Go With The Flow Integrating Rehabilitation Service at St Vincent s Hospital, Sydney Dr Shari Parker JP FAFRM MBBS (hons) BScmed (hons) Rehabilitation Physician On behalf of the RITH Team Innovation in Health Conference 16-17 June 2014, Novotel St. Kilda Victoria
Drivers for change capacity & efficiency LOS, NEAT, NEST, ABF address egress block Right Treatment Patient Time Place Innovativeevidence based models of care EarlyRehabilitation better outcomes Intensity better outcomes Integrationrehabilitation across patient journey Population trends COAG National Partnership agreement
In-Reach Rehabilitation Settings Inpatient Outpatient Day Hospital Outreach Home Based Rehabilitation
ICU Rehabilitation at St Vincent s, 2007 Acute Subacute Inpatient Rehab Home
Rehabilitation at SVH Sydney 2013 ICU Acute Subacute Inpatient Rehab Home
Staged Implementation 1. Inpatient Intensity (March 2010) 2. Outpatients enhancement (June 2010) 3. Mobile Rehabilitation Team (MRT) In- Reach Commenced October 182010 4. Rehabilitation in the Home Team (RITH) (with POW, commenced April 2012)
RITH Evidence Ideal for Similar outcomes for suitable patients Patients greater initiative, express goals No Morbidity and Mortality Quality of life and satisfaction Less risk nosocomial infection Shorter LOS, Cost savings Facilitated early discharge still requiring intensive rehab Community patients at risk of admission Rehabilitation with community focus
Model of Care 6 weeks, 3-5 times per week Service level agreement with POWH Evidence Based, trams-disciplinary Patient / carer involvement Case conference Transport car share RITH isn t: Providers of personal care, Transport service, Long term case management, Primary medical care
Staffing Allied Health Assistant 1.0 Co-Ordinator 0.5 Clinical Nurse Consultant 0.5 Social Worker 0.5 Physiotherapist 2.5 Rehab Physician (Medicare) Speech Pathologist 0.2 Occupational Therapist 2.0
Transport Go Get, Car Share Partnership hospital, industry, community, Sedan, station wagons, vans Online booking, Card for access Cost savings
Issues Often addressed Pain Spasticity Falls Wounds Bowels Bladder Mood Confidence Adjustment Weakness Endurance Walking Stairs Personal ADLs Carer Training Equipment Mods Meal prep Laundry Cleaning Community Public Transport Shopping Return to work Payments Services Recreational Swimming Golf Cycling Rowing.
Results Apr 2012 -June 2013 142 patients 56% Male 44% female Ready for admission to admission 1.5 days Average LOS = 35 days 5 weeks Average Occasions of service = 22.8 Average 1 visit each weekday (0.91) Average 13-15 patients on program POWH 53.3% SVH 46.7%
Age Average = 65.4 years 100 90 80 70 60 50 40 30 20 Individual Patients
Impairments Big 4 = Stroke, De-con, Ortho, Other neuro 50 45 40 35 30 25 20 15 10 5 0 SVH POW
54% avoided admissions Discharge from acute, by-passing rehabilitation subacute inpatient, Living in community at risk of admission functional deterioration
Functional independence Measure (FIM) FIM Eff 0.30 118 98 Start End 78 58 38 18 FIM Total fim Motor FIMCognitive
4 3.5 3 2.5 2 1.5 1 Lawton s Scale 17.28 22.45 Start End
GAS Goal Attainment Scale Heterogenous population with differing DIAGNOSES SEVERITY PRIORITIES Patient s Voice Collaboration and Communication with patient and the team Should be usable by all disciplines Outcomes pre-set 0 = expected +1 +2 (better), -1-2 (worse) Convert to T score normal distribution
The patient was able to leave the hospital and receive this program at home, achieving their independence and establishing a plan. To be able to rebuild your skills in your own home is a good thing.
This service definitely added to a faster & more enjoyable recovery for my mother & our nan. It has reduced the stress on the family who had to conform to hospital times during working hours in order to take part in her recovery. The only way of improvement is if the program became a permanent fixture for all to access.
Summary of Benefits Less impairment, disability, handicap, Greater activity and participation Self efficacy Patient and carer satisfaction Facilitate early discharge Prevents avoidable admissions Greaterefficiency & capacity Cost savings
Key Ingredients Elasticity flexibility of approach to mx Equity $ Executive buy in Ease KISS Excellence of Staff Evidence Based Practice Environment co-location MRT / RITH Expression communication Egalitarianism Extension of roles breaking down the barriers
Rehabilitation at SVH Sydney 2013 ICU Acute Subacute Inpatient Rehab Home
Mobile Rehabilitation Team Parallel care, up to 2 weeks, 7 days Rehabilitation starts D3 Intensive multi disciplinary rehab CNC, PT, OT, SW, psychology, med In addition to usual therapy Aim to de-conditioning, function, early discharge planning, integration of care between acute and rehab, avoid admission to inpatient rehab where possible. Those who still need admission, arrive in a better functional statue and have a shorter admission. Day/Month/Year Footnote to go here Page 26
Example Ellen 44 year lady Married with 2 kids, MS 4 years. Works part time Acute cholecystitis admitted, admission cx by MS flare Risk of prolonged admission identified Mobile Rehabilitation team early intensive rehabilitation in parallel with acute medical / surgical care Inpatient rehabilitation admission avoided Discharged home with family and with ongoing RITH Then onto outpatients for less intensive therapy.later, functional deterioration, falls risk of admission RITH gives intensive home based rehabilitation Admission avoided Day/Month/Year Footnote to go here Page 27
Overall Results achievewd 2010-2013 Efficiency generated equivalent to capacity of 17.9 beds (90% occupancy) rehab LOS by 23%, from 23.9 to 18.4 days 77% in rehabilita on episodes 106% patients managed by outpatients Mobile Rehabilitation Team discharged 55% patients directly home RITH - subacute admission avoided in 54%
Results Achieved Integrated rehabilitation service, providing right care at the right time in the right setting Annual efficiency of $4 854 247, for annual investment of $1 121 124 30 28 Subacute IP, OP commences MRT commences RITH commences All 4 models operating 26 Number of days 24 22 20 23.88 23.56 23.29 20.75 20.63 18.44 18 16 14 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 (Jul - Dec) Day/Month/Year Footnote to go here Page 29
Breaking down the silos ICU Acute Inpatient Rehabilitation Home Community Illness Trauma Surgery Disease Impairment (structure, function) Disability (Activity Limitation Handicap (Participation Restriction) Personal factors Environment Patient Family Acute doctors Rehab doctors Geriatricians Primary care Nursing Physio OT Speech path Dietetics, pharm Social work Psychology
Breaking down the silos ICU Acute Inpatient Rehabilitation Home Community Illness Trauma Surgery Disease Impairment (structure, function) Disability (Activity Limitation Handicap (Participation Restriction) Personal factors Environment Patient Family Acute doctors Rehab doctors Geriatricians Primary care Nursing Physio OT Speech path Dietetics, pharm Social work Psychology
The Future TITH (Therapy in the home) since Sep 2013 similar model, reallocation for underutilised resources Green light received for Integrated Rehabilitation service (IRS!) which will integrate Rehabilitation and Geriatrics care across the hospital and will incorporate: Inpatient intensity, MRT, TITH and Day Hospital
Patient flow committee Director of Rehabilitation Director of GAM GM Subacute services Program Manager GAM Head of Allied Health Community transfer team Geriatric Registrar Rehabilitation Registrar Amanda RN GAM Clinical Nurse Consultant Geriatric Fellow Rehabilitation Consultant Rehab Services Mobile Rehab Team Therapy in the Home Inpatient Inpatient rehab rehabilitation Day hospital Geriatric and Community Services Hospital in the Home Hospital in the Clinic TACP community care COMPACS
Acknowledgements All the patients, family, carers Ian Harris Associate Professor Steven Faux Emma Hamilton Nancy Lee Monique Alexis Louise Ringland Nicola Clark Anna Barlow Kate Knapp Amanda Miller Amberber Dr Sachin Shetty Dr Greg Bowring Helen Miller SVH Executive
Thankyou Questions?