Aim

To increase the number of patients enrolled into the Very High Intensive User programme (VHIU) from 120 cases to 600* cases by July 2013.

This will result in a reduction in unplanned presentation and admission to Middlemore Hospital.

*Goal of 600 includes:» GP Referrals: 200 cases» 5 Flag referrals: 400 cases

Driver Diagram

- Include Collaborative Driver Diagram

5 Flag Process Change Packages

Secondary Drivers

(Theory of change)

Change Ideas Tested

Describe Process

Screening and Triage

.

Process has been standardise to ensure consistent assessment and review of all patients

Risk Assessment Guide (RAG)

Improved the existing RAG form to include information relating to language and health literacy to enable more comprehensive and thorough assessment.

Streamline Data Collection

Improved the existing data sets enable process measures that facilitate the monitoring and assessment of the change ideas.

5 Flag Process Change Packages

Secondary Drivers

(Theory of change)

Change Ideas Tested

Describe Process

Patient Quality of Life Assessment

To demonstrate VHIU’s benefit to the patient.

Standardise Information to GP’s

To enable and ensure that GP’s receive clear and consistent information about what VHIU does and how they work with practices.

GP Process Change Packages

Secondary Drivers

(Theory of change)

Change Ideas Tested

Describe Process

GP referral, use of triage tool.

To enable GP to review their patients to identify those most likely to benefit from the VHIU programme.

Partnering with GP Practices

Working with Franklin, Otara & Mangere Practices, sharing expertise and information, sharing home and follow up visits. Developing a joint care plan.

Most Successful PDSA Cycles?

- Include PDSA Tree diagram

Most Successful PDSA Cycles?

Pt identification by GP

using PARR (Any score)

GP Heart sink

Patients (list)

Pt identification

by GP using

PARR(with High

score)

PARR & 5 Flag

comparison

5 flag generation

for GP

Test of 5 flag+PAR

R+Heart

sink pts

Trigger tool

GP identificatio

n/Referral

Our prediction before the PDSA:

GP’s can correctly identify the appropriate VHIU patients using the PARR tool.

PDSA data revealed that on its own the PARR tool did not correctly identify patients for the VHIU team

This PDSA led to the embedding of the trigger tool as part of patient identification

Measures Summary

• Outcome measures– Patients enrolled from 5 flags, Primary care & Secondary care– Reduction in unplanned presentations & admissions– Bed days saved– Patient outcome measure (pre and post VHIU programme)

• Process Measures– Number of patients completing the VHIU Programme– Number of times patients complete the VHIU Programme– Time between presentations at EC & time to next unplanned

presentation.

• Balancing Measures– Numbers of re- presenting patients to the programme

VHIU Dashboard

- Include Collaborative Dashboard

Version: 1.0Dated: 28/02/2013

Project Manager : Alison Howitt Clinical Leader: Harry ReaImprovement Advisor: Prem Kumar

ContactsVHIU DashboardFebruary 2013

Run Chart - Total No of Cases Referred to VHIU

461

477

460

500 500

453

498

518511

496

505

520

455

527

400

420

440

460

480

500

520

540

Month/Year

Co

un

t o

f R

efe

rra

ls

Data 1

Median

Run Chart of 5 Flag Referrals to VHIU

458 460

447

500 499

453

493

503498

470 468

513

444

519

400

420

440

460

480

500

520

540

Month/Year

Co

un

t o

f R

efe

rra

ls

Data 1

Median

Run Chart of GP Referrals to VHIU

2

17

13

0 0 0

4 4

15

10

14

28

0

7

0

5

10

15

20

25

30

35

40

45

50

Month/Year

Co

un

t o

f R

efe

rra

ls

Data 1

Median

Run Chart of No of Patients Enrolled into VHIU

14

9

14

2325

34

46

28

49

41

38

35 35

40

0

5

10

15

20

25

30

35

40

45

50

Month/Year

Co

un

t o

f C

as

es

Data 1

Median

Run Chart of Enrolments from 5 Flag Referrals

12

910

2324

34

41

20

41

33

19

22

28

37

0

5

10

15

20

25

30

35

40

45

50

Month/Year

Co

un

t o

f C

as

es

Data 1

Median

Run Chart of Enrolments from GP Referrals

1

0

4

0 0 0

4 4

8

5

9

5

0 00

2

4

6

8

10

Month/Year

Co

un

t o

f C

as

es

Data 1

Median

Run Chart of Total Number of Patients Discharged from VHIU

13 4

8

19

32

16

34

39

29 30

1614

0

5

10

15

20

25

30

35

40

45

50

Month/Year

Co

un

t o

f C

as

es

Data 1

Median

Run Chart of Average Time in days on VHIU Programme

1215

18

34

42

5862

81

62 63

72

58

73

55

0

10

20

30

40

50

60

70

80

90

100

Month/Year

Av

era

ge

Tim

e i

n D

ay

s

Data 1

Median

Average days between sending to LOC/Team Member and First Home Visit

17

8

13 13

22

1314

6

10

14

4 4

75

0

5

10

15

20

25

30

35

40

45

50

Month/Year

Av

era

ge

Da

ys

Data 1

Median

Implementation

Implementation Areas

Changes to Support Implementation

PDSA cycles

Standardisation Screening and Triage Process

Documentation Process Map

Training Developing training materials to support new staff.

Job Descriptions

Measurement Develop regular reports for outcome and process measures

Resourcing Review of Job Descriptions for new Staff recruited

Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.

Highlights and Lowlights

Highlights- The collaborative support from 20,000 days bringing focus and

drive that has provided a catalyst for change and increased momentum

- The mutual respect within the VHIU team of our interdisciplinary skill set

- Recognition of the importance of a Model of Care which includes home visit and an holistic approach

Lowlights- Confusion due to multiple agendas within Primary and

Secondary care- Resistance and misunderstanding about integrated care- Difficulty in breaking down silos of care

Achievements to date- Do you have a change package, measurement plan?

- Multiple PDSA have resulted in standardised data capturing and reporting which includes monthly VHIU dashboard.

- What has changed and what difference have the changes made? - The data has allowed us to focus on areas that make a

difference and abandon those that don’t.- Triage process improved to identify the patient acuity enabling

the timely intervention- Referral Process leading to identification of patients from across

the health sector- Patient identification: Increase the appropriateness of referrals

received

- Improvements for patient and family experiences- Right service by the right professional to the right patient

and at right time