Ambulatory Care Model

Ambulatory Care Model Hong Kong May 2013 Andrew Stripp Deputy Chief Executive & Chief Operating Officer

Outline What is the Alfred Centre? How does it fit into Alfred Health service model Key aspects of the Model of Care Outcomes to date A brief walk through the patient journey & centre design 2

Ambulatory Care Same day medical and surgical treatment Surgical interventions with LOS <3 days Radiology Cath Lab 3

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The Alfred 6

Alfred Health main provider of public healthcare to around 375,000 people residing in the local community About 50 % of the work comes from the tertiary and quaternary service Around $900 AUD million per annum Approximately 900 beds; 1,000 births, 75,000 ED presentations, 88,000 inpatient events; 162,000 outpatient attendances. Three hospital campuses - The Alfred, Sandringham Hospital and Caulfield Hospital Over 7,700 employees across the three sites. 7

Before Alfred Centre Access to services compromised Cancellation of elective surgery (>30%) Balance of emergency and elective surgery wrong High levels of ambulance diversion Emergency Department delays Increasing Financial pressures Service demand growing Aging and Inflexible infrastructure 9

Opportunity for Redesign Not just another service add on Redesign processes across health service Referral process peri operative process Scheduling Emergency Processes Theatre Schedules Specialist (outpatient) clinics Discharge and Follow up 10

Principles for Model of Care Separation of elective from emergency (physically and functionally) Focuses on patient s journey (starts with referral source eg GP, hospital) Purpose built facility (design standardised, patient spaces ) State of the art technology (most advanced) One stop approach to care (minimises patient attendances) Model forms the basis for all planning phases Business case Service design Facility design Role design IT design Plans and schedules care Standardisation (design and protocols) ICT enables Role design - multi-skilling and new skills 11

The Alfred Centre A Snapshot A New Model of Care Improved patient experience Separation of short stay elective from emergency care Diagnostic, procedural & interventional centre Stand alone & state of the art facility integrated within Alfred Service efficiency and effectiveness Access to services equity Innovation and excellence Based on extensive planning, consultation and research A unique development - a Demonstration Model 12

Since February 2007 there has been a 50% increase in episodes & exceeded 135,000 last fin. yr. Typically 350 patients are treated each day. FY11/12 YTD Activity FY 06/07 (to 24/6/2012) Variance Elective procedures at Alfred Centre 3551 10385 6834 Elective Same Day admissions 7277 Elective Multi-day admissions 3108 Medical Ambulatory Day admission 1593 5900 4307 Pre-admission Clinic visits 2356 5009 2653 Specialist Clinic visits 32423 68432 36009 Imaging Activity (all modes) 26564 43820 17256 Total Episodes of Care 66487 133546 67059 13

Wide range of activity & clinical specialities Surgery Endoscopy Specialist Clinics Medical Day Procedures Diagnostic Procedures Orthopaedics ENT Respiratory Plastics and burns Renal and urology Ophthalmology Breast and endocrine Vascular Range of general surgery ie - upper &and lower GI (requires LOS < 72 hrs and no ICU) GI Endoscopes Bronchoscopes Cystoscopes Orthopedics Urology Vascular General Surgery Plastic Ophthalmology ENT Trauma Gastroenterology Infusions (intragam, blood, chemo) Biopsies (liver, kidney) Lumbar punctures Paracentesis Therapeutic venesection Pre & Post interventional radiology care Multiple diagnostic investigations on 1 day Full range comprised of: 1 MRI 1 CT 2 X-ray 2 Ultrasound 1 Angio/fluoro 14

No. of procedures Total Procedures There has been a 57% growth in the number of surgical procedures performed at Alfred Health since The Alfred Centre opened. Total Surgical Procedures - The Alfred to 24 June 2012 25000 20000 15000 10000 Elective Emergency Grand Total 5000 0 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 Year 15

Cases 77% increase in same day surgical activity Elective Surgery - The Alfred 8000 7000 6000 5000 4000 3000 2000 1000 0 05/06 06/07 07/08 08/09 09/10 10/11 11/12 Financial Year Alfred Centre Multiday Alfred Main Multiday Alfred Centre Sameday Alfred Main Sameday 16

No. Longwaits Significant reduction in long wait patients Alfred Health is on track to have no patients waiting for surgery outside clinically recommended waiting times by the end of 2013 1200 Alfred Health elective surgery wating list longwaits (Ready and Not Ready for Care) 1000 800 600 400 200 0 Jul- 06 Sep- 06 Nov- 06 Jan- 07 Mar- 07 May- 07 Jul- 07 Sep- 07 Nov- 07 Jan- 08 Mar- 08 May- 08 Jul- 08 Sep- 08 Nov- 08 Jan- 09 Mar- 09 May- 09 Jul- 09 Sep- 09 Nov- 09 Jan- 10 Mar- 10 May- 10 Jul- 10 Sep- 10 Nov- 10 Jan- 11 Mar- 11 May- 11 Jul- 11 Sep- 11 Nov- 11 Jan- 12 Mar- 12 May- 12 Month 17

Cancellations Significant reduction in cancellations Less than 1% of cancellations occur in The Alfred Centre Surgical Cancellations 30% 27% 25% 20% 18% 15% 12% 11% 11% 11% 9% 10% 10% 10% 5% 6% 5% 6% 8% 7% 8% 6% 6% 6% 6% 5% 7% 7% 6% 5% 0% 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 06/07 07/08 08/09 09/10 10/11 11/12 18

Day of Surgery Admission Rates 100% DOSA rate in Alfred Centre Alfred Health Day of Surgery Admission Rate (DOSA) 92% 90% 88% 86% 84% 82% 80% 78% 2006 2007 2008 2009 2010 2011 2012 Fiscal Year 19

% Failed Sameday Failed day case rates % of Failed Sameday Admissions 30% 25% 20% 15% 10% 5% 0% 2006 2007 2008 2009 2010 2011 2012 Fiscal Year 20

What does the facility house Procedure unit Day-of-procedure-admission 6 Operating Rooms 2 Procedural rooms 12-1 st stage recovery beds 35 2 nd stage recovery day beds/chairs Overnight accommodation 18 Short Stay multi-day beds 16 Medical Day Unit beds 8 Medihotel multi-day beds Pre and post procedure care Diagnostic Unit MRI and CT Digital X-ray Ultrasound Angio and Fluoro suite Future Expansion potential currently leased tenants Future Expansion potential currently leased tenants Future Expansion potential currently leased tenants Plant Room Intervention Zone Vacant expansion Intervention Zone Expansion (vacant) Future Expansion potential as service need grows Speciality Surgical Clinics Gen Surg, Ortho, Urology, Vascular, Plastics Short Stay Zone Diagnostics Zone Speciality Surgical Clinics Preadmission Patient Services Centre Lobby/ Pharmacy/Cafe Speciality Clinic Expansion - 2013 Patient Services Centre and Preadmission Planning patient journey Scheduling centre 8 consulting rooms Administration hot desks Entry and reception (on all 3-levels) meet and greet Registration Basement 1 : Car Park Basement 2 : Car park Speciality Clinic Expansion to commenced late 2012 ENT, Ophthalmology & Gastroenterology Clinics 21

The Model of Care Principles completely informed planning & facility design Model of Care Principles Separation of elective from emergency (physical and functionally) Focuses on patient s journey (starts with referral source eg GP, hospital) State of the art technology (most advanced) One stop approach to care (minimises patient attendances) Standardisation (design and protocols) Expected Outcomes Guarantee access for elective surgery plan with confidence No cancellations Includes other health services into care episode, particularly at point of referral and discharge planning Access to best equipment supported by tertiary hospital system, for example patients with complex needs Ensures other health services are involved in patient preparation and follow-up discharge work Other health services will be factored into protocol that starts with referral source and completes with patient returning to that source Plans and schedules care Multi-skilling and new skills ICT focus Purpose built facility (design standardised, patient spaces ) Includes referring GPs/consultants into care episode A patient scheduling centre will coordinate patients care and ensure patient is ready for procedure (reduce DNAs). Draws on skills and expertise of other health services to support the patient s journey, for example state wide rehabilitation service Will enable streamline electronic transfer of information between referring consultants and health services Design enables flexibility to address changes in service demand with built in future expansion (capacity) Emphasis on pre-procedure preparation by GPs, health services supported by The Alfred 22

New Model of Care Major paradigm shift in the management of elective surgery Focus on the patient journey Focus on the patient experience Development of a framework and definition of the type of care and mode of delivery 23

3 Streams of Surgical Care Alfred Surgical Patient Elective Cases Emergency Surgical Cases Short Stay Target <3 Day Length of Stay Short Stay Target >3 and < 5 Days Length of Stay Expected Length of Stay >5 Days Alfred Centre Alfred Main Dedicated Short Stay Beds Alfred Main Inpatient Ward 24

Model of Care Pre-redesign Referral Outpatents Clerk Preadmission Clinic Operating Theatre No clear referral guidelines No front end screening of referral Placed on the waiting list, health questionnaire sent to patient via clerk, on return no clinical review of patient status Decision for PAC made by the clerical staff or Doctors secretary based on patient s age and diagnosis No development of the patients plan of care Surgical list decided by clerk or doctor based upon patient s ready as opposed to waiting time, 25

The New Surgical Patient Journey Referral Specialist Clinics Patient Service Centre Preadmission Clinic Operating Theatre Procedural Suites Beds Discharge & Continuing care Referral guidelines Peri-operative Coordinator Review & patient plan of care developed One stop approach to scheduling Co-locates bed assignment, waiting list, peri-operative coordinators and schedulers Protocol driven Booked 4-6 weeks prior to surgery date Surgery booked 2-4 weeks prior to planned date, no cancellations Electronically scheduled at the time of surgical booking Event driven discharge Links back to GP s for ongoing care minimising outpatient attendances Protocol-led process throughout the entire journey 26

Peri-Op Co-ordinator Role New role Experienced surgical nurse Key contact for patients & staff Supports the designated surgical unit in co-ordinating the patients care & journey Guided by protocols developed & authorised by the Surgical Unit & Dept of Anaesthesia Day to day works closely with the surgical unit, however are part of the Patient Service Centre Monitor unit performance and outcomes Coverage across all surgical units 16 EFT 27

What is the Patient Service Centre? Brings together key staff involved in the scheduling, booking & co-ordination of a patients journey to surgery. Incorporates: Bed assignment office Peri-operative coordinators Clerical staff from PAC, W/L & designated surgical units and services PSC clerks assigned to designated units aligned to a peri-op coordinator 10 EFT 28

Standardised Approach to Care 29

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Patient Discharge Information 31

Key Design Features Functional areas are grouped and located Emphasis on the patient journey Non-departmental based Generic floor designs Ensure adaptable for future uses Interior design Promotes as Wellness Approach Layout Multidisciplinary team based approach Effective work processes and clinical pathways (standardization) Physical Link to existing facilities (ease of movement / support services) Utilises site wide support services through tunnel connections with main Alfred (hub and spoke model) Future Expansion Design caters to future expansion vertical and horizontal 32

Ambulatory Care Model Hong Kong May 2013 Andrew Stripp Deputy Chief Executive & Chief Operating Officer

Ground Floor Foyer/Patient Service Centre 34

1 st Floor Short Stay & Diagnostic Zone 35

2 nd Floor Intervention Zone 36

The Alfred Centre 37

Front Entry 38

Cafe 39

Foyer 40

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Patient Services Centre 42

Shorts Stay Ward 43

Overnight Accommodation 44

Patient Lounge Area 45

Medical Day Unit 46

Medical Day Unit 47

Radiology 48

Radiology 49

Theatres 50

Procedural Room 51

Decontamination Unit 52

Link-way to Alfred Main 53

Patient & Visitor Car Park 54

Ambulatory Care Model Hong Kong May 2013 Andrew Stripp Deputy Chief Executive & Chief Operating Officer