A Quality Initiative and Research Project from the Chronic Care Program

Service Redesign On The Run

Katrina Scott-Charlton, Care Coordinator, Chronic Care Program, ACT Health

Improving the management and quality of life for ACT residents with:

Chronic Obstructive Pulmonary Disease Chronic Heart Failure Parkinson’s disease

The Chronic Care Program

The Chronic Care Program

Client Nurse Care Coordinator C

omplex?

Respiratory specialist

podiatrist

Community nursing

Endocrine

ACAT

oxygen cylinder hire

Medication management

Mobility aids

Social worker

GP

OT

Hospital Admission

s

Cardiology

Community services

Physio

Geriatrici

an

Provide holistic assessment, care planning, education and support

Assist clients to access health and community services

Attend appointments with clients

Provide psychosocial support and advocacy

Facilitate Advance Care Planning

Support for carers/family

Clinical Care Coordinators

Action Research

Problem

Plan

ActObserve

Reflect

Problem

1) Create a safe, systematic approach for moving clients toward self-management and discharge

2) More time efficient

Plan

Literature review

Category 1: high needs (usual input)

Category 2: Low needs (monthly phone call only)

Act

Graduation discharge to CCP

nurse support

9 month trial Quantitative

◦ Monitoring of: Staff to client ratios Numbers of Category 1 and Category 2 clients Activity through Occasions Of Service

Qualitative◦ Client feedback via survey◦ Staff feedback via regular team meetings ◦ Staff focus group

Observe

46.6% increase in staff to client ratio

58.4% increase in clients receiving care coordination

79% increase in Occasions of Service

Quantitative Outcomes

Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-130

20

40

60

80

100

120

Pts

Cat2 Pts

Cat1 Pts

Project Imple-mentation ↓

Total Numbers of Clients/Category 1 and 2

Staff Feedback:◦ Occasional home visits were needed for some

Category 2 clients

Client Survey:◦ 52% response rate!◦ 90% felt they had enough support and

information through a monthly phone call◦ 45% felt that it would be beneficial to have an

occasional home visit

Qualitative Outcomes

Staff Focus Group Feedback:◦ Trial streamlined service, increased efficiencies but

remained flexible and client focussed

◦ Occasional home visits in addition to phone contact was important to ensure client safety and compliance

◦ Part of the success of the monthly phone call was due to relationship built during face to face contact during home visits

Qualitative Outcomes Con’t

1) Create a safe, systematic approach for moving clients toward self-management and discharge?

2) More time efficient?

Reflect

What Next?

Service redesign and research is possible - even on the run

Start planning earlyStay client/patient focussedMix methods

What we learnt

The Care Coordination Clients Wendy Appleton and Toni Heazlewood, Care

Coordinators, Chronic Care Program Chronic Care Program team Jan Ironside, Manager, Chronic Care Program Associate Professor Paul Dugdale, Director,

Chronic Disease Management Dr Geetha Isaac-Toua, Deputy Director, Chronic

Disease Management Claire Pearce, Senior Project Officer, Chronic

Disease Management

Acknowledgements

Questions ??