Presented by. Lori Brown RN(EC), NP-PHC

Transcription

1 Presented by Lori Brown RN(EC), NP-PHC NPSTAT Program Coordinator Nurse Practitioner MH LHIN Expo: Transforming Health Care in the MH LHIN September 29, 2010

2 Transferring elderly long-term care residents to hospital can have negative effects on both the healthcare system and the seniors themselves. Unnecessary movement of seniors to hospital means that muchneeded beds are not available for other patients, and it can also put the seniors at risk of adverse events such as serious infections, drug reactions, and skin breakdown due to long waits on an emergency room gurney all of which have the potential for serious or fatal complications. Residents also suffer from transfer distress, characterized by disorientation, confusion, rapid deterioration in their condition, and co-morbidity. Often, the residents never regain their previous levels of functioning and quality of life.

3 What s our NPSTAT mandate? Provision of acute episodic outreach care to MH LHIN s 27 LTC Homes (4136 beds)* see Algorithm Averting & preventing ED transfers of LTCH residents. Helping facilitate earlier hospital discharges and decreased hospital length of stay (LOS). Acting as LTCH resource for discharged residents with higher acuity and complexity. Building capacity in LTCH nursing staff.

4 NPSTAT Program 7 NPs 5 Full-time NPs (1 FT > 50% Coordinator: 50% NP Clinician role) 2 Part-time NPs NP Availability 9 am 9 pm Monday to Friday 9 am 5 pm Saturday Access : Blackberry (phone/ ) NPSTAT office located at The Wenleigh LTC Administrative Supports 1 PT Program Assistant at CVH > 1:30-4:30 pm daily CVH infrastructure (Finance, Payroll, IT, Library services etc.)

5 NPSTAT: Evidence-Based Indicators & Results Indicators reported to the MH LHIN by LTCHs Number of transfers to ER Time of transfer - days [ ], evenings [ ], nights [ ], weekends [Saturday], weekends [Sunday] Reason for transfer/provisional diagnoses

6 NPSTAT: Evidence-Based Indicators & Results NPSTAT Indicators reported to the MH LHIN by NPSTAT referrals Urgency of referral (urgent, acute, non-acute, palliation, follow-up) NP consultation referral (telephone, , coordination of care, family conference, education/capacity building) Decision to transfer to ER/hospital (physician, RN, NP, family)

7 NPSTAT: Evidence-Based Indicators & Results NPSTAT Indicators reported to the MH LHIN by NPSTAT Referrals Reason for transfer (as indicated above) Facilitated transfer (between hospital and home) ED transfers (number of ED transfers, number of averted ED transfers) CTAS level (1, 2, 3, 4 or 5)

8 All encounters Urgent Acute 1450 Non-acute 258 Palliation 82 Follow-up Telephone - 60 Statistics July 1, 2009 to March 31, 2010 Total acute & urgent = 1589 Averted transfers of above = 1467 Therefore 92% averted transfers for acute and urgent cases

9 Indicators NOT reported to the MH LHIN but captured by NPSTAT Visit date Advanced directive NP name Time/Duration of call

10 Indicators NOT reported to the MH LHIN but captured by NPSTAT NP process coordination of care - orders Rx/tests/interventions, consultation [LTC RN/admin, LTC Allied, Pharmacy, MD, NP, Hospital/ED, CCAC/Agency, Community/Clinic, SDM/POA], education [LTCH staff nurses, family/sdm/poa, resident], capacity building Testimonials

11 Factors Contributing to Success Using Advanced-Practice Nursing Model Integrating with all team members in every home; we become part of that team Collaboration with community partners Leadership role in system-wide innovation (1 st dose antibiotics, communication continuum in the circle of care, developing key protocols/processes-g Tubes, Warfarin, etc.)

12 Factors Contributing to Success Further defining our niche what else can we do to maximize the success of the linkages between NPSTAT, LTCHs and community partners? Includes: Role in repatriation between hospital and home Role in decreasing hospital LOS; creating opportunities to increase capacity in LTCHs

13 Factors Contributing to Success Developing an /list serve to enhance communication and collaboration between the NPs and LTCH physicians; including others, like DOCs/LTCHs, when relevant

14 Greatest Learning and Program Challenges Relationship building to ask why?/why not? and work collaboratively with community partners for change Developing mutually defined data concepts /parameters to yield statistically significant findings for data reporting Enhance our capabilities for data analysis that accurately reports our program outcomes

15 Program Gaps/Opportunities for Improvement Maximizing on our success using current resources including: Increasing services/capacity building to LTCHs on evenings/weekends Improving data collection-management-reporting to increase our efficiency/outputs Program planning: not doing more than we can effectively handle/service

16 Conclusion NPSTAT has emerged from a period of growth & development to stabilization to move ahead. NPSTAT is now strategically moving forward responding to health system innovation. Between July 1, 2009 to March 31, 2010, NPSTAT s averted transfer rate was 92%. NPSTAT wants to acknowledge the MH LHIN, CVH and our health system partners for guiding this innovative program to meet the needs of seniors and their families in this new millennium.