The Health Roundtable

Charting a course for change for people with chronic illness: The St George experience

Presenters: Linda Soars, Daniel Shaw, Karen Ng, Nicole Wedell

Hospital Code Name: St George HospitalKey contact: Linda.Soars@sesiahs.health.nsw.gov.au

Mob 0400 518 777

Innovation Poster SessionHRT1215 – Innovation AwardsSydney 11th and 12th Oct 2012

The Health Roundtable

KEY PROBLEM

Increased identification of patients with unplanned admissions due to cardiac, respiratory and diabetes health issues

Need for a timely method to identify, rapidly assess and link patients to the right type of care (acute, rehab, primary) at the right time in their journey with chronic illness

Each patient needs to have clear health goal and action plan (self management), GP linked, carer identified and supported

The Health Roundtable

AIM OF THIS INNOVATION

Create a patient navigation hub for chronic disease services using technology, outbound call centre and connecting care more rapidly in the community

Streamline the patient journey after an unplanned admission with a chronic illness

Chart a new course between the acute and community interface – with embedded referral lines

The Health Roundtable

BASELINE DATA

Need to streamline linking patients to correct services

The Health Roundtable

KEY CHANGES IMPLEMENTED

St George Hospital – redesign of existing Access and Referral services and alignment with District wide service descriptors and referral paths

Development of outbound call process – quick patient identification, timely calls, standardised assessments and referrals, early review and escalation for home based review

Specific programs – Connecting Care in the community (Care Coordination), Health Coaching phone service (SESLHD/Healthways Australia), Aboriginal patient 48 hour follow up

The Health Roundtable

OUTCOMES SO FAR Outbound calls – navigating the system with the

patient….. Linked to care coordination/health

coaching/community services

Makes me feel good that people care…

Good advice on meds –

decreased asthma meds

because of advice

They helped me determine when I needed to go to

hospital!

The Health Roundtable

OUTCOMES SO FAR

Outbound calls - July/Aug/Sept 2012 data

Slightly more outbound calls now per month than inbound calls

Patients navigated to services increasing – 100% 120% growth in referral rate each month to Connecting Care and follow up

Potential to increase referrals to specialty chronic care teams – direct identification

Risk assessment completed and consent PFP process new – developing roles

The Health Roundtable

LESSONS LEARNT

Small steps – using clinical redesign process – engage key sponsors and stakeholders

Key staff development – mentoring and coaching, change in job responsibilities and daily activities

Ongoing Training – on the job, inservice and formal sessions educational support – health behaviour change

capacity building technology improvements (computers and phones)

Celebrate the achievements along the way!