Country Health SA Local Health Network
Strategies for Improving Strategies for Improving The Country Patient The Country Patient
JourneyJourney
Pam Pratt
Patient Liaison Network CoordinatorPatient Liaison Network Coordinator
CHSALHN
Patient Journey Initiative
The Patient Journey Initiative aims to
improve the outcomes for people living in
country South Australia needing to access country South Australia needing to access
health services locally, regionally & from
Adelaide-based services
Tip of the iceberg!
Inpatient services
Private hospitals &services
Other Health Services (Allied Health, Dental)
Outpatients – Public & Private
Patient Journey Initiative
The Patient Journey Initiative was established
in 2006 with the following strategies in mind:
> To reduce the number of avoidable referrals
> To improve the journey for people from country S.A.
Patient Journey Initiative
> To decrease the length of time
> To improve discharge planning
> To improve and develop appropriate health services and clinical networks across country South Australia
Key Issues Identified for Action
> Referral systems and processes
> Transport, accommodation and carer support services
> Discharge planning from Adelaide hospitals back to Country S.A.
Key Issues cont.
> The Patient Journey for particular groups of people from Country SA
> Avoiding unnecessary journeys> Avoiding unnecessary journeys
> Availability of health services in country locations
> Informing consumers and carers
Achievements to date include
Patient Liaison Network established
The CHSA Patient Liaison Nurse (PLN) role at
Country hospital sites formally began in 2007
Rural Liaison Nurses at major metropolitan public
hospitals
Patient Liaison Network Forum
Benefits of a Liaison Role
> Coordination
> Linking points of care
> Central Contact
> Improved discharge planning
> Improved understanding
> Improved patient outcomes
Country Health SA Nursing and Midwifery Transfer
Form
(Used when transferring to a metropolitan health unit, another country health unit or residential care
facility)
Achievements to date include
Country Home Link (CHL)
Rapid Intensive Brokerage Scheme (RIBS) Hospital avoidance program
Transitional Care Package (TCP)
Health Literacy Resources
Available on the CHSALHN Web site
Aboriginal Patient JourneyResource
Step Down Services
Enhancement of Step Down services at Port Augusta and Ceduna
Port Augusta Step Down Unit
Patient Liaison Network Coordinator
Provide corporate support services to the
Patient Liaison Network
Metropolitan/Country Patient Flow NetworkMetropolitan/Country Patient Flow Network
Central contact
Referral point
Coordination
Pulmonary Rehab Program
The following locations established
pulmonary rehab programs during 2011:
• Mount Gambier
• Millicent
• South Coast (Victor Harbor)• South Coast (Victor Harbor)
• Mount Barker
• Wallaroo
• Murray Bridge
• Port Augusta
• Port Pirie
• Port Lincoln
• Whyalla
Cardiac Rehabilitation Programs
The following locations have established cardiac rehabilitation programs:
• Mount Gambier
• South Coast (Victor Harbor)
• Mount Barker• Mount Barker
• Wallaroo
• Murray Bridge
• Port Augusta
• Port Pirie
• Port Lincoln
• Whyalla
• Berri
• Gawler
Achievements to date include
GP Plus Services (out of hospital /primary care services)
Better Care FacilitationBetter Care Facilitation
Rehabilitation Services
Cancer Services
Achievements cont.
Alternatives to travelling to access Health
Services
> Telemedicine / IT solutions
> Digital radiology services > Digital radiology services
> Expand advanced care/extended care roles in country SA
Health Diaries
Folder for adults with chronic and/or complex health conditions to use to better manage their health
Patient Journey Communiqué
Patient Journey Storybook
Operational Business Intelligence (OBI)
Dashboard
SA Health completed the work to develop
and implement a near to real time
‘dashboard’ in the areas of inpatients,
emergency departments and elective
surgery across all metropolitan hospitals
Country Patients in Metro
Information available about country
inpatients in metropolitan hospitals
Country patients are ‘flagged’ at broadCountry patients are ‘flagged’ at broad
category level
Access to patient lists/names was restricted
Patient Liaison contacts in country hospitals
Country Patient Lists
Advantages of OBI Dashboard
Quick and easy to use
Improves Communication
Monitor patients Progress
Commence Discharge Planning Home
Decrease occupied Bed Days!!!!
Good News Story
Allied Health workers identified known local clients
Negotiated direct transfer home
Confirmed home assessment and Confirmed home assessment and modifications were completed
Better client outcome
(Clinical Liaison Nurse/ Hospital in the Home
Coordinator, Port Pirie Regional Health Service)
Good News Story
Contacted patient having elective surgery in Metro
Discharge himself against medical advise
Post op complications - staying longerPost op complications - staying longer
Remained for extra days required then discharge
(Patient Liaison Officer, Kangaroo Island Health Service)
OBI Dashboard
The OBI Dashboard has proven to be an
excellent resource for country hospitals to
allow viewing of local patients in metro,
monitoring of their progress and initiating monitoring of their progress and initiating
transfers back
Overnight SA Country Patients in Metropolitan
Hospitals
Total Overnight Country Patients
in Metro28000
Separations
23000
24000
25000
26000
27000
28000
2009 2010 2011 2012 2013
SA Country Patients Transfer Summary
Transfer Summary
3000
3500
4000
4500
0
500
1000
1500
2000
2500
3000
Country to Metro Metro to Country
2009
2010
2011
2012
2013
Right care,
right team,
right time and
right place
QUESTIONS?QUESTIONS?
Top Related