St John Project Transport to the Medical Home

20,000 Days Campaign Learning Session 3 11-12 March 2013

Project Manager: Jo Goodfellow

What do we want to achieve?

To increase the number of Status 3 and 4 patients who are transported by St John to a primary care / community setting as an alternative to transporting to the Emergency Department

….and why?The number of self presentations to ED across Auckland is increasing by around 10% pa putting pressure on DHBs. A proposal developed with St John was presented to and endorsed by GAIHN’s Alliance Clinical Network and Leadership Team (October / November 2011)

Clinicians from the regions EDs, primary care sector and Accident and Medical sector were consulted and together with St John developed clinical guidelines for the paramedics to support their decision making on the scene (November 2011)

Setting the Scene

Low acuity patients who call 111

A pathway for low acuity patients to be transported to an A&M by St John as an alternative to ED was established in December 2011 with the cost of the treatment paid for by POAC

This was a result of increasing pressure on EDs from the continued rise in unplanned presentations, predominately self-referrals

Ambulance transports account for around 33 percent of all hospital presentations and the number of transports in the region has increased by 3.84 percent over the last 12 months

36% of all transports to ED go to Middlemore, 28% to Auckland Hospital, 23% to North Shore, 9% to Waitakere, and 4% to Starship

82% of all ambulance calls are Moderate (Status 3) or Minor (Status 4). In the last 12 months, St John attended 126,869 calls in Auckland which resulted in 102,141 transports to an ED or other medical facility

Since the establishment of the pathway, approximately 1400 patients have been transported (regionally) to an A&M who would otherwise have been taken to an ED

St John Project Driver Diagram

To increase the number of low acuity

(St John status 3 & 4)

patients being

transported to, and

managed in a primary

care setting from 5 to 10 patients per day, by 01 July 2013

Patient

General Practitioner

(GP)

St John

Availability of St John

Education of crews

Education

Capacity

St John Project Driver Diagram

Doctor availability

Location of patient

1° 2°

Education

Change Concepts

Increase capacity

Increased public awareness of primary care to be treated in primary care

‘Relaunch’ pathway with St John crews to assist in embedding into practice

Extend transport to include more

A&Ms and GPs for pt treatment

Hours of service of A&Ms / GP practices

Communication with GPs regarding

involvement in pathway

Specific Change Ideas

Accident & Medical Centre

Opening hours

Patient expectation

Patient status

Triage by call centre

Pt choice of ED, or primary

care

Location of A&M or GP

Driver decision where to take pt

Medical skill/confidence

Change Packages

Secondary Drivers

(Theory of change)

Change Ideas Tested

Regionally agreed guidelines developed

ED clinicians in support of project and confident guidelines ensure patient safety

Individual A&M centres consulted and processes agreed

All centres keen to come on board and sign an MoU with POAC

Regional implementation of the guidelines and pathway

Initial teething issues in individual A&Ms

Some variation in practice within the A&M centres

Pt transfer to A&M centre

Additional 4 A&M centres included in project for CMDHB area

Measures Summary

Feb

2013

Jan2

013

Dec

2012

Nov

2012

Oct

2012

Sep

2012

Aug

2012

Jul2

012

Jun2

012

May

2012

Apr

2012

Mar

2012

Feb

2012

Jan2

012

Dec

2011

Nov

2011

Oct

2011

Sep

2011

Aug

2011

Jul2

011

Jun2

011

May

2011

Apr

2011

Mar

2011

Feb

2011

Jan2

011

Dec

2010

Nov

2010

Oct

2010

Sep

2010

Aug

2010

Jul2

010

Jun2

010

May

2010

Apr

2010

Mar

2010

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2010

Jan2

010

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2009

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2009

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2009

Sep

2009

Aug

2009

Jul2

009

Jun2

009

May

2009

Apr

2009

Mar

2009

Feb

2009

Jan2

009

600

550

500

450

400

Month/ Year

No o

f C

ase

s

_X=506.0

UCL=624.9

LCL=387.0

Pilot start Formal Launch of Project

Feb

2013

Jan2

013

Dec

2012

Nov

2012

Oct

2012

Sep

2012

Aug

2012

Jul2

012

Jun2

012

May

2012

Apr

2012

Mar

2012

Feb

2012

Jan2

012

Dec

2011

Nov

2011

Oct

2011

Sep

2011

Aug

2011

Jul2

011

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011

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2011

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2011

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2011

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2011

Jan2

011

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2010

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010

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010

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2010

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010

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2009

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2009

Oct

2009

Sep

2009

Aug

2009

Jul2

009

Jun2

009

May

2009

Apr

2009

Mar

2009

Feb

2009

Jan2

009

160

120

80

40

0

Month/ year

Movin

g R

ange

__MR=44.7

UCL=146.1

LCL=0

Dec2011Sep2011

Ambul Presentation to MMH EC (Triage Cat 4)

Feb

2013

Jan2

013

Dec

2012

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2012

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2012

Sep

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Aug

2012

Jul2

012

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012

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012

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011

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010

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009

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009

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2009

Apr

2009

Mar

2009

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2009

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009

600

500

400

Month/ Year

Num

ber

of

Case

s

_X=514.7

UCL=634.8

LCL=394.5

Pilot Start Formal Launch of Project

Feb

2013

Jan2

013

Dec

2012

Nov

2012

Oct

2012

Sep

2012

Aug

2012

Jul2

012

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012

May

2012

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012

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011

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011

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010

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010

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010

Dec

2009

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Oct

2009

Sep

2009

Aug

2009

Jul2

009

Jun2

009

May

2009

Apr

2009

Mar

2009

Feb

2009

Jan2

009

160

120

80

40

0

Month/ Year

Movin

g R

ange

__MR=45.2

UCL=147.6

LCL=0

Sep2011Dec2011

I-MR Chart of Ambul. Presentation to MMH EC (TC 4&5)

Feb

2013

Jan2

013

Dec

2012

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Apr

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Mar

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Feb

2009

Jan2

009

20

15

10

5

0

Month/ Year

No o

f C

ase

s

_X=8.72

UCL=17.13

LCL=0.31

Formal Launch of ProjectPilot Start

Feb

2013

Jan2

013

Dec

2012

Nov

2012

Oct

2012

Sep

2012

Aug

2012

Jul2

012

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012

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012

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011

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011

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2009

Mar

2009

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2009

Jan2

009

12

9

6

3

0

Month/ Year

Movin

g R

ange

__MR=3.16

UCL=10.34

LCL=0

Sep2011 Dec2011

Ambul Presentation to MMH EC (Triage Cat 5)

Version: 1.0Dated: 04/03/2013

St JohnCollaborative Dashboard-February

Created by:

Contacts:

Improvement Advisor: Prem Kumar

Project Mgr : Monique Davies & Jo Goodfellow Clinical Leader: Campbell Brebner

Pt Transport to A&M- Region

Jan13Dec12Nov12Oct12Sep12Aug12Jul12Jun12May12Apr12Mar12Feb12Jan12

4

3

2

Month/ Year

Avera

ge c

ase

s

__X=2.657

UCL=3.681

LCL=1.633

Jan13Dec12Nov12Oct12Sep12Aug12Jul12Jun12May12Apr12Mar12Feb12Jan12

2.5

2.0

1.5

1.0

Month/ Year

Sam

ple

StD

ev

_S=1.723

UCL=2.457

LCL=0.988

Tests performed with unequal sample sizes

Number of Cases managed in Primary Care by St JohnAverage per day

J an13Dec12Nov12Oct12Sep12Aug12Jul12Jun12May12Apr12Mar12Feb12Jan12

100

80

60

40

Month/ Year

Tota

l N

um

ber

of

case

s

_X=69.69

UCL=98.50

LCL=40.88

Jan13Dec12Nov12Oct12Sep12Aug12Jul12Jun12May12Apr12Mar12Feb12Jan12

40

30

20

10

0

Month/ Year

Movin

g R

ange

__MR=10.83

UCL=35.40

LCL=0

Total Number of Cases managed in Primary Care by St John by Month

Jan1

3

Dec

12

Nov

12

Oct

12

Sep

12

Aug

12

Jul1

2

Jun1

2

May

12

Apr

12

Mar

12

Feb1

2

Jan1

2

0.20

0.15

0.10

0.05

0.00

Month/ Year

Pro

port

ion

_P=7.9%

UCL=0.1727

LCL=0

Tests performed with unequal sample sizes

Percentage of Subsequent Admisssion to Hospital by St John

Feb2

013

Jan2

013

Dec

2012

Nov

2012

Oct

2012

Sep2

012

Aug

2012

Jul2

012

Jun2

012

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2012

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012

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011

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011

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011

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2011

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011

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011

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2010

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Sep2

010

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010

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010

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2010

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010

Jan2

010

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009

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2009

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009

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009

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2009

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2009

Mar

2009

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009

Jan2

009

2000

1800

1600

1400

Month/ Year

No o

f C

ase

s

_X=1742.6

UCL=1996.1

LCL=1489.1

Pilot Start Formal Launch of Project

Feb2

013

Jan2

013

Dec

2012

Nov

2012

Oct

2012

Sep2

012

Aug

2012

Jul2

012

Jun2

012

May

2012

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2012

Feb2

012

Jan2

012

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2011

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2011

Oct

2011

Sep2

011

Aug

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011

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011

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2011

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2011

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2011

Feb2

011

Jan2

011

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2010

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2010

Oct

2010

Sep2

010

Aug

2010

Jul2

010

Jun2

010

May

2010

Apr

2010

Mar

2010

Feb2

010

Jan2

010

Dec

2009

Nov

2009

Oct

2009

Sep2

009

Aug

2009

Jul2

009

Jun2

009

May

2009

Apr

2009

Mar

2009

Feb2

009

Jan2

009

300

200

100

0

Month/ Year

Movin

g R

ange

__MR=95.3

UCL=311.5

LCL=0

Sep2011 Dec2011

Ambul Presentation to MMH EC_Triage Cat 1,2,3

Feb2

013

Jan2

013

Dec

2012

Nov

2012

Oct

2012

Sep2

012

Aug

2012

Jul2

012

Jun2

012

May

2012

Apr

2012

Mar

2012

Feb2

012

Jan2

012

Dec

2011

Nov

2011

Oct

2011

Sep2

011

Aug

2011

Jul2

011

Jun2

011

May

2011

Apr

2011

Mar

2011

Feb2

011

Jan2

011

Dec

2010

Nov

2010

Oct

2010

Sep2

010

Aug

2010

Jul2

010

Jun2

010

May

2010

Apr

2010

Mar

2010

Feb2

010

Jan2

010

Dec

2009

Nov

2009

Oct

2009

Sep2

009

Aug

2009

Jul2

009

Jun2

009

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2009

Apr

2009

Mar

2009

Feb2

009

Jan2

009

2600

2400

2200

2000

Month/ Year

Num

ber

of

case

s

_X=2257.3

UCL=2542.1

LCL=1972.5

Pilot Start Formal Launch of Project

Feb2

013

Jan2

013

Dec

2012

Nov

2012

Oct

2012

Sep2

012

Aug

2012

Jul2

012

Jun2

012

May

2012

Apr

2012

Mar

2012

Feb2

012

Jan2

012

Dec

2011

Nov

2011

Oct

2011

Sep2

011

Aug

2011

Jul2

011

Jun2

011

May

2011

Apr

2011

Mar

2011

Feb2

011

Jan2

011

Dec

2010

Nov

2010

Oct

2010

Sep2

010

Aug

2010

Jul2

010

Jun2

010

May

2010

Apr

2010

Mar

2010

Feb2

010

Jan2

010

Dec

2009

Nov

2009

Oct

2009

Sep2

009

Aug

2009

Jul2

009

Jun2

009

May

2009

Apr

2009

Mar

2009

Feb2

009

Jan2

009

400

300

200

100

0

Month/ Year

Movin

g R

ange

__MR=107.1

UCL=349.9

LCL=0

Sep2011 Dec2011

Ambul Presentation to MMH EC_Overall

Implementation

Implementation Areas

Changes to Support Implementation

Standardisation Review of current regional St John guidelines

Define process for paramedics to liaise with the medical home

Documentation Prepare a communications plan

Define project governance and reporting arrangements

Training St John developing a plan to educate paramedics

Communication plan to educate GPs and practice staff about the change

Measurement The number of patients

transported to the medical home

to an Accident and Medical (A&M) centre

subsequently transferred to hospital (from A&M and medical home)

transported to a primary provider and then self presents to ED within 7 days

Resourcing Continue to work to roll out in April 2013 – it is not anticipated that there will need to be an increase in resource

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

Risk & Mitigation StrategiesRisk Current situation Mitigation

High rate of subsequent transports to ED 9% of patients currently referred on to hospital (not all transported by St John)

Review of guidelines to ensure appropriate for transport to medical home

Clinical governance review by POAC of all St John referrals

Patients become aware of the pathway and use it as a way to access free care (particularly those who are ‘friends of St John’)

No indication of this occurring – no cases where an individual who is a ‘friend of St John’ has been transported to an Accident & Medical facility (A&M) more than once

Continue to monitor

Ensure guidelines are clear that only those patients who would normally be transported to ED are included in the scheme

Monitor impact of enhanced triage at St John call centre and number of low acuity call outs

Patients who would have previously been transported to their medical home anyway and paid their usual co-payment, are included

Ensure guidelines are clear that only those patients who would normally be transported to ED are included in the scheme

Monitor impact of enhanced triage at St John call centre and number of low acuity call outs

Clinical governance review of appropriateness and any scope creep

Achievements to date

Expansion of St John Transport project to the Medical Home (starting April 2013)

The reason for expansion of the project is to ensure patients who don’t require ED treatment are transported, when necessary, to the best possible place. The medical home is often more appropriate than an A&M facility due to the capability to provide continuity of care with ongoing education for the patient, including re-engagement with the medical home.

As St John is already making the decision not to transport patients to an ED (under the original scheme) this expansion is unlikely to increase the number of affected patients, but gives patients more appropriate options for care. Further work during 2013 / 14 needs to be undertaken to ensure Primary Care’s continued capability to be able to accept urgent patients from St John.

Patient and family experience

Recently this project has received HRC funding (as part of the review of the Auckland Regional After Hours Network) and patient interviews will be conducted as part of this process over the ext few months