Andrew Perta & Janelle Russell - Alfred Health - TCP MODEL 3 | Providing Timely Quality Care within...
-
Upload
informa-australia -
Category
Health & Medicine
-
view
259 -
download
0
description
Transcript of Andrew Perta & Janelle Russell - Alfred Health - TCP MODEL 3 | Providing Timely Quality Care within...
Timely Quality Care within the Transition Care Program (TCP)
Andrew Perta, Clinical services Director – Rehabilitation Aged And Community Care Director of Nursing and Site Coordination – Caulfield Hospital Janelle Russell, Service Co-ordinator, Transition Care Program
TCP Overview
Alfred Health Transition Care Program commenced in August 2006.
Transition Care program has increased to 68 bed based places. 21 places are located onsite at Caulfield Hospital 47 are located off site under Contracts
Plus 20 Community home based places .
Total of 88 TCP places.
Drivers for change….
• Performance against benchmarks • Demand on inpatient beds across Alfred Health • National Standards • Redesigning Inpatient Rehabilitation Project • Alfred Timely Quality Care • CH redevelopment feasibility study - a ‘model of care’ for the future
Pascal’s Law
• an external pressure applied to a fluid in a closed vessel is uniformly transmitted throughout the fluid
Guiding Concepts for Alfred Health Timely Quality Care
• The patient should be seen by the most appropriate senior decision maker, as soon as possible along all points in their journey.
• Trust the referrer • Accountability & responsibility begins on referral • Right place, right time, 1st time • Treat in turn • Active management of patient’s throughout their
journey • No tolerance for ‘waiting’
Integration of TCP
• Complex Care • Bed Access • Ward Meetings • Continuum • Location • E-Referral
Stream Options & Partnerships
• Bed based Services – I onsite – 2 offsite
• Best Fit – Medical Complexity – Care Needs – Home location
Methodology
Journey Board & Briefs
Client Experience
Workshop -‐ Pa<ent Mapping – Ideal Pathway Workshop -‐ Shared Purpose &
Principles
Data Collection
E-‐referral Workshop -‐ Measuring Success
Workshop - Shared Purpose
As the Transition Care Program we provide: • Individualised, client focused, goal directed, collaborative interdisciplinary
care following a hospital admission. We aim to optimise functional capacity and independence facilitating appropriate and timely discharge outcomes within the service scope.
Principles (Ideal State) • Person Centred - in partnership with the patient/client and responsible
person empowering them to make informed decisions • Goal directed – time-framed and realistic • Supportive, safe nurturing environment allowing time for informed decision
making • Consistent approach to care delivery across settings • Smooth transitions across the program
Patient Mapping – Ideal Pathway & Real Pathway
• Referral to Discharge
• Staff
• Medical Record Audit
“Ideal Patient/Client Map”
Smooth transi<on Pa<ent/client is safe and comfortable
Pa<ent/client’s plan is clarified
Pa<ent/client is involved in a personalised program
Pa<ent/client has confidence
in their discharge plan
Journey Boards & Briefs
• Implementation
• 3 sites
• Evaluation – Attendance – Board completion – Staff Satisfaction – Other metrics:
> EDD, DD, time of arrival to first interdisciplinary discussion
Journey Board & Brief Onsite Evaluation
Journey Board & Briefs Evaluation
• Reduced variation between time of arrival and first interdisciplinary discussion of EDD and DD
• Pre Journey Boards 2-22 days, average 10 days • Post Journey Board 0-3 days
Journey Board & Briefs Evaluation
Staff Satisfaction Survey: 8 respondents – 3 Nursing & 5 Allied Health
• 88% (n=7) agreed or strongly agreed that the Journey Board & Briefs improve communication within the care team.
• 63% (n=5) agreed or strongly agreed that the Journey Boards & Briefs assist/support the clinical handover process.
• Comments suggested that the Journey Board provided a good snapshot & 1 brief per week might be enough.
Electronic - Referral
Staged roll out organisation wide resulting in:
• Improved organisational communication • Greater interdisciplinary collaboration • Improved quality of referral • Collection of KPI’s and monitoring of service efficiencies • Positive user feedback
Phase 2 • ACAS link
Client Experience
Marjorie is a recent TCP client who spend 11 weeks 4 days in bed based care offsite. She had been living independently at home by herself and has no husband or children. She has a very supportive sister, niece & nephew. Marjorie spent months in hospital due to a number of complications and underwent a BKA.
It was a very difficult decision for Marjorie to make when considering her long term discharge options and she believed:
• The amount of time she spent with TCP was appropriate so that she could make the right decision to go to low level care and feel very comfortable with her discharge plan.
• That staff involved her in decisions about her discharge plan and her family and home situation was taken in to account.
• Nursing & Medical input met care expectations • Physio Input – needed more given she was accustomed to twice per day • Home visit – provided clarity about her decision in that she would not cope at
home
Where to from here…
• Patient Mapping Detail Completion • Metric refinement • Dashboard – reporting
QUESTIONS?!