1. 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

2. 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

3. 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

4. The Health Roundtable BASELINE DATA  Need to streamline linking patients to correct services

5. 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

6. 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!

7. 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

8. 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!