1. St John Project Transport to the Medical Home 20,000 Days Campaign Learning Session 3 11-12 March 2013 Project Manager: Jo Goodfellow

2. What do we want to achieve? To increase the number of Status 3 and 4 patients who are transported by St John to a primary care / community setting as an alternative to transporting to the Emergency Department ….and why? The number of self presentations to ED across Auckland is increasing by around 10% pa putting pressure on DHBs. A proposal developed with St John was presented to and endorsed by GAIHN’s Alliance Clinical Network and Leadership Team (October / November 2011) Clinicians from the regions EDs, primary care sector and Accident and Medical sector were consulted and together with St John developed clinical guidelines for the paramedics to support their decision making on the scene (November 2011)

3. Setting the Scene Low acuity patients who call 111  A pathway for low acuity patients to be transported to an A&M by St John as an alternative to ED was established in December 2011 with the cost of the treatment paid for by POAC  This was a result of increasing pressure on EDs from the continued rise in unplanned presentations, predominately self-referrals  Ambulance transports account for around 33 percent of all hospital presentations and the number of transports in the region has increased by 3.84 percent over the last 12 months  36% of all transports to ED go to Middlemore, 28% to Auckland Hospital, 23% to North Shore, 9% to Waitakere, and 4% to Starship  82% of all ambulance calls are Moderate (Status 3) or Minor (Status 4). In the last 12 months, St John attended 126,869 calls in Auckland which resulted in 102,141 transports to an ED or other medical facility Since the establishment of the pathway, approximately 1400 patients have been transported (regionally) to an A&M who would otherwise have been taken to an ED

4. St John Project Driver Diagram

5. Change Packages Secondary Drivers (Theory of change) Change Ideas Tested Regionally agreed guidelines developed ED clinicians in support of project and confident guidelines ensure patient safety Individual A&M centres consulted and processes agreed All centres keen to come on board and sign an MoU with POAC Regional implementation of the guidelines and pathway Initial teething issues in individual A&Ms Some variation in practice within the A&M centres Pt transfer to A&M centre Additional 4 A&M centres included in project for CMDHB area

6. Measures Summary

7. Implementation Implementation Areas Changes to Support Implementation Standardisation Review of current regional St John guidelines Define process for paramedics to liaise with the medical home Documentation Prepare a communications plan Define project governance and reporting arrangements Training St John developing a plan to educate paramedics Communication plan to educate GPs and practice staff about the change Measurement The number of patients transported to the medical home to an Accident and Medical (A&M) centre subsequently transferred to hospital (from A&M and medical home) transported to a primary provider and then self presents to ED within 7 days Resourcing Continue to work to roll out in April 2013 – it is not anticipated that there will need to be an increase in resource Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.

8. Risk & Mitigation Strategies RiskCurrent situationMitigation High rate of subsequent transports to ED9% of patients currently referred on to hospital (not all transported by St John) Review of guidelines to ensure appropriate for transport to medical home Clinical governance review by POAC of all St John referrals Patients become aware of the pathway and use it as a way to access free care (particularly those who are ‘friends of St John’) No indication of this occurring – no cases where an individual who is a ‘friend of St John’ has been transported to an Accident & Medical facility (A&M) more than once Continue to monitor Ensure guidelines are clear that only those patients who would normally be transported to ED are included in the scheme Monitor impact of enhanced triage at St John call centre and number of low acuity call outs Patients who would have previously been transported to their medical home anyway and paid their usual co-payment, are included Ensure guidelines are clear that only those patients who would normally be transported to ED are included in the scheme Monitor impact of enhanced triage at St John call centre and number of low acuity call outs Clinical governance review of appropriateness and any scope creep

9. Achievements to date  Expansion of St John Transport project to the Medical Home (starting April 2013) The reason for expansion of the project is to ensure patients who don’t require ED treatment are transported, when necessary, to the best possible place. The medical home is often more appropriate than an A&M facility due to the capability to provide continuity of care with ongoing education for the patient, including re-engagement with the medical home. As St John is already making the decision not to transport patients to an ED (under the original scheme) this expansion is unlikely to increase the number of affected patients, but gives patients more appropriate options for care. Further work during 2013 / 14 needs to be undertaken to ensure Primary Care’s continued capability to be able to accept urgent patients from St John.  Patient and family experience Recently this project has received HRC funding (as part of the review of the Auckland Regional After Hours Network) and patient interviews will be conducted as part of this process over the ext few months