Transcript Chronic Care Program Canberra Hospital

Service Redesign On
The Run
Katrina Scott-Charlton, Care Coordinator,
Chronic Care Program, ACT Health
Improving the management and quality of life
for ACT residents with:



Chronic Obstructive Pulmonary Disease
Chronic Heart Failure
Parkinson’s disease

Client
Nurse
Care Coordinator
oxygen
cylinder hire
Respiratory
specialist
Community
services
Hospital
Admissions
Geriatrician
GP
Endocrine
Social worker
podiatrist
Community
nursing
ACAT
Cardiology
Physio
OT
Medication
management
Mobility aids
 Provide holistic assessment, care planning,
education and support
 Assist clients to access health and community
services
 Attend appointments with clients
 Provide psychosocial support and advocacy
 Facilitate Advance Care Planning
 Support for carers/family
Problem
Reflect
Observe
Plan
Act
Problem
Plan
1) Create a safe, systematic approach for
moving clients toward self-management
and discharge
2) More time efficient
Literature review
Act
Category 1: high
needs (usual input)
Category 2: Low
needs (monthly
phone call only)
Graduation
discharge to CCP
nurse support
Observe
9 month trial

Quantitative
◦ Monitoring of:
 Staff to client ratios
 Numbers of Category 1 and Category 2 clients
 Activity through Occasions Of Service

Qualitative
◦ Client feedback via survey
◦ Staff feedback via regular team meetings
◦ Staff focus group



46.6% increase in staff to client ratio
58.4% increase in clients receiving care
coordination
79% increase in Occasions of Service
120
100
Project
Implementation
↓
80
Pts
Cat2 Pts
60
Cat1 Pts
40
20
0
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13
Staff Feedback:
◦ Occasional home visits were needed for some
Category 2 clients
Client Survey:
◦ 52% response rate!
◦ 90% felt they had enough support and
information through a monthly phone call
◦ 45% felt that it would be beneficial to have an
occasional home visit
Staff Focus Group Feedback:
◦ Trial streamlined service, increased efficiencies but
remained flexible and client focussed
◦ Occasional home visits in addition to phone contact
was important to ensure client safety and compliance
◦ Part of the success of the monthly phone call was due
to relationship built during face to face contact during
home visits
Reflect
1) Create a safe, systematic approach for
moving clients toward self-management
and discharge?
2) More time efficient?
What Next?
 Service
redesign and research is
possible - even on the run
 Start planning early
 Stay client/patient focussed
 Mix methods







The Care Coordination Clients
Wendy Appleton and Toni Heazlewood, Care
Coordinators, Chronic Care Program
Chronic Care Program team
Jan Ironside, Manager, Chronic Care Program
Associate Professor Paul Dugdale, Director, Chronic
Disease Management
Dr Geetha Isaac-Toua, Deputy Director, Chronic
Disease Management
Claire Pearce, Senior Project Officer, Chronic
Disease Management