NEED TO DO BETTER;

Relevance of electronically coordinated care between providers to reduce

avoidable admissions for over 65 year olds

Trudy Yuginovich

THIS PAPER; findings from phase 1 of a current ARC-

funded project: ‘Minimising the inappropriate and unnecessary hospitalisation of frail older people (over the age of 65)’.

This research addresses a need for formative evaluation of process, impact and outcomes.

ISSUES At any given time people accessing health

services can have up to 9 different records (hospital, primary care, dental, community health, mental health and others).

Result from the lack of a unique patient identifier and results in services using their own separate identifiers which is a barrier to sharing of patient information between providers and better coordination of care

Globally this is reflected in poor communication between providers, duplication and gaps in services.

AIMS: develop, trial and evaluate a tool that

enhances the continuity of patient care and patient safety

provide a single point of access to data that identifies and provides information to all clinicians involved

evaluate the perceived need for an e-communities of care

LITERATURE; In Australia, a number of persons over 65

years are admitted to or remain in hospital because they are unable to access community-based supports

cannot be discharged as medically safe until either these supports become available or until they have spent longer recovering in hospital

people utilising hospital-based health care could remain at home if alternative supports were made available (Metropolitan Health Division Department of Health 2004)

literature (cont) variety of new aged care models

emerging which aim to provide appropriate collaborative aged care services;

in Australia change has been slow

OTHER CURRENT MODELS OF CARE; Program of All inclusive Care for the Elderly

(PACE), the Systeme de Soins Integrés Pour

Personnes Agees (SIPA) Program of Research to Integrate Services

for the maintenance of Autonomy (PRISMA) in Quebec and France (Kodner and Kyriacou 2000; Hébert, Durand et al. 2009)

In the Northern Territory in Australia, the HealthConnect Northern Territory (HCNT) Shared Electronic Health Record Service (SEHR) was implemented

APPROACH: Fourth Generation Collaborative

Evaluation (FGE) theoretical framework has been used

extensively in nursing research since the 1980’s

uses a constructivist, inquiry paradigm to provide a shared process of accountability (Guba and Lincoln 2003).

METHOD; Purposive sampling A Project Steering Committee of key

stakeholders The Project Team of the researchers and

project staff A Site Management Group (SMG) Stakeholders semi-structured interviews (n-7)

FINDINGS A need for the ‘right information at the

right time and place approved health care providers should

be able to ‘download relevant information from a GP’ for other relevant services to coordinate care for the frail over 65years olds

A Coordinated approach to care was seen as potentially reducing avoidable admissions for this age group

THEMES; interconnectivity between providers communication, For a fast contact with a

[General Practitioner] GP, the caller must be at least an RN.

access to resources and avoidable hospitalisation.

major difficulties exist with networking services within the health sector. Waiting for a doctor is a major reason for unnecessary time spent in hospital. ..Assessment teams are often unavailable.

THEMES(CONT..) difficulties retrieving information out of

systems problems linking directly with other

providers for cross sector information The least effective communication mode

was identified as being email. Most common means of communication-

Phone and fax in all cases. Some respondents indicated that sometimes fax is useful only as a follow up

THEMES significant numbers of people at risk of

avoidable hospitalization A need for the ‘right information at the

right time and place’ approved health care providers should

be able to ‘download relevant information from a GP’ for other relevant services to coordinate care for the frail over 65years olds

VALUE OF AN E-COMMUNITY overnight hospital stays were seen by all

respondents as being a result of poor coordination and/or inability to communicate leading to delays in finding needed information.

Better connectivity between GPs and other service providers would make a big difference.

A common waiting list would help a lot. At least we could do a better job of

coordinating information exchange with the hospitals-so much time and effort wasted on this that adds to length of stay

VALUE OF E-COMMUNITY OF CARE No respondents suggested that they

were aware of any options for linking between departments providing services to the aged care community

all agreed that this was an optimal solution thus reflecting comments by others

CONCLUSIONS The main at-risk group for avoidable admission

to hospital was seen as being people with poorly managed chronic conditions who need extra services not easily available in the community.

A free-flow of information, between providers is imperative to streamline care for the frail elderly.

Currently there is no facility to generate an electronic discharge summary and/or provide a linked approach to care in the region

A linked approach to care is seen as crucial to coordinated approaches to care to reduce avoidable admissions.