Access for Older People’s complex care close to home

A rural and Metro partnership model

Debra Tooley - District Manager Aged Care Services

John Cullen - Geriatrician

2

Where are

we?

Western NSW…

Population: 277,353

18% Aged over 65 yrs

Our Services…

4

Why Telehealth Enhanced Model?

Data Analysis Project Design Implement & Test

Increased demand

Pt complexity

No Geriatrician

Increased waiting times

Increased travel for services

No funding for Geriatric Medicine services

Collaborative solution design

Technology

Funding source

Leadership

Clinical – pt selection

Patient engagement

Role clarity

Quality & Audit process

Staff Education

Honorary medical contracts

Service Agreement

Purchase of Telehealth devices

Development of protocols

Data collection –activity & cost

Rostering of staff

Communication strategy

Person Centred, directed and empowered

Primary care based

Targeted

Continuously improved

Collectively accountable and

mutually beneficial

Shared information

Principles

Enablers

Engagement Partnerships Governance

Funding Leadership Capability

Culture Technology Information

Telehealth Model – a component of a

comprehensive geriatric model of careClinics

Scheduling

Equipment, Patients and Geriatrician

Booking

Transcription service

Workforce

Metro: Geriatrician

Local: Clinician

Liaison with GP

Patients

Clinical assessment

& reports collated

Mgt plans

Technology

Booking

Equipment testing

Education

Health Record

Shared clinical notes

Audit process

Governance & Funding

Clinical gov.

Local leadership

Evaluation

Quadruple Aim

Continual improvement

• Well accepted by patients and carers

• Family patient education and care

planning discussions

• Cognitive Assessments and diagnosis

• Capacity Assessments

• Comorbidities / Chronic disease

assessment ( and management)

• Medication reviews

• Driving assessments

• General healthy ageing advice

• Advanced care planning discussions

• Gait, Falls and Bones evaluation

What Works Well

• Telehealth is not “instead of” face to

face clinics

- complimentary

• The Medicare model rather than ABF

funding model

• The enterprise has had the support

of both CEs of both LHDs

• The network has been reliable and

the equipment continues to improve

• Patient characteristics

– severe deafness

• Non-cooperation – extremely rare

• Assessments requiring hands on

physical examination

- (undertaken at face to face clinics)

What Doesn’t Work

Measuring Success

Improved experiences for people, families and

carers

Improved experiences for clinicians and service

providers

Improved health outcomes for the

population

Improved Health Systems

QUADRUPLE AIM

Measuring Success

“Great service in our own town”

“No different to a face to face appt”

“Great not having to travel to Sydney (6-10 hours)”

“Felt like I had specialists’ full attention the whole time”

“Perfect for country people”

“Excellent team work – felt supported”

“Technology easy to use”

“Very organised clinic”

“Feel connected to the patients and carers”

“I can do clinics from my own office”

Decreased waiting time for patients – less stress

Improved Patient &

Carer ExperienceImproved Clinician

Experience

0 5 14 2240

5576

56

85

3652

55

140

150132

110138

160

0

50

100

150

200

250

300

2010 2011 2012 2013 2014 2015 2016 2017 2018

WNSWLHDGeriatric Medicine Program

Consults FTF Consults via Telehealth

0

20

40

60

80

100

120

140

160

180

2010 2011 2012 2013 2014 2015 2016 2017 2018

Consults via Telehealth

Consults via Telehealth

Measuring Success & Sustainability

Outcomes

People, families and carers

• I can access specialist services in my own town

• I don’t have to re-tell my story

• I know that there are a team of skilled staff that assist with my health and social care needs

Service Providers and clinicians

• I can access all relevant information about the patient so I can provide high quality care (comprehensive assessment, restorative care, GP collaboration)

• I work in an efficient system that supports me to provide high quality care

• I collaborate and communicate effectively with other providers to deliver the best care possible

Population

• Care addresses the social determinants of health

• Care for people with long term conditions is improved

Health Care System

• The system is efficient and results in timely and appropriate management

• Health care service in NSW connected with social care

• IT systems and processes are integrated across the health system

• Financially viable

• WebRTC – using the web to connect to patients and

carers on their own devices in locations that are

convenient to them

(including RACFs)

• Use of wearable devices

- Embedded into clothing

• In home monitoring

• Linking outside the health network e.g. with AMSs

Where to from Here?

Quote for John Cullen

‘The Geriatric Medicine Service

is one of the more worthwhile

and satisfying things I do as a

clinician and a service manager’

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Thank you!

Where to

from here?

Debra Tooley - District Manager Aged Care Services

email: Debra.Tooley@health.nsw.gov.au