Ghnjasryj. Aged Care Emergency. Model of Care

Transcription

1 Ghnjasryj Aged Care Emergency Mdel f Care Nvember 2013

2 INTRODUCTION It is well dcumented that lder peple require emergency care mre ften than ther ppulatins, and generally have lnger Emergency Department (ED) length f stay and higher admissin and readmissin rates. Older peple accunt fr greater than 60% f hspital admissins and are at risk frm hspitalisatin itself, particularly delirium. Older peple wh becme acutely unwell in Residential Aged Care Facilities (RACF) are a cnsiderable prprtin f ED presentatins. A number f studies have fund that fr certain disrders r cnditins, effective treatment des nt necessitate presentatin t ED frm the RACF. Fr example, thse with acute infectins treated in their residence have similar r better survival and fewer cmplicatins cmpared t thse transferred t hspital fr treatment, even accunting fr severity. While there is evidence that there are cnditins that have resulted in presentatins by lder peple t the ED which culd be equally r better managed in ther settings, the ED is likely t remain an imprtant pint f entry t the health care system fr lder peple and that the lder persn s health care needs are different t ther ppulatins in bth ED and hspitals. The literature and plicy dcuments cnsistently identify the need t imprve cgnitive assessment, pain management, and transitinal care in bth directins between RACFs and EDs. When lder peple d present t the ED, be it frm a RACF r the brader cmmunity, they ften require supprtive care t ensure their immediate safety and ther needs are met in the ED envirnment. There is als a need t minimise risks assciated with ED attendance, hspitalisatin and readmissin (in particular delirium, disrientatin, pain and falls) thrugh screening fr risk factrs and prviding early interventin. The Aged Care Emergency (ACE) prgram was successfully implemented at Jhn Hunter Hspital Emergency Department during and and is designed t address the identified gap in supprting staff in RACFs t facilitate residents nn life threatening acute care needs being met within the facility and aviding an ED presentatin. A further 10 NSW Hspitals were als prvided with funding t implement the mdel. The ACE mdel was develped based n the mdels previusly develped at Hrnsby Kur ing gai Hspital (Geriatric Rapid Acute Care Evaluatin GRACE) (available at and the Aged Care Triage(ACT) mdel develped at Cncrd Hspital. This dcument describes detail f hw the mdel wrks including key principles and business rules, benefits and challenges f the mdel, what is required t run the mdel and hw the mdel shuld be evaluated. Several dcuments are available t assist with implementatin f the ACE mdel and include: A general guide fr setting up a new ACE service, a generic ACE clinical algrithms manual and links t educatinal material fr use in establishing ACE Examples f prmtinal material fr the varius stakehlders invlved in the ACE prgram (RACF staff, General Practitiners, ED staff and patient s relatives and carers). The final evaluatin reprts f the mdel s implementatin at 11 NSW Hspitals These dcuments are available n the NSW Emergency Care Institute s website

3 ACE Mdel f Care What is the mdel? Implementatin f the ACE Service is designed t address an identified gap in supprting staff in RACFs t facilitate residents nn life threatening acute care needs being met within the facility and aviding an ED presentatin. The ACE mdel is specifically aimed at reducing the need fr residents f Residential Aged Care Facilities (RACFs) t present t an ED fr acute care, r where ED presentatin is required, t practively manage the visit. The ACE mdel shuld wrk in cnjunctin with Aged Care Services in Emergency Team (ASET) nurses in the Emergency Department (ED) if available r ther suitably identified resurces which manage care f aged care patients. Why use the mdel? The ACE mdel is a strategic apprach t better manage residents frm RACFs wh becme acutely unwell. It is built upn a cllabrative relatinship between the management and staff f RACFs, the ED and hspital fr the benefit f the residents/patients. Acknwledgement f the varying stakehlders, rganisatinal funding structures, reprting and business rules is essential fr this mdel t functin. ACE incrprates a telephne cnsultatin prcess with the staff frm RACFs. Evidenced based algrithms fr cmmn prblems experienced by residents frm RACFs s RACF staff can better manage the acute symptms experienced by the resident. Establishing patient and ED gals f care prir t transfer. Practive case management in ED. Key principles The ACE Service is implemented with the aim t better manage demand n EDs r avid the need fr transfer t the ED, imprve the patient experience and quality f care f residents frm RACFs. The ACE Service serves the fllwing tw purpses: prvide supprt t RACF staff t better manage residents experiencing acute nset symptms r cnditins within the facilities and avid transfer t ED when apprpriate enhance the flw and crdinatin f care f patients wh are apprpriately transferred t the ED frm the RACF. The ACE Service shuld have the fllwing cre cmpnents: a telephne liaisn/cnsultatin service t RACFs an educative and supprtive service t RACFs a cllabrative wrking relatinship with GPs, cmmunity and hspital care prviders The ACE prgram shuld aim t empwer RACF staff t manage acutely unwell r injured residents, rather than take ver respnsibility fr the care. The hspital and acute care services must wrk in partnership with the RACFs, Medicare Lcals and NSW Ambulance t ensure that the patient s gals f care are

4 met. Cmmunicatin f and respect fr the patient s and their families wishes in relatin t Advanced Care Plans shuld be evident thrughut all parts f the care cntinuum Cllabratin and relatinship building with all relevant stakehlders is essential t the success f this mdel between and shuld be maintained thrugh regular cmmunicatin led by the hspital ACE service. Benefits f the mdel A psitive experience fr all stakehlders including ED and hspital staff, RACF staff and patients and their families. Psitive impact n inpatient services demnstrating a 35% reductin in hspital LOS at the pilt site. The service discriminates effectively and safely the needs f lder peple in terms f whether t transfer an lder persn residing in a RACF t the ED/hspital r nt. Has been demnstrated t prvide a 16% reductin in presentatins t the ED frm RACFs. Imprved relatinships between ED/hspital and the RACFs with a shared philsphy f care fr lder peple. Guides RACF staff in relatin t care practices and demnstrated t reduce transfer f lder peple t ED A greater appreciatin f the cntext f residential aged care fr ED and hspital staff and vice versa has been highlighted. Natinal Emergency Access Target (NEAT) perfrmance imprvements fr this chrt. Challenges Sustainability f the mdel either as an adjunct t existing resurces r within existing resurces. RACF rganizatinal plicies and prtcls may nt always allw cmpliance with the ACE clinical algrithms. Accurate data cllectin is a challenge, as there is large variatin in the methd fr identifying that a patient resides in a RACF Change management f a variety f stakehlders Cmpeting ED pririties depending n activity ( i.e. Staff Specialists assisting with clinical advice fr ACE nurse in a timely way) Risk that the primary carer (GP) will feel alienated frm the resident s care if nt engaged adequately and early. Dcumentatin f decisins in the patient medical recrd High turnver f RACF staff, RACF staff skill mix ( heavily rientated t the nnprfessinal wrkfrce)

5 Case fr implementatin Stcktake f existing Hspital and Lcal Health District utreach services that supprt RACFs is an essential first step in this prcess. Yu may nly need t add t existing services, rather than implement an new service such as ACE. T prepare fr implementatin r refinement f this mdel in yur ED/hspital cnsider the fllwing: What is the activity f patients that present frm RACFs t yur ED? Are there particular RACFs that frequently send patients t the ED fr lw acuity, lw cmplexity prblems? Are there particular RACF s that frequently send patients t the ED fr chrnic prblems where gals f care are nt evident? Des yur ED experience inefficient patient flw fr patients frm RACFs? What is the average length f stay, particularly fr discharged triage categry 3 5 patients, frm RACFs? What prprtin f patients frm RACFs that are admitted t hspital may have benefitted frm early interventin and supprt which may have reduced the requirement fr transfer t the ED? Is there a histry f adverse events fr patients that present t ED frm RACFs that may be addressed by a fcus n the care f this patient chrt? What yu need t run the mdel Staff ACE CNC t have ready access t ED Cnsultant, Geriatrician r equivalent GP VMO as apprpriate fr acute care cnsultatin Engage Geriatrics r General Medicine services in the Hspital ACE CNC with the fllwing attributes: Change manager Ability t build relatinships Have bth acute care and aged care skillset Experience in the delivery f clinical educatin Excellent written and cmmunicatin skills Physical resurces Office space with access t cmputer and relevant prgrams Access t pl car Dedicated phne line either mbile r desk Statinary and printing Gds and services IT supprt ACE Clinical Supprt Manual ACE brchures fr GPs, families& carers and ED staff

6 Business Rules Leadership Senir medical leadership is essential t this mdel. Relatinship building and supprt ACE staff are respnsible fr engaging and establishing relatinships with RACF staff Medicare Lcals and GPs (i.e. regular stakehlder meetings). ACE are als respnsible fr maintenance f these relatinships. ACE shuld address apprpriate educatinal gaps identified by RACF staff (in relatin t the ACE algrithms). The ACE service shuld case manage the patient s arranged ED visit accrding t clinical need, the patient s gals f care and any Advance Care Plans. In additin t prviding supprt s that the patient des nt require ED care, the ACE service may facilitate access t nn ED utpatient care. Cmmunicatin ACE staff carry phne between nminated hurs ASET r ther nminated staff carry the ACE phne n weekends r after hurs (please cnsider that there may be cmpeting pririties here, staff need t be able t return calls t RACFs in a timely manner t deal with their issue if they are engaged in direct patient care r interviews in ED at the time f an ACE call) Clear bundaries must be established with regards t transprt f the patient t the mst apprpriate hspital by ambulance. The ACE service may prvide advice t a large number f RACFs within the Lcal Health District, hwever when an ambulance is called, the patient must still be transprted t the clsest, mst apprpriate hspital. ACE is respnsible fr cntacting the apprpriate hspital and advising f the RACF s cntact with ACE and advice given. Dcumentatin Reprting When an ACE call cmes in, ACE will lg phne call nt the nminated IT system ( eg utpatient recrd, telehealth r ther) ACE is t clearly dcument the presenting prblem, vital signs, past medical histry, which algrithm was identified as suitable fr the patient, patient gals f care, Advanced Care Plans in place and any ther relevant infrmatin. ISBAR can be used fr this purpse. Recmmendatins and utcmes shuld als be dcumented (e.g. stay in RACF with GP fllw up, present t hspital/ed fr X ray, is patient apprpriate fr Extended Care Paramedic interventin if available?) At the cmpletin f interactin, ACE is t cmplete a discharge letter frm the ACE service fr RACFs and GP ( r fax) ACE is respnsible fr maintaining accurate data cllectin and reprting t the lcal stakehlder grup

7 Mnitring & evaluatin measures Review f health utcmes related data ED Length f Stay data Hspital LOS Bed days utilised by patients frm RACFs Number f ED presentatins frm RACFs Rates f re presentatin t same ED within 48 hurs NEAT Cllabrative meetings and dcumentatin f discussins with all stakehlders Adverse utcmes mnitring (IIMS) Cmpliments and cmplaints ACE phne call recrd

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