1. The Health Roundtable 1-1d_HRT1212-Session_AUSTEN_GOSFORD_NSW Care Coordination decreases hospital reliance-Case Study Presenter: Alison Austen Central Coast LHD NSW Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1

2. The Health Roundtable  Implementing NSW Connecting Care Program to target patients with chronic disease at high risk of admission.  Identify patients with frequent admission via 3 rd admission Flag and direct referrals.  Patients often have low capacity to prioritise health and poor self management.  Lack of coordinated care between services.  Lower level triage categories in ED and Frequent unplanned admissions to Hospital impacting on patient flow.  Central Coast has a low ratio of GP FTEs per population, which are lower than the recommended national levels. KEY PROBLEM 2

3. The Health Roundtable AIM OF THIS INNOVATION  Minimise unplanned hospital admissions/ ED presentations  Establish Shared Care Plans and increase quality GP involvement  Coordinate patient care  Organise Specialist review as appropriate  Confirm Diagnosis –Improve patient disease knowledge  Increase medication compliance  Provide a process of monitoring to identify exacerbations  Reduce pressure on Emergency and hospital admissions  Supporting Transfer of Care policy 3

4. The Health Roundtable BASELINE DATA  Influenced by residents at Dpt Housing complex  On parole  Not contactable by phone  Previously attended Smoking Cessation clinic once  ? capacity to change  Client aware of problems with short term memory  MMSE – 24/30  ACE – 78/100  HAD – Anxiety 12/21  Depression 8/21  K 10 - 29  Male 59 yrs  Multiple presentations to A&E and Hospital admissions  2010 - 9 A&E LOS 3 to 9 hrs and 2 admissions 3 & 4 days  2011 - 7 A&E LOS 1 to 14 hrs and 1 admission over night  Short of Breath - ? Asthma  Direct referral from Continuing Care Nurses  Minimal GP contact  Smoker  Tobacco since aged 13years  Cannabis $100 F/n since 30yrs 4

5. The Health Roundtable KEY CHANGES IMPLEMENTED  Enrolled into Connecting Care program February 2012 for case management  14 home Visits, 3 GP visits, 2 specialist visits, and multiple phone case management with other service providers.  GP contact  Respiratory Physician/ non charge clinic  Memory assessment prior to behaviour change  Referral for Neuropsychologist assessment  Neurologist review 5

6. The Health Roundtable OUTCOMES SO FAR  1 ED presentation since enrolment in 2012 – compared to 16 ED presentations over the previous two years.  Diagnosis confirmed-COPD not Asthma and Medications adjusted  Neuropsychologist review - Client recommended for (financial)  guardianship  Neurologist review - MRI this week to investigate vascular dementia  Referral to Complex Care Allied Health Social Work for assistance with appointing public trustee for Power of Attorney  Improve social support – example Neighbors, and Parole.  Planned smoking cessation 6

7. The Health Roundtable LESSONS LEARNT  The need to assess clients capacity & motivation to change  Necessity of one to one holistic assessment preferably in home environment  Continuous long term reinforcement of instructions–clients may not have capacity to initiate instructions given-health coaching  Benefits of accessing specialist services - case study example- home memory assessment  Importance of communication with other services eg Medical, Community - case study example - Parole office  High risk clients need one to one input though supported case management 7