Presentation on theme: "The Health Roundtable Charting a course for change for people with chronic illness: The St George experience Presenters: Linda Soars, Daniel Shaw, Karen."— Presentation transcript:
The Health Roundtable Charting a course for change for people with chronic illness: The St George experience Presenters: Linda Soars, Daniel Shaw, Karen Ng, Nicole Wedell Hospital Code Name: St George Hospital Key contact: Linda.Soars@sesiahs.health.nsw.gov.auLinda.Soars@sesiahs.health.nsw.gov.au Mob 0400 518 777 Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012
The Health Roundtable KEY PROBLEM Increased identification of patients with unplanned admissions due to cardiac, respiratory and diabetes health issues Need for a timely method to identify, rapidly assess and link patients to the right type of care (acute, rehab, primary) at the right time in their journey with chronic illness Each patient needs to have clear health goal and action plan (self management), GP linked, carer identified and supported
The Health Roundtable AIM OF THIS INNOVATION Create a patient navigation hub for chronic disease services using technology, outbound call centre and connecting care more rapidly in the community Streamline the patient journey after an unplanned admission with a chronic illness Chart a new course between the acute and community interface – with embedded referral lines
The Health Roundtable BASELINE DATA Need to streamline linking patients to correct services
The Health Roundtable KEY CHANGES IMPLEMENTED St George Hospital – redesign of existing Access and Referral services and alignment with District wide service descriptors and referral paths Development of outbound call process – quick patient identification, timely calls, standardised assessments and referrals, early review and escalation for home based review Specific programs – Connecting Care in the community (Care Coordination), Health Coaching phone service (SESLHD/Healthways Australia), Aboriginal patient 48 hour follow up
The Health Roundtable OUTCOMES SO FAR Outbound calls – navigating the system with the patient….. Linked to care coordination/health coaching/community services Makes me feel good that people care… Good advice on meds – decreased asthma meds because of advice They helped me determine when I needed to go to hospital!
The Health Roundtable OUTCOMES SO FAR Outbound calls - July/Aug/Sept 2012 data Slightly more outbound calls now per month than inbound calls Patients navigated to services increasing – 100% 120% growth in referral rate each month to Connecting Care and follow up Potential to increase referrals to specialty chronic care teams – direct identification Risk assessment completed and consent PFP process new – developing roles
The Health Roundtable LESSONS LEARNT Small steps – using clinical redesign process – engage key sponsors and stakeholders Key staff development – mentoring and coaching, change in job responsibilities and daily activities Ongoing Training – on the job, inservice and formal sessions educational support – health behaviour change capacity building technology improvements (computers and phones) Celebrate the achievements along the way!