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THE V.I.P. Program
Reducing presentations to hospital by identifying & addressing the social determinants of health.
VIP Program THE V.I.P. Program Reducing presentations to hospital - - PowerPoint PPT Presentation
VIP Program THE V.I.P. Program Reducing presentations to hospital - - PowerPoint PPT Presentation
VIP Program THE V.I.P. Program Reducing presentations to hospital by identifying & addressing the social determinants of health. Who is a Very Intensive Patient? = Patient representing to ED 8 times in 12 months = Patient readmitted
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Who is a Very Intensive Patient?
= Patient representing to ED ≥ 8 times in 12 months = Patient readmitted to hospital ≥ 4 times in 12 months
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VIP Model of Care
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What is the problem? Staff / Patient Surveys & Interviews
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The NEW Patient Journey
8) VIP follow-up & monitoring 1) Identified as a VIP
- SCALE-UP Score
- Alert on CAP
2) VIP Care Coordinator Case management & care coordination 3) Make contact with his GP 4) Senior Medical input Reviewed 1st by a consultant in ED/ward 5) Collaborate with other services: NSW Ambulance, Home care, D&A, OT, Physio, Mental health, Palliative Care, Connecting Care 6) Pharmacist Review Medication reconciliation contact with local chemist 7) VIP Case Conference Meet the patient, carers clinicians & services 6) VIP Action plan Personalised care plan for hospital & community
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Key Changes Implemented
1. Patient Flow Portal to identify frequency of readmission 2. “Scale-up tool” to explore history and meet with person to ask
- What bought you back to hospital ?
- What can we do to help you stay well at home ?
- What matters to you?
3. Social Workers involvement from the beginning 4. Focus on social determinants of health factors which impact on patients goals of care and the ability to remain at home .
- 5. Actively involve patient and their family in
goals of care
- 6. “Patient Care Boards” to promote communication
- 7. NSW Ambulance actively involved
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Gender 2016-18
39% 48% 13% Female male blank
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Age VIP’s 2016-18
18-25 26-40 41-60 61-75 76-85 86-90 blank Series1 4 11 78 103 132 82 3 20 40 60 80 100 120 140 Axis Title
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Scale up tool results 2016-18
200 33 2 7 141 33 5 364 4 101 19 2 10 46 28 50 100 150 200 250 300 350 400 Umemployed Transport Iliterate Non-English speaking Lives alone Aboriginal Homeless Co-morbidities score as per scale up tool Palliative Depression and anxiety Bipolar and schizophrenia Trauma Self harm and borderline personality Drug/ETOH Dementia Hoarding
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Readmitted within 28 days 2016-18
1% 99% yes No
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ED presentations within 6 months 2016-18
1 ED Presentations 2 ED Presentations 3 ED Presentations 4 ED Presentations 5 ED Presentations 6 ED Presentations 7 ED Presentations Series1 47 58 80 60 117 1 1 20 40 60 80 100 120 Total VIPS presentations
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Lessons Learnt
- The most important step are to identify VIPs and ask them what bought you
back to hospital and what matters to you ?
- Engage the patient in goals of care that they identify as important to them.
- Work with medical teams around the patients goals of care verses goals of
treatment .
- Assist the family and patient to engage with available social support networks
and community services
- To sustain your program include the Executive on the journey
- For more information Contact: Sandra McKendry or Geraldine Hanlon
ph:43817
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Acknowledgements and Thank you
- Roslyn Barker
- Maryann Ferreux
- Sarah Scudds
- Clinton Starrett
- NSW Ambulance
- Dianne Holmes
- Dr Michael Hayes and Medical Department at CMN