Managing Emergency Department Frequent Attendees Polly Grainger
Christchurch Hospital and Ta-Mera Rolland Middlemore Hospital
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What is the problem? High utilisation of ED services by
frequent attendees account for disproportionate amount of the total
ED workload contribute to overcrowding increase acute demand Care
can be limited many have complex needs system is fragmented
episodic nature of ED visits Pillow et al (2013)
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What is the size of the problem? In the year ending February
2010 at Middlemore ED: 64,409 patients presented to ED 88,565
times. 1711 patients were flagged as Very High Intensity Users
(VHIU) and had 8756 presentations between them 61% stayed overnight
Total bed days for the year were 25,768 Median of 10 bed days per
patient Total cost of VHIU patients was $31.5 million
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So what have we tried? Case Management Systems Integration
Interdisciplinary Approach Christchurch Story & Middlemore
Story
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Case Management Benefits Patient experience Staff experience
Department experience Care standardisation Continuity of care
Condition clarification Agreed limitations e.g., investigations,
medications Multi-service inputs Potential for reduction of visit
frequency and LOS Opportunity for health promotion Opportunity for
referral follow-up
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Christchurch activity NB: Number of patients, not number of
attendances
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Christchurch Story Participants 4+ ED visits in 12 months Case
management Excluded no one Began 2001 focus: ED & mental health
patients Hiatus 2006 almost no staff to maintain process Resumed
2011 focus: ED & mental health patients Extended 2012 focus:
COPD patients community integration
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Basic model Personnel ED Team = 1 nurse, 1 consultant, GP and
patient As suitable = ED staff, medical/surgical etc specialists,
psychiatric services, social workers Process 1.Identify patient
data reports, requests from clinicians and requests from customer
services office 2.Confirm and collate history 3.Draw up draft plan
4.Distribute to interested parties / potential contributors +/-
patient 5.Complete plan and publish
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Supporting Initiatives Health & Wellbeing Connection Target
population: early high users, worried well Canterbury Clinical
Network (CCN) Target population: known as a high likelihood of ED
attendance +/- admission over winter Collaborative Care Management
Solution (CCMS) Web-based case management plan Range of personnel
can access with security limits HealthPathways website HealthInfo
website
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Measures Christchurch Presently Quantitative: number completed,
number falling into inclusion category (to start plan development)
Qualitative: Nil Future? Quantitative: ED attendance frequency, ED
LOS, Admission frequency, Inpatient LOS Qualitative: Patient
experience, staff experience, department experience (flow etc),
risk mitigation Suggestions sought
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Middlemore Story Over 800 Beds Population 490,610 (2011)
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Ethnicity
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VHIU Criteria 5 th presentation to Emergency Care (EC) in last
12 months Referral from GP,Consultant & other health care
providers Live in CMDHB area 15 years old + Exclusions may include
health conditions e.g. maternity, surgical cluster, haematology
3115 referrals with 1674 accepted onto the programme since Nov
2010
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VHIU Programme Integrated care programme Includes Primary and
Secondary care Interdisciplinary team Holistic approach Medical
Psycho-social Cultural support Emphasis is on self-management Good
links with primary care Community-based organisations Appropriate
access to secondary care
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VHIU Process Home visit Risk Assessment Guide (RAG) Develop
Care Plan Interdisciplinary Team Review Physician Nurse
Physiotherapist Social Worker Pharmacist Referrals to other
agencies
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Areas of risk identified from RAG
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3 5 5 6 % 3.7 10.8 8.7 6.7 8.6 4.3 9.5 2.8 Percentage of
patients flagged for the practice versus the whole of
Manurewa/Papakura
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Benefits Strengthening the link between GP, Patient &
hospital Erodes boundaries between primary & secondary care
Ensures engagement with GP Facilitates access to specialist teams
Reduction in avoidable hospital presentations Improved health
outcomes
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Supporting Initiatives 20,000 days collaborative - funding and
project support Localities development - clinical network
development Sharing electronic records -integrating primary and
secondary information
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Patient stories Middlemore Post MI with patient and wife made a
difference including accessing healthcare, WINZ and Pathways
helping to return to work RA patient too stiff and painful to
attend OPA no meds for 3 years needs specialist to go to the house
-living in lounge- no access to phone
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Measures Middlemore Presently Quantitative: EC presentations
pre and post VHIU enrolment Bed days pre and post VHIU enrolment,
Time to Home visit Qualitative: Patient stories and interviews
Future? Quantitative: Process measures for improvement Qualitative:
EQ5D- quality of life pre & post
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Wins and Challenges Christchurch and Middlemore Co-ordinated
case management of the complex patient decreases frustration for
patients, families and clinicians across the system improves health
outcomes by decreasing access barriers Needs investment now for
future gains
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Benefits of plans return Knowing what: resources have already
been involved resources can yet be involved has already been
investigated i.e., where to start this attendance, what to do,
where to stop Collaboration to obtain consensus Web-based plans:
One venue, integrating community and ED plans = Coordination not
confusion
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Challenges to the process Broad team with different drivers
across services = conflicting priorities Specialists now referring
to the team = symptom of silo system How to measure and what?
Longitudinal benefits of system integration Funding models across
the system
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Where next? Christchurch: Look at other models such as NZ -
Middlemore, UK - Hull Royal Infirmary, USA - St Vincent Hospital,
Green Bay, Wisconsin, and Baylor College of Medicine, Houston,
Texas Enabling measurements Middlemore: Top of the complexity
triangle Specialist team partnering across the system Spread and
Integrate vertically and horizontally Support IDT development in
primary care Refining measurements across the system