Readmissions

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Referral to
Lily
ED
Endoscopy
GP
ENT surg
Surg reg 2
Surg reg 1
Med Reg
Cardiac techs
Audiologist
Med Ward
Rheum reg
Cardiologist
Maori Mobile Nurse
Dietician
DN
SW
OT
Maori Disability co-ordinator
Physiotherapist
WINZ
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Communication back
Lily
ED
Endoscopy
GP
ENT surg
Surg reg 2
Surg reg 1
Med Reg
Cardiac techs
Audiologist
Med Ward
Rheum reg
Cardiologist
Maori Mobile Nurse
Dietician
DN
SW
OT
Maori Disability co-ordinator
Physiotherapist
WINZ
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Purpose of service

• A co-ordinated approach to a persons medical care
• Assisting a patient in self management
• Reducing hospital admissions
• Reducing hospital outpatient appointments
• Encouraging regular contact with General
  Practitioners

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• To ensure that all members of a persons health
  care team are kept informed of progress and
  changes to care.
• To ensure a good Quality of Life

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Care Co-ordination ProgrammeFrequent attenders

• 2 or more chronic illnesses
• 3 or more admissions to medical services in 6
  mths
• Be at risk of mismedicating
• Have social or lifestyle risks that make it
  difficult to manage their own illness

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Setting

• In medical (HVDHB) team of 1
• Medical/surgical (CCDHB), a team of 2
• Within secondary services
• Work across primary and secondary care
• Home visits, outpatient appointments and
  inpatient consults

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Primary/Secondary interface

• Communication
• Face to face
• Phone
• Written
• Role promotion
• Run multidisciplinary meetings

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The ProcessHVDHB

• Referrals from Consultants, CNL, and computer
  generated list of frequent attenders
• Regular visits to patients in their homes
• Who are they already seeing do they still
  require this?
• Contact General Practitioner
• Assess their individual education needs
• Ensure each person has individual action plans
  for their various conditions
• Refer to appropriate multi-disciplinary teams

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• Refer to community services as appropriate
• Check medication compliance and understanding
• Compile patient held notes
• Compile patient summary and send to all members
  of a persons health care team

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• Attend outpatient appointments if necessary
• Attend General Practitioner appointments
• Promote early detection/prevention of illness
• Few discharges

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The ProcessCCDHB

• Referrals from daily computer list
• Phone referrals from inpatients, ED and SSU and
  outpatients
• Written or phone referrals from NASC
• Other

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Process cont..

• Investigate
• Consult Primary and secondary
• Patient and family
• Assessment
• Care Planning
• Care Management or Co-ordination
• Discharges

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Issues (strengths and weaknesses)

• Statistics do we make a difference?
• Capacity to work flexibily
• Driven by patient need
• Transfer of dependence
• Limited numbers on the programme
• Stay in for the long term
• Generalist/specialist nature of role
• Many health professionals involved ?duplication

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Cost

• Admissions approx 18,000
• Outpatient consultant 250
• Allied health 4,000
• Ambulance call outs approx 25,000
• Total 47,250

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Cost

• Admissions approx 2570
• Outpatient consultant visits 750
• Allied health contacts 300
• ED presentations 230
• Ambulance callouts 1,000
• Total 4,850

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Comparison of cost

• 6 months prior 47,250
• 5 months post 4,850
• Difference 42,400

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Questions?