Managing Emergency Department Frequent Attendees Polly Grainger Christchurch Hospital and Ta-Mera Rolland Middlemore Hospital

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)

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

So what have we tried? Case Management Systems Integration Interdisciplinary Approach  Christchurch Story & Middlemore Story

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

Christchurch activity NB: Number of patients, not number of attendances

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

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

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

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

Middlemore Story Over 800 Beds Population 490,610 (2011)

Ethnicity

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

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

VHIU Process Home visit Risk Assessment Guide (RAG) Develop Care Plan Interdisciplinary Team Review – Physician – Nurse – Physiotherapist – Social Worker – Pharmacist Referrals to other agencies

Areas of risk identified from RAG

% Percentage of patients flagged for the practice versus the whole of Manurewa/Papakura

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

Supporting Initiatives 20,000 days collaborative - funding and project support Localities development - clinical network development Sharing electronic records -integrating primary and secondary information

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

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

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

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

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

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