Heart to Heart: Partnership to improve outcomes for Chronic Heart Failure Patients in western Sydney

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1 Innovation Awards November 2014 Melbourne Heart to Heart: Partnership to improve outcomes for Chronic Heart Failure Patients in western Sydney Western Sydney Local Health District: Naomi Van Steel Hospital Code Name: Western Sydney LHD

2 Heart to Heart: Partnership to improve outcomes for Chronic Heart Failure Patients in western Sydney The Pitch Chronic Heart Failure (CHF) is a complex and disabling disease with increasing prevalence in Australia, affecting 10% of people over the age of 65 and an estimated cost of $1 billion per annum (National Heart Foundation 2011). Health Round Table Data for 2012/13 identified that CHF patients at Blacktown had a high ALOS and overall bed day use. This was thought to be a symptom of poor integration and transfer of care to community and primary care. Data, along with a number of diagnostic processes, helped to confirm this: 84% of CHF admissions at Blacktown Hospital are Potentially Preventable 28% of those patients are re-admissions within 28 days A team was established in February 2014 with the goal to reduce PPA from 84% to 70% by October 2015, developing strategies to support patients to live well at home, improve their health outcomes and experience of care over the lifetime of their disease. Implementation of solutions has commenced, with the A-HED data tool to be used to track progress over time

3 Presenters Summary Problem: 84% of CHF admissions Potentially Preventable, 28% of those re-admissions within 28 days. Communication between healthcare services is fragmented and the system is difficult to navigate; care is poorly co-ordinated; and patients are inadequately supported in self-management. ALOS 2 days above that of the exemplars Aim of Innovation: Goal -To support patients (and their carers) with Chronic Heart Failure living in Western Sydney to live well at home; and improve their health outcomes and experience of care over the lifetime of their illness. Objective -To reduce potentially preventable admissions of patient with Chronic Heart Failure under the care of a Cardiologist at Blacktown Hospital from 84% to 70% by October 2015 What we did: The New South Wales Agency for Clinical Innovation (ACI) Healthcare Redesign Methodology was utilised. Five phases including initiation, diagnostics, solution design, implementation and evaluation; the methodology emphasises partnership with patients and stakeholders. Over 5 months, 35 stakeholders including patients and staff from BMDH, Community, General Practice and Medicare Locals participated in workshops, interviews, forums and data collection. Eight solutions developed, and are currently being implemented between September 2014-June Outcomes: Early evaluation has identified clinician and patient involvement in the redesign process has facilitated local networking, development of capability in change management and redesign of clinical roles to facilitate transition of patients from hospitalto primary care including increased home visits from two to nine a week. Organisational commitment of a project officer facilitates ongoing solution implementation and evaluation.

4 Case for Change Health Round Table Data Identified: Relative Stay Index-103% vs. 71% (exemplars) High overall bed day use-4% of episodes use 17% of bed days High Average Length of Stay-6.5 days vs. 4.6 (exemplars) Health Round Table, F62 Sirius /13 Goal To support patients (and their carers) with Chronic Heart Failure living in Western Sydney to live well at home; and improve their health outcomes and experience of care over the lifetime of their illness. Objective To reduce potentially preventable admissions of patient with Chronic Heart Failure under the care of a Cardiologist at Blacktown Hospital from 84% to 70% by October 2015 Chronic Heart Failure 2012/2013 Health Round Table data initially identified Chronic Heart Failure as a Healthcare Redesign opportunity. Chronic Heart Failure (CHF) is a complex and disabling disease with increasing prevalence in Australia, affecting 10% of people over the age of 65 and an estimated cost of $1 billion per annum(national Heart Foundation 2011). CHF hospitalisations are potentially preventable when patients have timely access to healthcare services; receive evidence based, coordinated care across the continuum of primary, secondary and tertiary services.

5 Case for Change COST PER CAPITA EXPERIENCE OF CARE HEALTH OUTCOMES LACK OF UNDERSTANDING 84% Potentially Preventable Admission I am hopeful my heart failure will get better. I can t do what I used to do which is very frustrating 28% patients readmitted in 28 days 14% reduction would save $285,156 p.a. and 340 bed days FEAR AND ANXIETY The weight, fluid restriction, the tablets -that s the easy part. It s the stuff you don t think about. I used to lift stuff for my wife, I can t do that now. If I do, I have to rest for 4 hours.i can t help and I feel like a hindrance. To meet the needs of the future

6 Baseline Data

7 Methodology Methodology Diagnostics The New South Wales Agency for Clinical Innovation (ACI) Centre for Healthcare Redesign Methodology was utilised. Five phases including initiation, diagnostics, solution design, implementation and evaluation. This methodology emphasises partnership with patients and stakeholders. Over 5 months, 35 stakeholders including patients and staff from BMDH, Community, General Practice and Medicare Locals participated in workshops, interviews, forums and data collection. A range of diagnostic activities were undertaken to understand the problem Patient and carer interviews Staff interviews Process Mapping 48 hour discharge follow up phone calls General practitioner forum Stakeholder workshops Data analysis- Health Round Table, HIE, A-HED February September June 2015 Project Initiation & Start up Diagnostics Solution Design Implementation Implementation Monitoring Evaluation / Sustainability

8 Solutions Solutions 1. Development of e-documentation and e-referrals for the Chronic Heart Failure service 2. Increasing the number of e-discharge summaries beingsentouttogp sfrom1%to 80%byOctober % of patients with Chronic Heart Fail discharged from Blacktown Hospital with an electronic selfmanagement action plan that is available to patients, carers, community and acute staff and sent with discharge summary to GPs % of patients with CHF discharged from Blacktown Hospital referred to Connecting Care 5. 95% of patients discharged with CHF from Blacktown Hospital receive a 48 hour follow up call 6. 80% of CHF patients known to Blacktown Hospital enrolled on an electronic register 7. Promotions and Communication of Chronic Heart Failure services to staff, community and patients 8. GP Hotline so that GPs can access specialist information and advice to prevent unnecessary Emergency Department presentations Implementation September 2014-June 2015

9 Outcomes A-HED data tool Project commencement Implementation commenced15 th September2014 Using A-HED data tool to track progress of implementation, along with a number of other matrix Early evaluation has identified clinician and patient involvement in the redesign process has facilitated local networking, development of capability in change management and redesign of clinical roles A-HED tool showing 28 day re-admission rate for CHF for all F62A & F62B admissions; indicating start of project and implementation This process has facilitated improved transition of patients from hospital to primary care including increasedhomevisitsfromtwotonineaweek Organizational commitment of a project officer facilitates ongoing solution implementation and evaluation

10 Lessons Learnt Lessons Learnt: There are inherent challenges with multi-sector partnership associated with variable funding models and resistance to change. Through early clinician and patient involvement in the redesign process, development of a shared vision, active sponsorship and a clear case for change connected to local priorities, we have been able to demonstrate the gains to be made through working in partnership to improve patient outcomes. The use of Accelerative Implementation Methodology, including the training of the project team, sponsors and solution owners. Visible, vocal and active Sponsorship throughout the Redesign process Integration with District Wide initiatives such as a Whole of District Approach including ehealth, HealthPathways, and the Western Sydney Diabetes Prevention and Management Initiative. Embed into the Cardiovascular service plan and transition into the expanded Blacktown Hospital Significant stakeholder and consumer involvement Local ownership and accountability for the solutions Role of Implementation Project Officer to support local capability building and ownership of solutions

11 Contact Heart to Heart Project Team Remia Morada Naomi Van Steel Julie Jones The Team At the getting to the heart of the issue workshop

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