational structures, including admission criteria, documentation, clinical and operational management processes, quality improvement and reporting criteria. This structure results in operational, workforce, and financial inefficiencies and often fragmented service delivery for patients. Additionally, admission to the Rehab@Home services is confusing for referrers and potentially results in longer hospital length of stay for hospital inpatients or avoidable hospital presentations or admissions. Clients can experience lengthy admissions to the current separate services due to fragmentation of service delivery. Historically, a significant amount of care for TCP clients has been delivered by non-government providers through a brokerage or outsourcing model. Whilst a brokerage model has some benefits such as flexibility and reduction of inhouse staff travel time, feedback from TCP staff and other stakeholders including clients identifies several issues with the outsourced model. These issues potentially result in longer length of stay for clients on TCP, increased case management workload through inability to provide an integrated interdisciplinary model of care, and a greater focus on assessment and prescription rather than rehabilitation. Integrated professional and operational accountabilities have been identified as a key component of effective allied health management (Dawber, Crow, Hulcombe and Mickan, 2017). Evidence supports the establishment of a shared nursing/allied health governance and leadership structure with establishment of stream-based portfolios and collaboration between profession specific managers (Xyrichis & Lowton, 2008). Evidence also supports internally integrated service provision between hospital based and community-based rehabilitation teams as superior to externally outsourced models. As a result of the current model within TCP, a significant proportion of the clinicians’ workload involved managing outsourced service delivery. In the Rehab@Home model the shift to an inhouse model will reduce this administration and communication burden and enable clinicians to focus on direct service delivery. Staff will have a mixed clinical and case management responsibility as lead clinician role for a small number of clients. This model currently exists in both CARS and RR@S. A component of the new model of care will be to incorporate telehealth strategies in the delivery of care. This will include telehealth consultations between clients and clinicians and between clinicians within the service.


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4. Details of Proposed Change

Option 1 – No change (not supported by MSH Executive)

What Maintain current workforce structure and program separation

Benefits Nil additional benefits

Implications • Inefficiencies result in reduced capacity of each service to admit clients. With TCP this can result in a reduction in occupancy and consequently a reduction in Commonwealth revenue, further reducing the service’ ability to response to community and HHS demands for community rehabilitation services.

• Complex governance and reporting structures within the service can limit staff satisfaction, development and career progression

Risks • Inability to meet community/HHS demand for community-based rehabilitation services

• Poor staff retention

• Inability for teams to initiate and implement quality improvements and research

• Not supported by MSH executive as per 2018 approved and implemented business case for change process for phase I

Option 2 – Amalgamated Rehab@Home Service (Recommended)

What • Amalgamate TCP, CARS and Rapid Response@Home into a single Rehab@Home Service.

• Service to be organised into a hub and spoke model with three hubs: Redland, Eight Mile Plains CHC and Logan CHC, with initial spokes at Beenleigh and Browns Plains CHC. Further spokes to be considered with changing client demographics.

• Operational governance within each hub will be provided by Nurse Unit Manager (NG7) and Allied Health Manager (HP5) in a shared governance structure.

• Clinical staff will provide clinical care to clients within each hub following an allocation process by senior clinical leaders. Allocation of patients will be made with consideration to client needs, staff skill level, staff workload, geographical location of client and treating team structure. Where possible, junior staff will be supported by senior clinicians within the client’s treating team.

• All clients will be allocated a key clinician from within the team. This clinician will coordinate the client’s care while they are admitted to the service and be the key point of contact for the client. Each clinician will be the identified key clinician for 4-6 patients as well as discipline specific clinician for a cohort of clients. These allocations will vary depending on clinical workload, client support needs and geographical location of clients.

• Rehab@Home Access team (nursing and allied health) will be established as single point of contact for Rehab@Home service for referrers and collaborate with hospital and Rehab@Home staff to facilitate timely and safe entry to the service

• Initial staffing realignment to be undertaken within current budget allocation. Further workforce reviews will be undertaken in Phase 3 of the service redesign once TCP activity and revenue are optimised (with some minor exceptions for services not currently existing at some sites, e.g. pharmacy, speech therapy, psychology and Dietetics)


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• Provision of personal care, domestic assistance and allied health assistance to be reviewed in Phase 3 to achieve service efficiencies and appropriate delegation of tasks the supporting operational workforce.

• Nursing and Personal Care staff will report operationally to the Nurse Unit Manager and professionally report through the Nurse Unit Manager to the Director of Nursing Community (MSH@Home and HEAU).

• Allied Health clinicians and Allied Health Assistants will report operationally to the Allied Health Team Leader and professionally through to Discipline Director (facility alignment to remain unchanged subject to further consultation). Due to the complexity of the Allied Health structure for Metro South Health@Home Services, there will be close communication and collaboration between Rehab@Home service and the relevant professional directors to ensure optimum service delivery.

• Nurse Unit Managers, Allied Health Team Leaders and Rehab@Home Access Team (NG7 and HP5) will operationally report to the Director Rehab@Home and professionally through the appropriate discipline Director (Nursing or Allied Health)

• Medical resources remain unchanged and aligned with Transition Care Program.

• Administration workforce FTE and reporting lines will remain unchanged. Administration workload will change as a result of the amalgamation of the services due to a reduction in outsourced delivery of services and increase in in-house clinical staff. The change will be communicated to the Administration workforce and impacts monitored by the Administration Supervisor Metro South@Home and facility leadership teams.

2 stage workforce approach: Stage 1 a) Convert non-labour outsourced service budget for Nursing and Therapy to labour budget (see Attachment 2 – Proposed Interim Organisational Structure) b) Convert a proportion of Early Discharge budget to non-labour budget to support additional staffing (vehicles, telecommunications and IT). Proportion to be converted is current year spend for Home modifications and meals which will cease end June 2019. Stage 2 Increased activity to optimise Commonwealth Transition Care Program funding. Additional realised funding to be utilised to provide additional clinical positions within the service.

Benefits. • Improved access for clients to high quality care close to home

• Improved efficiency in operational and clinical service delivery

• Increased activity and revenue from TCP

• Simplification of referral process to Rehab@Home services (improved uptake and patient flow in referring facilities)

• Improved workforce structure that will enable improved care coordination for clients and integration of care.

• Enabling and empowering Rehab@Home workforce through provision of a structure that supports the development of capable and accountable leadership

• Providing a foundation for Metro South@Home to develop agile and innovative health services

• Support inpatient units to achieve timely and safe discharge services for patients


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• Opportunities to enhance research and quality improvement across the service through improved interprofessional teamwork

• Development of clear operational and professional governance framework for clinicians in consultation with MSH professional directors

Implications • Separation of client activity required to maintain reporting obligations (activity and financial) and compliance with Aged Care Act 1997, for Transition Care Program.

• Changed referral and entry processes for Rehab@Home that will impact discharge from inpatient units, Emergency Department and GPs.

• Changes to role descriptions required to accommodate expanded scope for clinicians.

• Development of process and service outcome dashboard to monitor and evaluate service delivery

Risks • Insufficient accommodation for larger teams in current Community Health Centres

• Additional fleet vehicle requirements to be ascertained following implementation of the model

Referral Pathway


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Patient Journey

(Note: The current and proposed interim and future organisational structures in Option 2 are attached)

Referral• Referral to Rehab@Home

Access

Team

• Rehab@Home Access Team to manage all referrals to Rehab@Home:

• Management of TCP referrals via My Aged Care Portal

• Prioritisation of all referrals as per Rehab@Home Priority Response Framework

• Monitoring and evaluation of service responsiveness as per Rehab@Home Priority Response Framework and Key Performance Indicators

• Waitlist management, monitoring and monthly reporting via the Rehab@Home Scorecard

Allocation

• Hub Team Allocation of clients to be conducted by NUM or Allied Health Team Leader or their delegate

• Allocation will include Identification of Key Clinician who will assume case managment and care coordination responsibiliity for the client throughout client's admission. All staff with a clinical caseload (excluding Allied Health Assistants and Personal Care Workers) will have Key Clinician and clinical responsibilities with workload determined through consultation with leadership team with consideration to client needs, geographical location of client and non-clinical responsibilities of clinician.

Assessment

• Assessment will be a two tiered system:• Holistic Initial Assessment to be completed by any member of the clinical team (excluding Allied Health Assistants and Personal Care Workers) on initial home visit to client. Some components of this assessment may be completed in subsequest visits dependant on client priorities

• Discipline specific assessments as determined by indificual professional group

Care Planning

• A flexible and tailored care plan, or rehabilitation plan, will be developed for all clients inclusive of EDD and reviewed regularly

• All clients to have case conference within 1 week of admission to service


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5. Recommendation It is recommended that Option 2 is progressed for the following reasons:

• The current and expected future short fall in MSH acute and subacute inpatient beds has led to a focus on hospital avoidance and substitution strategies and an increased reliance on community services. Improving access to and integration of community-based aged care and rehabilitation services across the continuum of care will support Metro South Health deliver high quality, evidenced based care in, or close to, the patients home, avoiding disruption to patients through unnecessary or prolonged hospital admissions. Providing care in the home has been demonstrated to improve functional recovery for older patients and those requiring ongoing rehabilitation.

• The initial phase of option 2 is cost neutral service redesign. The final phase will capitalise on the additional capacity within the service to optimise Commonwealth Transition Care funding. These changes will increase the capacity for MS Health@Home service to provide community care, but it is acknowledged that further resourcing is required to meet demand.

6. Next Steps The following steps will be followed: (Dates to be inserted following Executive Approval)

Date Activity

10/9/19 Communicate Proposed Change to directly affected staff and relevant unions

10/9/19 Table Business Case for Change to Nursing and Health Service Consultative Forums

10/9/19 Consultation period for feedback on Business Case opens

22/9/19 Consultation period for feedback on Business Case closes

29/9/19 Feedback on the proposed change considered and responses provided to staff and relevant unions and incorporated where relevant

If Option 1 is pursued, then no further steps will be undertaken. If Option 2 is pursued than the following is proposed:

Date Activity

2/10/19 Communicate Proposed Implementation plan to directly affected staff and relevant unions.

2/10/19 Consultation period for feedback on proposed Implementation Plan opens

16/10/19 Consultation period for feedback on proposed Implementation Plan closes

23/10/19 Amendment of Implementation Plan (if required)

23/10/19 Final Implementation plan provided to all staff and unions

7. 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 1800 604 640. This confidential service can be accessed through self-referral to OPTUM, 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/

http://qheps.health.qld.gov.au/eap/


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• availability of Organisational Unit management to support staff.

8. Feedback contacts Stakeholders are invited to provide feedback by Week 3 regarding the business case. Feedback may be provided to the following officers by email, phone or face to face: Lesley English Karen Drayson Director Rehab@Home Senior Consultant, Human Resources [email protected] [email protected] 31569704 or 0436672051

9. References

Dawber J, Crow N, Hulcombe J and Mickan S, (2017) A realist review of allied health management in Queensland Health: what works, in which contexts and why. Brisbane, Qld Queensland Health Mickan S, Rodger S 2000. Characteristics of effective teams: a literature review. Aust Health Rev. 2000;23(3):201-8 Metro South HHS (2018) Business Case: Change Management – Metro South Health@Home, Create New Position: Director Rehab@Home

mailto:[email protected]

mailto:[email protected]


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10. Attachments Attachment 1 - Current Organisational Structure

Director Metro South @Home

Director Rehab @Home

NUM TCP Brisbane South 1.0FTE NG7

(20FTE)

NUM TCP Bayside 1.0FTE NG7

NUM TCP Logan (Beenleigh) 1.0FTE NG7

CARS Program Manager 1.0 FTE HP5

NUM Rapid Response 1.0FTE NG7

Nurse CNC 1.0 FTE NG7 CN 6.0 FTE NG6



Team Leader 1.0 FTE HP5

Nurse CN 4.0 FTE NG6

Occupational Therapist 1.0FTE HP4 Case Manager:

1.0FTE HP3 1.0FTE HP4

Occupational Therapist 0.63FTE HP5

0.5FTE HP4 5.0FTE HP3(case manager)

Occupational Therapist 1.0FTE HP4 3.0FTE HP3

Occupational Therapist 2.0 FTE HP5

2.17 FTE HP4 2.0 FTE HP3

Occupational Therapist 1.0FTE HP4

Case Manager: 2.0FTE HP3

Physiotherapist 1.0FTE HP4 1.0FTE HP3

Case manager: 1.0FTE HP4

Social Worker 0.5 FTE HP4

Operational CHA 4.0 FTE OO3 PCW 2.0 FTE OO2

Physiotherapist 1.0FTE HP5


Physiotherapist


Social Worker Case Manager: 1.0FTE

HP3

Operational CHA 4.0 FTE OO3

Operational CHA 4.0 FTE OO3

Physiotherapist 1.5FTE HP5 1.0 FTE HP4 3.0 FTE HP3

Social Worker 1.0 FTE HP5

1.0 FTE HP4 0.6 FTE HP3

Physiotherapist 1.0FTE HP4

1.0FTE HP3

Operational PCW 7.0 FTE OO2

Speech Pathologist 0.5 FTE HP5 1.5 FTE HP4

Dietitian 1.0FTE HP4

Operational Allied Health Assistant

2.3 FTE OO3

NG7 7

NG6 22

HP5 8.63

HP4 17.67

HP3 20.6

OO3 14.36

OO2 9.0

Total FTE: 99.26


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Attachment 2 – Proposed Interim Organisational Structure

Note : positions in red are new roles.


Director Rehab@Home/ Deputy Director

Allied Health

Logan Eight Mile

Plains Bayside

Access Service NG7

Clinical Nurse Consultant

1.0 NG7

Allied Health Advanced

1.0 HP5

Nurse Unit Manager

1.0 NG7

Allied Health Team Leader

1.0 HP5

Nurse Unit Manager

1.0 NG7


1.0 HP5

Nurse Unit Manager

1.0 NG7


1.0 HP5


1.0 NG7

Clinical Nurse 5.4 NG6

Personal Care Workers

2.0 OO2

Physiotherapist

1.0 HP5 2.0 HP4 4.0 HP3

Occ. Therapist 1.0 HP5

2.0 HP4 4.0 HP3

Speech Pathologist

1.0 HP4 0.5 HP3

Social Worker 1.0 HP5 1.4 HP3

Dietitian 1.0 HP4

Allied Health Assistant

4.8 OO3


1.0 NG7


Personal Care Worker

4.67 OO2


1.0 NG7



2.0 OO2

Clinical Nurse 1.0 FTE

Physiotherapist

0.0 HP5 3.0 HP4 4.2 HP3

Occ. Therapist 0.5 HP5 2.0 HP4 4.2 HP3

Speech Pathologist

1.0 HP5 0.5 HP3

Social Worker 1.0 HP3

Dietitian 0.5 HP3


5.0 OO3

Physiotherapist 0.5 HP5 1.5 HP4 4.5 HP3


Speech Pathologist

0.5 HP4

Social Worker 1.0HP4

1.0 HP3

Dietitian 0.5 HP3


4.8 OO3

NG7 7

NG6 22

HP5 10.0

HP4 16.39

HP3 30.8

OO3 14.36

OO2 8.67

Total FTE: 109.22

Clinical Nurse (backfill/float) 3.6 FTE NG6


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Attachment 3 – Proposed Future Organisational Structure


Director Rehab@Home/Deputy Director Allied Health

Logan Eight Mile

Plains Bayside

Access Service


1.0 NG7

Allied Health Advanced

1.0 HP5

Nurse Unit Manager

1.0 NG7


1.0 HP5

Nurse Unit Manager

1.0 NG7


1.0 HP5

Nurse Unit Manager

1.0 NG7


1.0 HP5


1.0 NG7


Personal Care Workers

2.0 OO2


Occ. Therapist 1.0 HP5

2.0 HP4 5.4 HP3

Speech Pathologist 1.0 HP4 1.0 HP3


Dietitian 1.0 HP4


4.8 OO3


1.0 NG7



4.67 OO2


1.0 NG7



2.0 OO2

Clinical Nurse 1.0 FTE NG6



Speech Pathologist

1.0 HP5 1.0 HP3


Dietitian 1.0 HP3


5.0 OO3



Speech Pathologist 1.0 HP4


Dietitian 1.0 HP3


4.8 OO3

NG7 7.0

NG6 22.0

HP5 11.0

HP4 17.0

HP3 38.2

OO3 14.36

OO2 8.67

Total FTE: 118.23 NB: recruitable FTE for HP4 positions

Clinical Nurse (backfill/float)

3.6 FTE NG6

Pharmacist Senior 1.0 FTE HP4


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Attachment 4 – Current Professional Structure


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Attachment 5 – Proposed Professional Structure

Director of Nursing Community (MSH@Home and HEAU)

Rehab@Home Princess Alexandra Hospital 2019 Service Model · • Rehab@Home Access team (nursing...

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