Geri-Connect AN INNOVATIVE APPROACH TO CLINICAL SERVICE DELIVERY - - PowerPoint PPT Presentation
Geri-Connect AN INNOVATIVE APPROACH TO CLINICAL SERVICE DELIVERY or how a region Introduced a new disruptive, clinical service model supported by technology into Residential Aged Care Facilities (RACF) which: Polypharmacy by up to 17%
AN INNOVATIVE APPROACH TO CLINICAL SERVICE DELIVERY
Introduced a new disruptive, clinical service model supported by technology into Residential Aged Care Facilities (RACF) which: Polypharmacy by up to 17% falls by up to 43% waiting times by two months access to clinical services by 90% new revenue
Loddon Mallee Region
Acute Beds 25% Sub-Acute beds 1%
Aged Care 67%
TCP 3%
4%
Yes 5% No 95%
RACF Patients with Geriatric Medical input into care plans 2-3 month wait for a Geriatrician Outpatient Review Decline in GP’s wanting to visit RACFs
Health th Service ice
1st t Priori rity ty 2nd Prior
ty 3rd d Prior
ty
Echuca Regional Health
Pain Management
Geriatrician Services
Cancer Services
Swan Hill District Health Geriatrician Services
Fractures Clinic
Cohuna District Health Service Geriatrician Services
Pre-Surgical Consultations Skin Disorder
Inglewood District Health Service Geriatrician Services
Mental Health
Kyabram District Health Service Geriatrician Services
Huntington's Disease Orthopaedics
Heathcote Health Geriatrician Services
Mental Health Social Worker
Boort District Health Service Geriatrician Services
Aged Care Mental Health
Kerang District Health Geriatrician Services
Urgent Care Urgent Mental Health
Kyneton District Health Service
Trauma Support
Geriatrician Services
Urgent Mental Health
Rochester and Elmore District Health Geriatrician Services
Fractures Clinic
Maryborough District Health Geriatrician Services Castlemaine Health Geriatrician Services
Rehab Support Urgent Care
Robinvale District Health Service Geriatrician Services
Trauma Support GP Services into Aged Care
Vision ion A self-sustaining specialist Geriatrician virtual service hub to improve equity & quality of care provided to older adults across regional Victoria Scope Initial scope of implementing a service into 15 public health service Residential Aged Care Facilities across the Loddon Mallee Region.
No Geriatricians No money
Recurrent funding source
Ability Technical and Financial Resource
Workforce
Desire
Clinical (Market) Technology
Concept
Sustainable Service Model
Recurrent funding source
Ability Technical and Financial Resource
Workforce
Desire
Clinical (Market) Technology
Concept
Sustainable Service Model
Recurrent funding source
Ability Technical and Financial Resource
Workforce
Desire
Clinical (Market) Technology
Concept
Sustainable Service Model
Kick start funding required to accelerate the program (provided by Better Care Victoria Financially stable proposition Scalability proposition
Service Specialist engages and develops ongoing relationship with GP Ongoing conversations Referral Sent Consultation held Specialist letter sent to GP Care Plan implementted Tria ged yes No
GC Clinical Nursing Coordinator educated Nursing staff
Service (how and when to engage) Point of care nurses engage with Patients and Families to identify suitable residents Nursing Staff complete Referrals Discuss/ engage with the GP Copy of Specialist letter sent to RACF approv ed
No Yes
Risk sk Did it eventuat ntuate? e? GPs won’t refer to the service No Not all Regional Health Services participate in the service Yes Unable to recruit sufficient clinical staff (Consultants & Registrars) No RACF Staff will not support the program Yes MBS items for telehealth no longer supported Not yet! Poor Technology acceptance No
Initial ial Scope: 15 Loddon Mallee (Vic) region public health service RACFs
RACFs = Residential Aged Care Facilities
A new disruptive, clinical service model supported by technology/connectivity into Residential Aged Care Facilities (RACF) which: Polypharmacy by up to 17% falls by up to 43% waiting times by two months growth of access to clinical services by 90% new funding
2019 onwards: Increased Access, Scope & Evaluation of Outcomes
Loddon Mallee 2017- Hume 2019- 2019 on Stage 1 Stage 2 Stage 3
Chronic Disease Management
Aged care
Dementia
Small Rural Hospitals Common Telehealth, Tele-monitoring & Technology Platform
Stage 2 & 3
Health th Service ice
1st t Priori rity ty 2nd Prior
ty 3rd d Prior
ty
Echuca Regional Health
Pain Management
Geriatrician Services
Cancer Services
Swan Hill District Health Geriatrician Services
Fractures Clinic
Cohuna District Health Service Geriatrician Services
Pre-Surgical Consultations Skin Disorder
Inglewood District Health Service Geriatrician Services
Mental Health
Kyabram District Health Service Geriatrician Services
Huntington's Disease Orthopaedics
Heathcote Health Geriatrician Services
Mental Health Social Worker
Boort District Health Service Geriatrician Services
Aged Care Mental Health
Kerang District Health Geriatrician Services
Urgent Care Urgent Mental Health
Kyneton District Health Service
Trauma Support
Geriatrician Services
Urgent Mental Health
Rochester and Elmore District Health Geriatrician Services
Fractures Clinic
Maryborough District Health Geriatrician Services Castlemaine Health Geriatrician Services
Rehab Support Urgent Care
Robinvale District Health Service Geriatrician Services
Trauma Support GP Services into Aged Care
Health th Service ice
1st t Priori rity ty 2nd Prior
ty 3rd d Prior
ty
Echuca Regional Health
Pain Management
Geriatrician Services
Cancer Services
Swan Hill District Health Geriatrician Services
Fractures Clinic
Cohuna District Health Service Geriatrician Services
Pre-Surgical Consultations Skin Disorder
Inglewood District Health Service Geriatrician Services
Mental Health
Kyabram District Health Service Geriatrician Services
Huntington's Disease Orthopaedics
Heathcote Health Geriatrician Services
Mental Health Social Worker
Boort District Health Service Geriatrician Services
Aged Care Mental Health
Kerang District Health Geriatrician Services
Urgent Care Urgent Mental Health
Kyneton District Health Service
Trauma Support
Geriatrician Services
Urgent Mental Health
Rochester and Elmore District Health Geriatrician Services
Fractures Clinic
Maryborough District Health Geriatrician Services Castlemaine Health Geriatrician Services
Rehab Support Urgent Care
Robinvale District Health Service Geriatrician Services
Trauma Support GP Services into Aged Care
Health th Service ice
1st t Priori rity ty 2nd Prior
ty 3rd d Prior
ty
Echuca Regional Health
Pain Management
Geriatrician Services
Cancer Services
Swan Hill District Health Geriatrician Services
Fractures Clinic
Cohuna District Health Service Geriatrician Services
Pre-Surgical Consultations Skin Disorder
Inglewood District Health Service Geriatrician Services
Mental Health
Kyabram District Health Service Geriatrician Services
Huntington's Disease Orthopaedics
Heathcote Health Geriatrician Services
Mental Health Social Worker
Boort District Health Service Geriatrician Services
Aged Care Mental Health
Kerang District Health Geriatrician Services
Urgent Care Urgent Mental Health
Kyneton District Health Service
Trauma Support
Geriatrician Services
Urgent Mental Health
Rochester and Elmore District Health Geriatrician Services
Fractures Clinic
Maryborough District Health Geriatrician Services Castlemaine Health Geriatrician Services
Rehab Support Urgent Care
Robinvale District Health Service Geriatrician Services
Trauma Support GP Services into Aged Care
Tele - ICU Endocrinology Tele Paediatrics Aged Care Assessments (ACAS) Transition Care (TCP) Assessment Tele Palliative Care CDAMS Clinic Mental Health MDT’s Oncology MDT’s
Opportunity:
eConsults Tele - ICU Multi- Disciplinary Teams
Inpatient / Hospital Outpatient / Community Consultations Remote Monitoring Foundations
Mental Heath Tele - Stroke UCC Support Hospital in the Home Assessments E-Advice In Hospital telemetry Remote Patient Monitoring Electronic Patient Record Quality Programs Sepsis Program Community Health System
eCredentialling
Authors: Assoc Prof Marc Budge mbudge@bendigohealth.org.au Jackie Plunkett Jackie.Plunkett@lmrha.org.au
Assessment and Prevention Electronic Health Record Personal Health Record ‘Home’ monitoring and Self Management Information Connectivity / Sharing Service Management Evidence Base and Pathways Coordinated Development Funding
Marc Budge 2009
Stage 3: Development of a comprehensive, Ambulatory and Outreach Health Service…. for Older Adults
chronic disease and other acute illnesses through remote monitoring of patients;
timely manner;
Hospital Admission Risk Program (HARP), Home and Community Care Program for Younger People (HACC PYP) programs, and a shared relationship with the client’s local GP.
transition of clients and client clinical information throughout the care continuum seamlessly.
PRELUDE TO ->
Assessment and Prevention Electronic patient Record My Health Record ‘Home’ monitoring and Self Management Information Connectivity / Sharing Service Management Evidence Base and Pathways Coordinated Development Funding
Marc Budge 2009
https://www.kingsfund.org.uk/publications/making-sense-integrated-care-systems
https://www.kingsfund.org.uk/sites/default/files/2018-09/Year-of-integrated-care-systems-reviewing-journey-so-far-full-report.pdf