Download Improved Management Of Patients With Severe Chronic

07-27)
Improved Management of Patients
with Severe Chronic Respiratory Disease &
Severe Chronic Cardiac Disease
in the Community
July 2010
FINAL DRAFT
Note:
This proposal is subject to comment, change and endorsement from the peak clinical
bodies in NSW; the Chronic Cardiac Clinical Expert Reference Group and the ACI
Respiratory Network Steering Committee.
Additionally, the Australian Heart Foundation is developing a position statement on
chronic heart failure. The statement is scheduled for release in August 2010. The
developers of this proposal have been advised that the position statement is highly
compatible with the proposal. Nonetheless, the proposal remains open to further
change, in accordance with the position statement on chronic heart failure.
NSW Agency for Clinical Innovation
PO Box 6314, North Ryde NSW 2113
Tel: 02 9887 5728
Fax: 02 9887 5646
www.health.nsw.gov.au/ACI/
Email: [email protected]
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CONTENTS
ACKNOWLEDGEMENTS............................................................................................................................................................5
GLOSSARY OF TERMS..............................................................................................................................................................6
PROPOSAL AIMS .......................................................................................................................................................................7
EXECUTIVE SUMMARY .............................................................................................................................................................8
KEY RECOMMENDATIONS .....................................................................................................................................................10
1.
CONTEXT ....................................................................................................................................................................11
2.
BACKGROUND..........................................................................................................................................................16
3.
2.1
Burden of Chronic Respiratory and Cardiac Disease ..............................................................................16
2.2
An Increasing Problem................................................................................................................................19
2.3
Current Services and Management Practices ...........................................................................................21
PROPOSAL FOR A SEVERE CHRONIC RESPIRATORY & CARDIAC DISEASE PROGRAM ...............................24
3.1
Introduction - Towards an Improved Model of Care .................................................................................24
3.2
Aims of a Severe Chronic Respiratory & Cardiac Care Program (SCRCCP) .........................................25
3.3
Severe Chronic Respiratory & Cardiac Care Program (SCRCCP)...........................................................26
3.4
3.3.1
Key Strategies: R-E-M-E-D-I-A-L ...................................................................................................26
3.3.2
Key Features ...................................................................................................................................27
3.3.3
Key Performance Indicators ............................................................................................................31
SCRCCP Experience - Existing ‘SCRCCP-type’ Services in NSW ..........................................................32
3.4.1
3.5
The Respiratory Coordinated Care Program at St George Hospital, Kogarah NSW .......................32
Cost-Benefit Analysis..................................................................................................................................34
3.5.1
Savings ..........................................................................................................................................34
3.5.2
Costs ..............................................................................................................................................35
3.5.3
Cost-Savings Equation ...................................................................................................................36
3.6
Workforce Education and Training ............................................................................................................38
3.7
Implementation ............................................................................................................................................39
3.7.1
Specialist Services ..........................................................................................................................39
3.7.2
Combined Care and Shared Care Services ....................................................................................39
3.7.3
Implementation of New Services .....................................................................................................40
3.7.4
Virtual Units .....................................................................................................................................40
4.
CONCLUSION .............................................................................................................................................................41
5.
REFERENCES ............................................................................................................................................................42
6.
APPENDICES..............................................................................................................................................................46
APPENDIX A:
SCRCCP-Eligible Diagnosis Related Groups (DRGs) ................................................................46
APPENDIX B:
Admissions and Cost-Savings Analysis: Data and Calculations by Hospital .........................47
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ACKNOWLEDGEMENTS
The first version of this proposal was prepared by clinical and consumer members of the Respiratory
Network of the NSW Agency for Clinical Innovation (formerly GMCT) and its subsidiary working
groups including the Infection / Acute Respiratory Failure Working Group, the Pulmonary
Rehabilitation Working Group, the Airways Education Working Group and the Rural Services Working
Group.
This second version of the proposal has been developed by the Respiratory and Cardiac Working
Group, a joint working group of the ACI and the NSW Department of Health’s Severe Chronic
Disease Management Program (SDMP), reporting to the Chronic Clinical Expert Reference Group
(CERG) and the ACI. Version two builds on the accomplishments of the ACI’s respiratory working
groups by including Chronic Heart Failure into the model of care.
This proposal was developed with contributions from the following people:
Tod Adams
Clinical Nurse Consultant (COPD Service)
Jenny Alison
Physiotherapist, Chronic Disease Programme
Shoalhaven Hospital
Royal Prince Alfred Hospital / USYD
Heather Allan
Director, COPD National Program
Australian Lung Foundation
Michelle Baird
Transitional Nurse Practitioner, Chronic & Complex Care
Dubbo Hospital
Gary Baker
Respiratory Physician
Armidale Hospital
Cecily Barrack
Respiratory Physiotherapist
Lismore
Patrick Bolton
Director of Clinical Services
Prince of Wales Hospital
Jane Civitico
CNC Chronic Disease Programme
Royal Prince Alfred Hospital
Nick Collins
Staff Specialist, Ambulatory Care
Campbelltown Hospital
Patricia Davidson
Professor of Cardiovascular and Chronic Care
Curtin University of Technology
Mary Dunford
CNC Respiratory
St George Hospital
Cate Ferry
Clinical Issues Manager
Heart Foundation
Betty Johnson
Consumer
ACI Respiratory Network
Chris Jones
Occupational Therapist, Respiratory Program
Northern Sydney Home Nursing Service
Ken Langbridge
Adult Asthma Educator
Gosford Hospital
Regina Leung
Pulmonary Rehabilitation Program Coordinator
Concord Hospital, Institute of Sports Medicine
Steven Lindstrom
Staff Specialist
St George Hospital
Nicole Mangone
Clinical Nurse Consultant
Central Coast Health
Annette Marley
Physiotherapist / Principal Project Officer
NSCCH / NSW Health
Nicholas Marlow
Area Manager, APAC
NSCCAHS
Tracey Marshall
CNC Asthma Education
The Children's Hospital at Westmead
Sunil Mathew
CNC, Respiratory
Bankstown Lidcombe Hospital
Sue McCullough
Consumer
Cancer Institute NSW
Dawn McIvor
Clinical Nurse Consultant
Hunter New England AHS
David McKenzie
Respiratory Physician
Prince of Wales Hospital
Zoe McKeough
Lecturer
Discipline of Physiotherapy, USYD
Renae McNamara
Respiratory Physiotherapist
Prince of Wales Hospital
Mary Roberts
Clinical Nurse Consultant
Westmead Hospital
Lissa Spencer
Physiotherapist, Chronic Disease Programme
Royal Prince Alfred Hospital
Robyn Speerin
Network Manager and Cardiology Nurse Practitioner
Agency for Clinical Innovation
Nick Spiliopoulos
NUM, Respiratory Coordinated Care Program
St George Hospital
Christina Thompson
Occupational Therapist
St Vincent's Hospital
Amanda Thomsen
CNC, Respiratory
Sydney Children's Hospital
Geoffrey Tofler
Chair, Preventive Cardiology
University of Sydney & Royal North Shore Hospital
Sandra Wales
CNC Respiratory
Sydney Children's Hospital
Sally Watts
Physiotherapist, Pulmonary Rehabilitation
Royal Rehabilitation Centre Sydney
Nick Wilcox
Manager, Respiratory Network
Agency for Clinical Innovation
Simon Willcock
Discipline of General Practice, Central Clinical School
University of Sydney
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GLOSSARY OF TERMS
ACAT
Aged Care Assessment Team
ACI
Agency for Clinical Innovation
ALOS
Average Length of Stay
CAPAC
Community Acute/Post-Acute Care
CCF
Chronic Cardiac Failure
CDMP
Chronic Disease Management Program
CERG
Clinical Expert Reference Group
CHF
Congestive Heart Failure
CLINICIAN
A professionally qualified, registered healthcare worker with direct patient
contact.
COPD
Chronic Obstructive Pulmonary Disease
DALYS
Disability-Adjusted Life Years
DRG
Diagnosis-Related Group
ECG
Electro-Cardio Graph
ED
Emergency Department
GMCT
Greater Metropolitan Clinical Taskforce
HF
Heart Failure
MAU
Medical Assessment Unit
PPH
Potentially Preventable Hospitalisation
RACF
Retirement and Aged Care Facility
RCCP
Respiratory Coordinated Care Program
SCDMP
Severe Chronic Disease Management Program
SCRCCP
Severe Chronic Respiratory & Cardiac Care Program
SRG
Service-Related Group
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PROPOSAL AIMS
The aims of this proposal are:
1.
To provide best-practice advice on improved management of patients with severe
chronic respiratory disease and & severe chronic cardiac disease in the community.
2.
To make specific recommendations to the NSW Department of Health for funding to
augment existing services and, where unmet need and potential staffing capacity can
be identified, to facilitate the development of new services across NSW.
3.
To provide advice on the method by which the recommendations and adaptable model
of care detailed in the proposal should be implemented in various healthcare settings
across NSW.
4.
To demonstrate the potential for return on investment, should the proposal be
implemented.
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EXECUTIVE SUMMARY
Chronic respiratory and cardiac diseases are responsible for over 25% of the total burden of
disease and injury in Australia. In terms of the burden on hospitals, respiratory and cardiac
illnesses consumed the third and fourth highest number of public hospital bed days in NSW in
2007-08, with over 700,000 patient days attributed to in-patient management of people with
cardiopulmonary disease.
In spite of many improvements in disease management by primary care physicians and modest
reductions in hospital length of stay, the burden of chronic respiratory and cardiac illnesses on the
healthcare system is increasing.
Further, notwithstanding the identification of progressive chronic disease, current management
practices of patients with these illnesses are often focussed on ‘last-minute’ treatment of
inevitable acute-on-chronic symptomatology. In this regard our proposal aligns with the advice of
successive healthcare reviews, which recommend that healthcare settings of all configurations
move away from reactive medicine, and towards an anticipatory and innovative paradigm of
disease management. Significant reductions in hospital admissions and associated costs will
require the introduction of progressive management practices and service models of care. For
patients with chronic and complex cardiac and respiratory disease the evidence demonstrates
that such reform should involve a fundamental shift towards regular, community-based monitoring
of patients with known progressive illness, facilitating early detection of disease deterioration and
proactive intervention.
The Severe Chronic Respiratory & Cardiac Care Program (SCRCCP) detailed in this proposal
aims to deliver such reform. An implemented SCRCCP has the potential to improve patient
outcomes, significantly reduce presentations to hospital emergency departments, reduce hospital
admissions, reduce the length of stay for those who are admitted to hospital, and achieve
substantial savings in both bed days and overall costs. The program points to a more productive
approach in the determination to find a balance between specialist and generalist services.
The goal of this proposal is to offer an evidence-based solution to improve patient outcomes and
reduce the burden of severe chronic respiratory and severe chronic cardiac disease to the NSW
healthcare system by using a range of coordinated strategies encompassed in the SCRCCP.
These strategies comprise a seamless interface between in-patient and community services with
links to existing services wherever possible.
The aims of a Severe Chronic Respiratory & Cardiac Care Program are:
ƒ
to improve equity of access to, and outcome from, best practice healthcare to patients in NSW
with severe chronic respiratory and cardiac disease
ƒ
to reduce of the burden of severe chronic respiratory and cardiac disease on patients, carers
and the NSW healthcare system
ƒ
to optimise patient well-being and quality of life by delivering the right care in the right place at
the right time
ƒ
to reduce the number of emergency department presentations, hospital admissions and
readmissions, and length of stay in hospital where appropriate
ƒ
to reduce access block by improving patient flow between the community and the hospital
ƒ
to augment existing services managing patients with severe chronic respiratory and cardiac
disease and transfer, where appropriate, specialist clinical care from the hospital to the
community
A Severe Chronic Respiratory & Cardiac Care Program provides evidence-based, coordinated,
patient-centred care, to people with chronic and complex respiratory disease. Services are
provided in the community with equivalent medical outcomes, improved quality of life and
improved measures of patient satisfaction compared to those achieved in hospital.
The Program is delivered by a multidisciplinary team of specialist respiratory & cardiac clinicians or generalist clinicians with a special interest in respiratory or cardiac medicine - including the
patient’s general practitioner.
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The Severe Chronic Respiratory & Cardiac Care Program adopts key clinical and service-related
strategies that may be summarised in the acronym ‘REMEDIAL’:
R
Risk & Review
Risk assessment and care level stratification / triage (to supported self-management, case management,
hospital-in-the-home etc)
Access to express medical review
E
Educate & Enrol
Educate patients on self-management
Enrol patients into pulmonary and cardiac rehabilitation programs and smoking cessation counselling
M
Monitor
Routine home / community monitoring of moderate to high-risk patients
E
Early detection
Early detection of the deteriorating patient
D
Direct communication
Direct communication between patients and their local clinical teams via a rapid-advice telephone line
I
Intervention
Evidence-based, multi-disciplinary intervention including supported self-management, case management,
hospital-in-the-home, planned hospital admission
A
Assessment
Assessment and evaluation of the Program (SCRCCP)
L
Links
Establish links to existing services wherever possible including primary and community healthcare (General
Practise, CAPAC services, aboriginal services, ‘co-morbidity’ services etc)
- For rural and regional programs in particular, the establishment of links with centres of excellence will
provide clinical support and training, to maximise skills transfer and service sustainability.
ACI proposes the development and implementation of a new program of care for patients with
severe chronic respiratory and cardiac disease, based on a revised model of care as described in
this document. We recommend the establishment of a line of funding to enable the development
of local SCRCCPs in clinical settings across NSW.
Should it be implemented, the clinical program detailed within this proposal will be accommodated
by the existing NSW Clinical Service Frameworks for Chronic Respiratory Disease and Heart
Failure and facilitate the implementation of the Frameworks’ accompanying Practice Guides for
the Optimal Treatment of Chronic Respiratory Disease and Heart Failure.
This proposal builds on the successes of the NSW Chronic Care Program by serving as an
adaptable implementation tool, or model of care, for the treatment of people with severe chronic
respiratory and cardiac disease. The model we present recognises and accepts wide variation in
resources and programs across clinical settings in NSW and is, therefore, flexible so that it may
be adapted by local clinical teams to suit existing service configurations and population need.
The proposal detailed in this document presents the evidence for an adaptable model of care for
patients with severe chronic respiratory and cardiac disease. The model seeks to promote
integrated hospital and community care, and strong links between specialist and generalist clinical
teams. The model recommends the transfer, where appropriate, of the care of patients with
severe chronic respiratory and cardiac disease out of hospital and into the community.
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KEY RECOMMENDATIONS
ACI proposes the development and implementation of a new program of healthcare in NSW for
patients with severe chronic respiratory disease and severe chronic cardiac disease, based on the
adaptable model of care described in this document.
1.
That NSW Health (Chronic Disease Management Program) accepts and adopts this
proposal as the best-practice model of care for the management of patients with severe
chronic respiratory disease and severe chronic cardiac disease in the community.*
*
This proposal is subject to comment, change and endorsement from the peak clinical
bodies in NSW; the Chronic Cardiac Clinical Expert Reference Group and the ACI
Respiratory Network Steering Committee.
Additionally, the Australian Heart Foundation is developing a position statement on
chronic heart failure. The statement is scheduled for release in August 2010. The
developers of this proposal have been advised that the position statement is highly
compatible with the proposal. Nonetheless, the proposal remains open to further
change, in accordance with the position statement on chronic heart failure.
2.
That NSW Health (Chronic Disease Management Program) recognises the potential for a
substantial return on investment, should the proposal be implemented.
3.
That a line of funding is established to augment existing services* and, where unmet need
and potential staffing capacity can be identified, to facilitate the development and
implementation (see Implementation section 3.7) of new services across NSW, in
accordance with the proposed model of care as detailed in this document.
*
Specialist Services: Existing services operating successfully as single-specialty entities
(that is, as respiratory or cardiac services alone) should be encouraged to continue
unchanged and, if insufficiently resourced, remain eligible for enhancement funding that
may ensue from this submission. Whilst combined care (cardiac + respiratory) and
shared care (specialist + generalist) models may be suitable for patients with lower-level
acuity illness, patients with severe and complex disease - particularly those enrolled in
hospital outreach programs - are ideally managed by, or in close conjunction with,
specialist clinical teams.
Combined Care and Shared Care Services: The model recognises and accepts wide
variation in resources and clinical care across NSW and is, therefore, flexible so that it
may be adapted by local clinical teams to suit existing service configurations and
population need. In practise this will mean different things in different clinical settings. In
some settings, synergies and efficiencies may be achieved by funding and delivering
respiratory and cardiac failure services ‘together’; that is, side-by-side. Joint models may
help to avoid duplication of services and allow sharing of common resources such as, for
example, occupational therapy, dietetics, clerical staff etc. In some sites gym space and
equipment might be shared. Variations of the model will have potential application in
settings where the majority of patient care is provided by generalist clinicians, such as in
much of non-metropolitan NSW.
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1.
CONTEXT
This proposal aligns with the seven strategic directions(1) of the NSW State Health Plan to:
1. Make prevention everybody’s business
2. Create better experiences for people using health services
3. Strengthen primary health and continuing care in the community
4. Build regional and other partnerships for health
5. Make smart choices about the costs and benefits of health services
6. Build a sustainable health workforce
7. Be ready for new risks and opportunities
Additionally, the recommendations in this proposal address many of the concerns detailed by
Commissioner Peter Garling SC in his Report of the Special Commission of Inquiry into
Acute Care Services in NSW Public Hospitals (November 2008) including the deficiencies in
present models of care in public hospitals, the ageing of the population, the expansion in numbers
of people with chronic and complex illnesses, and the challenges of healthcare service provision
in non-metropolitan NSW(2).
Commissioner Garling’s solutions to these challenges include the development and
implementation of innovative models of patient care to manage this large and costly group of
patients in the community and home setting, rather than in acute hospital beds.
“My recommendations…are designed to encourage models of care which enable the delivery of as
much care as possible in the home and not in the hospital…”
“…it is a necessary part of the overall strategy to control demand for acute care beds by treating
patients wherever possible in the community.”
“…the best solution for delivery of community health (as it relates to demand upon the public
hospital system) is to employ the concept of ‘the virtual hospital’. This would require organisation of
community health along the lines of admission-treatment-discharge as used in a public hospital, but
without the building. Those in need of care for chronic, complex diseases (which almost inevitably
lead to periodic admissions to acute care hospitals) would be admitted to care by the general
practitioner or a designated community based nurse and assigned to a virtual ward of up to say 50
other patients. The treatment protocols for any one disease would be where possible standardised.
The actual care would be delivered by an extension of the hospital to the home. Where needed,
teams including if necessary a specialist, would be available to visit the patient at home or in the
aged care facility. The patient’s progress would be recorded in the electronic medical record
available to the general practitioner and at-home treating teams. Community health would thus
become a structure which could make sure that all of the things which are good about hospital care
can be replicated in the community.”
Peter Garling SC, 2008
This proposal pertains in particular to Recommendations 3, 4, 7 and 67 in the Garling Report, as
supported by the New South Wales Government, in its response(3) to the Inquiry; Caring
Together - The Health Action Plan for NSW:
Recommendation 3:
NSW Health’s Severe Chronic Disease Management Program should be implemented and
expanded to include all very high risk and high risk patients over the age of 18.
Recommendation 4:
NSW Health should consider and develop a comprehensive plan for the expansion of Hospitalin-the- Home programs of care for chronic and complex patients. The program should be
implemented throughout NSW hospitals within 18 months.
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Recommendation 7:
The Clinical Innovation and Enhancement Agency should as a matter of priority develop a
model of care:
(a) that allows identification of those elderly patients for whom a hospital stay in the event of
deterioration would be likely to result in adverse health outcomes; and
(b) which outlines the appropriate treatment modalities for such patients out of hospital.
Recommendation 67 (2a & b):
[Regarding the roles and purposes of] the Clinical Innovation and Enhancement Agency...
…use the existing clinical network model to involve clinicians and patient representations in
continuous clinical redesign to deliver safer and better patient care;
…identify, review and enhance or else to research and prepare standard evidence based
protocols or models of care guidelines for every unexceptional surgical intervention, and the
common disease or syndrome treatment modalities encountered in NSW public hospitals;
…investigate, identify, design, cost and recommend for implementation changes in patient
care by way of enhancements or improvements in clinical practice, including the content and
method of such practice, in order to ensure, on an ongoing state-wide basis, better, safer,
more efficient and more cost-effective patient care;
…provide advice to NSW Health, or any Area, or functional Health Service, on any matter
relating to the enhancement or improvement of clinical practice.
Regarding Recommendation 7 this proposal advises a substantial extension to the stated
preference for out-of-hospital treatment in the likelihood of an adverse outcome in hospital: Given
the strong evidence for equivalent medical outcomes between in-hospital and out-of-hospital
care(4-19) patients, for whom a hospital stay is likely to result in equivalent outcomes to treatment in
the community, should also be managed out of hospital.
An implemented program dedicated to addressing severe chronic respiratory and cardiac disease
will assist to overcome similar challenges echoed in the Report of the National Health and
Hospitals Reform Commission (June 2009) including the growing pressures of population
change, increases in demand for and expenditure on health care, unacceptable inequities in
health outcomes and access to services, growing concerns about safety and quality, workforce
shortages, inefficiencies and service fragmentation(20). The program will meet the aims of
fundamental clinical redesign outlined in the Report, namely:
2.
to embed prevention and early intervention including, in particular, early identification of the
deteriorating patient,
3.
to connect and integrate health and aged care services by:
•
bringing together and integrating multidisciplinary health care services,
•
improving access to a more comprehensive and multidisciplinary range of primary health care
and specialist services in the community,
•
encouraging better continuity and coordinated care for people with more complex health
problems,
•
promoting better use of specialists in the community, recognising the central role of specialists
in the shared management of care for patients with complex and chronic health needs.
The NHHRC Report argues strongly for “the need to create ‘hospitals of the future’ and to expand
speciality services in the community as part of connecting and integrating health care”, a key
feature of our proposal.
Specific recommendations in the NHHRC Report to which this proposal pertains include:
Recommendation 20:
We recommend improving the way in which general practitioners, primary health care
professionals, and medical and other specialists manage the care of people with chronic and
complex conditions through shared care arrangements in a community setting. These
arrangements should promote good communication and the vital role of primary health care
professionals in the ongoing management and support of people with chronic and complex
conditions in partnership with specialist medical consultants and teams who provide assessment,
complex care planning and advice.”
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Recommendation 31:
We recommend that all hospitals review provision of ambulatory services (outpatients) to ensure
they are designed around patients’ needs and, where possible, located in community settings.
Recommendation 37:
The visibility of, and access to, sub-acute care services must be increased for people to have the
best opportunity to recover from injury or illness and to be restored to independent living. To do
this, we recommend:
•
funding must be more directly linked to the delivery and growth of sub-acute services;
•
a priority focus should be the development of activity-based funding models for sub-acute
services (including the cost of capital), supported by improvements in national data and
definitions for sub-acute services; and
•
the use of activity-based funding complemented by incentive payments related to improving
outcomes for patients.
Recommendation 38:
We recommend that clear targets to increase provision of sub-acute services be introduced by
June 2010. These targets should cover both inpatient and community-based services and should
link the demand for sub-acute services to the expected flow of patients from acute services and
other settings. Incentive funding under the National Partnership Payments could be used to drive
this expansion in sub-acute services.
Recommendation 39:
We recommend that investment in sub-acute services infrastructure be one of the top priorities
for the Health and Hospitals Infrastructure Fund.
Recommendation 40:
We recommend planning and action to ensure that we have the right workforce available and
trained to deliver the growing demand for sub-acute services, including in the community.
Accordingly, we support the need for better data on the size, skill mix and distribution of this
workforce, including rehabilitation medicine specialists, geriatricians and allied health staff.
Recommendation 41:
We recognise the vital role of equipment, aids and other devices in helping people to improve
health functioning and to live as independently as possible in the community. We recommend
affordable access to such equipment should be considered under reforms to integrated safety
net arrangements.
Recommendation 66:
Care for people in remote and rural locations necessarily involves bringing care to the person or
the person to the care. To achieve this, we recommend:
•
networks of primary health care services, including Aboriginal and Torres Strait Islander
Community Controlled Services, within naturally defined regions;
•
expansion of specialist outreach services – for example, medical specialists, midwives, allied
health, pharmacy and dental/oral health services;
•
telehealth services including practitioner-to-practitioner consultations, practitioner-tospecialist consultations, teleradiology and other specialties and services;
•
referral and advice networks for remote and rural practitioners that support and improve the
quality of care, such as maternity care, chronic and complex disease care planning and
review, chronic wound management, and palliative care; and
•
‘on-call’ 24-hour telephone and internet consultations and advice, and retrieval services for
urgent consultations staffed by remote medical practitioners.
Further, we recommend that funding mechanisms be developed to support all these elements.
Despite the strong evidence for out-of-hospital care(4-19), the Report of NSW Community Health
Review, 2008 (Part 2) identified a relative decline in the in the overall expenditure on community
health as a percentage of total expenditure from 18.0% to 14.5% over the period 2004/05 to
2006/07.
Further, with admitted patient services excluded, community health has been receiving a smaller
proportion of funding allocated to non-admitted services, with funding for community health
declining by 5.8% relative to other non-admitted services(21).
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“Short-term hospital demand management services have been increasing at the expense of
other services in the community, particularly prevention and early intervention.”
From: Eagar K et al (2008) State of Play: Report of the NSW Community Health Review
The Report of NSW Community Health Review (Part 3) identified a number of existing “Models
of Good Practice” in NSW which “illustrate a commitment to service improvement” at the local
level(22). The list included the ACI model of consumer and community participation in specialist
clinical networks and the Respiratory Coordinated Care Program (SCRCCP) at St George
Hospital, upon which a considerable proportion of this proposal is based.
The Report mentions that one issue contributing to service gaps is the “trend to establish more
tightly defined micro programs, each with their own eligibility criteria and narrowly targeted
recipients that limit the capacity of community health services to flexibly respond to local
needs”(22). The program detailed in this proposal does not fall within that category, with potential
application over a patient population which accounts for six percent of total inpatient costs in
NSW(23) and eight percent of all hospital bed days in NSW(23).
Additionally, the Report points to a more productive approach in the determination to find a
balance between specialist and generalist services, suggesting that there need be “no conflict at
all between generalist and specialist models”. Instead, Eager et al suggest that a number of
factors(22) should be taken into consideration:
1. the requirement for local and ongoing analysis of the best mix of outputs to meet the health
needs of a population (a combination of allocative and dynamic efficiency),
2. the availability of existing and projected resources, and
3. the strength of the interface between specialist community health programs and key partners
such as general practitioners.
To this end the Report highlighted text from two particular submissions:
‘the local community health centre could provide a very valuable ongoing support service to
…people with high support needs and significantly improve their health care and quality of life… A
health worker in each community health centre with a special interest …could develop some
expertise in these areas, network with primary and tertiary health providers, provide some case
work and run support groups.’
Submission from Dr Carolyn West, Director Spina Bifida Unit,
The Children’s Hospital at Westmead
‘This is not an argument for the separate identity and provision of community based healthcare, but
for resetting the balance between hospital and community components of integrated health
services, and shifting the centre of gravity of such services towards more accessible community
health services.’
Submission from Alan Rosen, Roger Gurr & Paul Fanning
As the Report states: “many of the key issues of the future are grouped around the strategies that
promote effective linkages within and beyond health”(22). In this regard the integration of services
based on this proposal with other clinical services is paramount. Indeed, the establishment of
effective links with existing services and clinical teams is critical to the sustainability of any
program, service or model of care that is based on our proposal. However, we reiterate the
Report’s reminder of Leutz’s Laws of Service Integration which state:
1. You can integrate some of the services for all the people, and all the
services for some of the people, but you can’t integrate all of the services
for all of the people.
2. Integration costs before it pays.
3. Your integration is my fragmentation.
4. You can’t integrate a square peg and a round hole.
5. The one who integrates calls the tune.
6. All integration is local.
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Should it be implemented, the clinical program detailed within this proposal will be accommodated
by the existing NSW Clinical Service Frameworks for Chronic Respiratory Disease(24) and
Heart Failure(25) and facilitate the implementation of the Frameworks’ accompanying Practice
Guides for the Optimal Treatment of Chronic Respiratory Disease(26) and Heart Failure(27).
This proposal builds on the successes of the NSW Chronic Care Program(28) by serving as an
adaptable implementation tool, or model of care, for the treatment of people with severe chronic
respiratory and cardiac disease. The model we present recognises and accepts wide variation in
resources and programs across clinical settings in NSW and is, therefore, flexible so that it may
be adapted by local clinical teams to suit existing service configurations and population need.
The proposal detailed in this document presents the evidence for an adaptable model of care for
patients with severe chronic respiratory and cardiac disease. The model seeks to promote
integrated hospital and community care, and strong links between specialist and generalist clinical
teams. The model recommends the transfer, where appropriate, of the care of patients with
severe chronic respiratory and cardiac disease out of hospital and into the community.
15
FINAL DRAFT
2.
BACKGROUND
2.1
Burden of Chronic Respiratory and Cardiac Disease
Australian Institute for Health and Welfare (AIHW) population data indicates that in 2007 chronic
respiratory and cardiovascular diseases were responsible for twenty five percent of the total
burden of disease and injury in Australia(29).
Chronic obstructive pulmonary disease (COPD) and asthma accounted for 46% and 34% of the
chronic respiratory burden respectively(29).
Figure 1: Burden of Chronic Respiratory and Cardio-vascular Disease in Australia
Fig 1(a)
Proportion of total burden of disease by broad
cause group (DALYs)
1(b)
Proportion of chronic respiratory disease
burden by specific cause (DALYs)
Australian data on the incidence and prevalence of heart failure in the Australian population is
limited. However, the National Heart Foundation & Cardiac Society of Australia & NZ (2010)
report that at least 300,000 Australians (or about 4% of the population aged 45 or more) have
chronic heart failure (CHF), with 30,000 new cases diagnosed each year(30). The point prevalence
of CHF is approximately 10% in people aged 65 years or more, and over 50% in people aged 85
years or more(31).
Fig 1(c)
Cardiovascular burden (DALYS) by specific cause
The prevalence of Chronic Heart Failure
among Australians aged 65 years or more is at
least 10%(31).
Source:
Begg et al (2007) The Burden of Disease and Injury in
Australia 2003. Australian Institute of Health and Welfare,
2007
16
FINAL DRAFT
Impact on Hospital Resources
In terms of the burden on hospitals, respiratory and cardiac illnesses consumed the third and
fourth highest number of public hospital bed days in NSW in 2007-08, with over 700,000 patient
days attributed to in-patient management of people with respiratory and cardiac disease(23).
Figure 2: Hospital Bed Days by Service Related Group, Public Hospitals NSW, 2007-08
(Excludes Mental Health and Obstetrics)
Source: Australian Institute of Health and Welfare 2009. Australian hospital statistics 2007–08, online www.aihw.gov.au
600,000
Hospital Bed Days
500,000
400,000
300,000
200,000
100,000
R
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Service Related Group
The diagnosis related groups (DRGs) of particular relevance to this proposal (full list Appendix A)
including COPD (E65A&B) Respiratory Infection/Inflammation (E62B&C), Heart Failure and
Shock (F62B) and Bronchitis & Asthma (E69C), account for eight percent of the total number of
public hospital bed days(23) (Fig 3). In NSW in 2007-08 this amounted to 399,103 bed days(23).
Figure 3: Top DRGs by Overnight Bed Days, Public Hospitals, Australia 2007-08:
(Excludes Mental Health and Obstetrics)
Source: Australian Institute of Health and Welfare 2009. Australian hospital statistics 2007–08, online www.aihw.gov.au
200,000
180,000
140,000
120,000
DRGs relevant to this proposal
100,000
80,000
60,000
40,000
20,000
E6
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Number of Bed Days
160,000
Diagnosis Related Group
17
FINAL DRAFT
Translated into costs, the DRGs related to this proposal account for six percent of all public
hospital inpatient costs (Fig 4)(23). In NSW in 2007-08 this amounted to $357 million(23).
Figure 4: Top DRGs by Cost* - Overnight Admissions, Public Hospitals, Australia 2007-08:
(Excludes Mental Health and Obstetrics)
Source: Australian Institute of Health and Welfare 2009. Australian hospital statistics 2007–08, online www.aihw.gov.au
* Based on the 2006–07 AR-DRG version 5.1 estimated public cost weights
160
140
Cost ($ million)
120
DRGs relevant to this proposal
100
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The total burden of chronic disease, however, is much higher than that attributable to direct
healthcare expenditure. An assessment of the economic impact of COPD alone by Access
Economics (2008) puts the financial cost of COPD at $8.8 billion(32). Of this:
ƒ
$6.8 billion (76.6%) was productivity lost due to lower employment, absenteeism and
premature death of Australians with COPD;
ƒ
$0.9 billion (9.7%) was direct health system expenditure;
ƒ
$0.9 billion (10.0%) was the deadweight losses (DWLs) from transfers including welfare
payments and taxation forgone; and
ƒ
$0.3 billion (3.6%) was other indirect costs such as aids and home modifications and the
bring-forward of funeral costs(32).
18
FINAL DRAFT
2.2
An Increasing Problem
In spite of many improvements in management by primary care physicians and a reduction in
hospital length of stay(23), the burden of chronic respiratory and cardiac disease on the healthcare
system is increasing(23). The successful Chronic Care Program (commenced 1999) led to
improvements in management of COPD and heart failure in many areas of the state but resources
were limited and demand for services has increased steadily over the past 10 years. This might
explain the decrease in separations and bed days between 1999 and 2003 but a steady increase
since then. The present trends are unsustainable without new models of care for these diseases
(Figures 5 and 7).
Figure 5:
Rising Annual Burden of Respiratory Diseases on Public Hospitals by number of patient
days(a), separations(b), cost(c) and ALOS(d) in Australia over the decade 1998-2008
Source: Australian Institute of Health and Welfare 2009. Australian hospital statistics 1998-2008, online www.aihw.gov.au
(a)
(b)
Number Patient Days ('000)
Number Hospital Separations
270
1,280
1,260
1,240
1,220
1,200
1,180
1,160
1,140
1,120
1,100
1,080
1,060
260
250
240
230
220
(c)
19
99
-0
0
20
00
-0
1
20
01
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2
20
02
-0
3
20
03
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4
20
04
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5
20
05
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6
20
06
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7
20
07
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8
19
98
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9
19
98
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9
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1
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2
20
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3
20
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4
20
04
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5
20
05
-0
6
20
06
-0
7
20
07
-0
8
210
(d) Average Length of Stay (days)
Cost by Volume ($ million)
6.0
1,400
1,200
5.5
1,000
5.0
800
4.5
600
4.0
400
19
98
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9
19
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20
00
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1
20
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2
20
02
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3
20
03
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4
20
04
-0
5
20
05
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6
20
06
-0
7
20
07
-0
8
20
05
-0
6
20
06
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7
20
07
-0
8
3.0
20
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5
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19
99
-0
0
20
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1
20
01
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2
20
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3
20
03
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4
3.5
19
98
-9
9
200
19
FINAL DRAFT
The prevalence of COPD, itself responsible for the largest proportion of the total burden of all
respiratory diseases at approximately 40%, is projected to double over the period 2008 to 2050
(Figure 6)(32). Such increases in respiratory disease are likely to continue with the ageing of the
population(33, 34).
Figure 6: Projected Prevalence of COPD by Gender, 2008 - 2050
Number of persons
Source: Access Economics. Economic Impact of COPD and Cost Effective Solutions, 2008. The Australian Lung Foundation
Note: The ‘kink’ in the chart reflects that the first time interval is two years (2008 to 2010) while the other intervals represent a decade
(2010 to 2020 etc). The chart outlines the projected prevalence of COPD in the total population on the basis of demographic ageing
only, not taking into account any changes in age-gender prevalence rates in the future (ie, assuming the same impacts of smoking in
the future as currently).
The incidence and prevalence of Chronic Heart Failure is also increasing(17, 25, 35, 36). In countries
such as Australia, New Zealand, the United States and the United Kingdom the occurrence of
CHF is increasing faster than any other cardiovascular disorder and projections suggest that the
prevalence will double over the 30-year period from 1996 to 2026(25). Both incidence and
prevalence are increasing in parallel with the age-adjusted decline in mortality from coronary
disease in these countries(25).
Figure 7:
Rising Annual Burden of Chronic Heart Failure on Public Hospitals by number of patient
days(a) and cost (b) in NSW over the decade 1998-2008
Source: Australian Institute of Health and Welfare 2009. Australian hospital statistics 1998-2008, online www.aihw.gov.au
(a) Number of Bed Days
(b) Cost by volume ($mill)
95,000
80.0
90,000
70.0
60.0
85,000
50.0
40.0
80,000
30.0
20.0
19
98
19 9 9
99
-0
20 0
00
20 0 1
01
20 0 2
02
-0
20 3
03
20 0 4
04
-0
20 5
05
20 0 6
06
20 0 7
07
-0
8
70,000
10.0
0.0
19
98
-9
19 9
99
-0
20 0
00
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20 1
01
-0
20 2
02
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20 3
03
-0
20 4
04
-0
20 5
05
-0
20 6
06
-0
20 7
07
-0
8
75,000
20
FINAL DRAFT
2.3
Current Services and Management Practices
Historically, health systems in Australia have been oriented towards ‘last-minute’ treatment of
acute diseases, or acute exacerbations of chronic diseases, dominated by a reactive, episodic
model of care. However, the challenges posed by the increasing burden of chronic diseases on
health systems require the development of healthcare service models that have a fundamentally
different orientation towards anticipatory and proactive care in addition to acute reactive care.
The Australian Institute of Health and Welfare lists many of the hospitalisations due to chronic
respiratory and cardiac disease as potentially preventable hospitalisations (PPHs). The definition
of PPHs are “those conditions where hospitalisation is thought to be avoidable if timely and
adequate non-hospital care had been provided”(23). In 2007-08, there were 20,082 PPHs of COPD
and 14,956 PPHs of congestive cardiac failure(23). The Institute notes that “these conditions may
be preventable through behaviour modification and lifestyle change, but they can also be
managed effectively through timely care (usually non-hospital) to prevent deterioration and
hospitalisation”(23). This proposal aims to facilitate the provision of such care.
At present, however, there is insufficient coordination in the approach to chronic cardiac and
respiratory disease and wide variance in management practices including evidence-based
protocols, models of care, antibiotic choices, length of stay and post-discharge support etc(37-39).
Additionally, there is inequitable access to best practice patient care. For patients with respiratory
disease, gaps in service access have been identified in early intervention following spirometry,
non-invasive ventilation (NIV) for acute-on-chronic respiratory failure, home NIV support, long
term oxygen therapy, pulmonary rehabilitation, smoking cessation and patient education services
to improve self care, exacerbation management and disease control(37-39). For patients with
chronic cardiac failure the gaps in care are most notable in the use of evidence-based drug
therapies, such as angiotensin-converting enzyme (ACE) inhibitors and β-blockers, that reduce
symptoms and hospital admissions and improve survival(40). Further gaps for CHF patients have
been identified in access to echocardiography, rapid access to cardiology advice, access to
specialised multi-disciplinary cardiac teams, and 24-hour telephone triage(40). Such services are
currently available to less than 10% of those needing them(40).
There are several interactions between chronic respiratory and cardiac diseases that would
benefit from a collaborative approach to management. Many patients with heart failure also have
respiratory disease with cigarette smoking a common risk factor in both diseases. Respiratory
failure leads to right heart failure. Sleep apnoea is a frequent complication of both diseases. Many
patients with heart failure benefit from nocturnal ventilatory assistance (eg with CPAP or
supplemental oxygen. Beta-blockers are relatively contra-indicated in some respiratory disorders
but often can be administered safely with appropriate specialist monitoring. Many components of
comprehensive pulmonary rehabilitation are beneficial for patients with chronic heart failure. The
present proposal has the potential to resolve many of the issues and gaps listed above.
21
FINAL DRAFT
ACI (GMCT) Survey of Respiratory Services in NSW Hospitals (2007)
Survey Part 1: Respiratory Infection, Outreach and Acute Respiratory Failure
Hospitals (N=35) in NSW with over 300 annual admissions for respiratory infection + COPD were
surveyed, including 11 principal referring hospitals, 13 major hospitals, and 3 district hospitals.
Responses were received from 27 hospitals, a response rate of 77%. The survey revealed the
following data on respiratory services provided in those facilities:
Acute Respiratory Infection Services
ƒ
42% (11 / 26) of surveyed hospitals do not have a pneumonia severity scoring system to
assist decision making in the management of community acquired pneumonia.
ƒ
68% (17 / 25) of hospitals do not have a pathway to promote the expedient delivery of
antibiotics to a patient recognised as having moderate and severe pneumonia.
ƒ
80% (20 / 25) of hospitals are without guidelines to enable early switch of intravenous to
oral antibiotics to facilitate early discharge of patients admitted with community acquired
pneumonia.
ƒ
50% (13 / 26) of facilities surveyed do not have a pathway for early discharge from
hospital.
Respiratory Outreach Services
ƒ
63% (17 / 27) of hospitals do not have a respiratory-specific outreach service.
ƒ
Of these 17 hospitals, 3 major metropolitan hospitals have no access to a generic
outreach service. They therefore have no access to either respiratory or generic outreach
services.
ƒ
Of the 10 hospitals with a respiratory-specific outreach service, only two facilities have
more than 1.0 FTE nurse staffing the service. And only 29% (6 / 21) provide Non-Invasive
Ventilation (NIV) / Continuous Positive Airway Pressure (CPAP) follow up.
ƒ
70% (14 / 20) of hospitals do not have a case management model for chronic patients.
Acute Respiratory Failure Services
ƒ
4 hospitals (3 principal referring and 1 major metropolitan) do not have access to NIPPV
on their respiratory wards. Respondents for these facilities indicated that nursing staff
levels are insufficient to set up an NIV unit.
ƒ
40% (10 / 25) of hospitals do not have an after hours on-call service for acute respiratory
failure patients.
ƒ
60% (9 / 15) of hospitals who have NIV machines indicated that they are reliant on funding
other than general hospital funds (SP&T or donations) to purchase this equipment. Of
these 9 hospitals, 4 (3 principal referring and 1 major metropolitan) indicated that they are
totally reliant on external funding sources to finance the purchase of NIV equipment.
22
FINAL DRAFT
Survey Part 2: Pulmonary Rehabilitation Services
Hospitals (N=38) in NSW with over 300 annual admissions for respiratory disease were surveyed.
Responses were received from 38 hospitals, a response rate of 100%. The survey revealed the
following data on pulmonary rehabilitation services provided in those facilities:
ƒ
5-10% of patients with moderate to severe COPD have accessed pulmonary rehabilitation
ƒ
77% of programs have a waiting period of greater than 4 weeks
ƒ
37% of programs have a waiting period of greater than 8 weeks
ƒ
11 out of 30 programs are able to assess and admit more than 100 patients per year to
pulmonary rehabilitation
ƒ
26% of programs do not accept referrals from general practitioners
ƒ
44% of programs do not accept referrals from allied health professionals
ƒ
48% of programs do not accept referrals from nursing professionals
ƒ
15% of programs conduct the gold standard program of three supervised exercise sessions
per week
ƒ
60% of programs are unable to offer maintenance exercise programs and follow-up
assessment and care
Survey Part 3: Respiratory Education Services
Hospitals (N=38) in NSW with over 300 annual admissions for respiratory disease were surveyed.
Responses were received from 35 hospitals, a response rate of 92%. The survey revealed the
following data on airways education services provided in those facilities:
ƒ
Over half of the hospitals surveyed (19 out of 35, 54%) have no airways educators or formal
airways education service.
ƒ
Airways education services in NSW are inequitable, with a range of resource capacity
stretching from 0FTE (in the 19 hospitals mentioned above) to 7FTE (in one principal referring
hospital alone).
These figures highlight the need to reform and reallocate respiratory services in line with our
recommendations.
23
FINAL DRAFT
3.
PROPOSAL FOR A SEVERE CHRONIC RESPIRATORY &
CARDIAC DISEASE PROGRAM
3.1
Introduction - Towards an Improved Model of Care
Notwithstanding the identification of progressive chronic disease, current management practices
of patients with these illnesses are often focussed on reactive treatment of inevitable acute-onchronic symptomatology at the ‘last-minute’(2, 4, 8, 9, 15, 16, 18-20, 22, 38-42). Healthcare settings of all
configurations are being encouraged to move away from the reactive mind-set towards an
anticipatory and innovative paradigm of healthcare delivery. Significant reductions in hospital
admissions and associated costs will require the introduction of progressive management
practices and service models of care(2, 4-20, 22, 31, 38-58). For patients with chronic and complex
cardiac and respiratory disease the evidence demonstrates that such reform should involve a
fundamental shift towards regular, community-based monitoring of patients with known
progressive disease, facilitating early detection of disease deterioration and proactive
intervention(2, 4-20, 22, 31, 38-58).
In NSW there are examples of respiratory and heart failure services which have successfully
reformed their management practises so that these patients are treated in a more anticipatory
fashion. These services include established Respiratory and Heart Failure programs (operating as
separate services) at St George Hospital. Similar - though newer - respiratory services operate
out of Westmead-Auburn-Blacktown Hospitals, Prince of Wales Hospital, Royal Prince Alfred
Hospital, Sutherland Hospital and Bathurst and Orange Hospitals. Other heart failure services
include Fairfield, North Sydney and North Coast. These services have demonstrated reductions in
presentations to emergency departments, reductions in admissions, reductions in length of stay in
hospital and reductions in overall costs.
Evidence from a 2004 systematic review of randomised trials of multidisciplinary strategies for the
management of patients with heart failure at high risk for admission showed that programs that
incorporate follow-up by a specialised multidisciplinary team (in either a clinic or a non-clinic
setting) reduce mortality, heart failure hospitalisations and all-cause hospitalisations(15). Since
then several authors have detailed the evidence for community-based monitoring and intervention
over in-hospital management practices (13, 14, 16-19, 40, 48, 50, 51, 53-58).
However, clinical reform of this type has been carried out in an ad-hoc fashion in NSW by a small
minority of services. Notwithstanding the potential for considerable long-term savings, such
programs remain largely unsupported by those who are unwilling to make prudent short term
investments in innovative clinical reform. If nothing is done, we can expect an increasing number
of admissions to hospital of patients with complex conditions who are unable to cope in the
community because of chronic cardiac and respiratory disease.
The model of care detailed in this proposal aims to facilitate progressive healthcare reform for
healthcare services in NSW that manage patients with severe chronic cardiac and respiratory
illness. The model is adaptable to the particular clinical setting but maintains a particular focus on
patients with severe chronic disease.
An implemented Severe Chronic Respiratory & Cardiac Care Program (SCRCCP) has the
potential to improve patient outcomes, significantly reduce presentations to hospital emergency
departments, reduce hospital admissions, reduce the length of stay for those who are admitted to
hospital, and achieve substantial savings in both bed days and overall costs.
24
FINAL DRAFT
3.2
Aims of a Severe Chronic Respiratory & Cardiac
Care Program (SCRCCP)
The goal of this proposal is to offer an evidence-based, cost-effective and adaptable
solution to improve patient outcomes and reduce the burden of severe chronic respiratory
and cardiac disease to the NSW healthcare system. This will be achieved by using a
range of coordinated, community-focussed strategies encompassed in the Severe Chronic
Respiratory & Cardiac Care Program (SCRCCP) as detailed in this paper. These
strategies comprise a seamless interface between in-patient and community services with
links to existing services wherever possible.
The aims of a Severe Chronic Respiratory & Cardiac Care Program (SCRCCP) are:
ƒ
to improve equity of access to, and outcome from, best practice healthcare to patients
in NSW with severe chronic respiratory and cardiac disease
ƒ
to reduce the burden of severe chronic respiratory and cardiac disease on patients,
carers and the NSW healthcare system
ƒ
to optimise patient well-being and quality of life by delivering the right care in the right
place at the right time
ƒ
to reduce the number of emergency department presentations, hospital admissions
and readmissions, and length of stay in hospital where appropriate
ƒ
to reduce access block by improving patient flow between the community and the
hospital
ƒ
to augment existing services managing patients with severe chronic respiratory and
cardiac disease and, where unmet need and potential staffing capacity can be
identified, to facilitate the development and implementation of new services across
NSW in accordance with the proposed model of care detailed in this document
ƒ
To transfer, where appropriate, specialist clinical care from the hospital to the
community
25
FINAL DRAFT
3.3
Severe Chronic Respiratory & Cardiac Care Program (SCRCCP)
A Severe Chronic Respiratory & Cardiac Care Program (SCRCCP) provides evidence-based(4-7, 11, coordinated, patient-centred care, to people with chronic and complex
respiratory and cardiac disease. Services are provided in the community with equivalent (or better)
medical outcomes, at equivalent or better cost, and with improved quality of life and improved
measures of patient satisfaction than those achieved in hospital(4-9, 11-19, 34, 38, 42-47, 51, 53-58, 60, 61).
19, 25, 27, 30, 31, 34, 35, 38-62)
The Program is delivered by a multidisciplinary team of specialist clinicians - or generalist clinicians
with a special interest in respiratory or cardiac medicine - including the patient’s general
practitioner.
3.3.1
Key Strategies: R-E-M-E-D-I-A-L
The Severe Chronic Respiratory & Cardiac Care Program adopts key clinical and service-related
strategies that may be summarised in the acronym ‘REMEDIAL’:
R
Risk Assessment & Review
Risk assessment and care level stratification / triage (to supported selfmanagement, case management, hospital-in-the-home etc)
Access to express medical review
E
Educate & Enrol
Educate patients on self-management
Enrol patients into pulmonary and cardiac rehabilitation programs and smoking
cessation counselling
M
Monitor
Routine home / community monitoring of moderate to high-risk patients
E
Early detection
Early detection of the deteriorating patient
D
Direct communication
Direct communication between patients and their local clinical teams via a rapidadvice telephone line
I
Intervention
Evidence-based, multi-disciplinary intervention including supported selfmanagement, case management, hospital-in-the-home, planned hospital
admission
A
Assessment
Assessment and evaluation of the Program (SCRCCP)
L
Links
Establish links to existing services wherever possible including primary and
community healthcare (General Practise, CAPAC services, aboriginal services,
‘co-morbidity’ services etc)
- For rural Programs: links with established centres of excellence will provide
clinical support and training to maximise skills transfer and service sustainability
26
FINAL DRAFT
3.3.2
Key Features
Risk Assessment & Review
Patients enrolled in an SCRCCP will undergo comprehensive risk assessment, including functional
and psycho-social evaluation, at the time of their enrolment to facilitate care level stratification
(triage).
Patients will then be assigned to an appropriate management plan incorporating a clear action plan
for occasions of disease exacerbation. Management plans of all levels may involve components of
community shared care as required.
Additionally, SCRCCP-enrolled patients will have access to express (no delay) medical review.
Educate & Enrol
Pulmonary and Cardiac Rehabilitation
All eligible patients(34) are enrolled in comprehensive pulmonary or cardiac rehabilitation which
includes physical and psychological disease management and self-management support
interventions, followed by on-going maintenance exercise programs.
A 2009 Cochrane review(43) demonstrates that pulmonary rehabilitation after acute exacerbation of
COPD substantially reduces the risk of hospital admission and mortality and improves health-related
quality of life. In the control group 57% of patients had admission to hospital, compared to 14% for the
pulmonary rehabilitation group(43).
Similarly, recent reviews(62, 63) of exercise-based cardiac rehabilitation demonstrate significant benefits
in terms of clinical outcomes and costs.
Respiratory and Cardiac Education and Disease Management Support
SCRCCP patients and carers are provided with a comprehensive understanding of their disease, how
it is investigated, and how it is managed. The aim is to maximise the patient’s capability in selfsurveillance, early symptom recognition and self-management practices at home in order to reduce
the need for unplanned admissions to hospital and to slow the progression of the disease through
early treatment. Action plans are developed with patients and carers to mitigate episodes of disease
relapse or exacerbation.
Educators provide advice on the proper use of medication delivery devices, oxygen, ventilators and
other equipment. They are well placed to coordinate and monitor oxygen and respiratory equipment,
communicating with the patient’s clinical team, equipment providers and Enable NSW (PADP).
A 2007 Cochrane review(44) systematically evaluated the impact of self-management education for
patients with COPD compared to usual care. The review demonstrated “a significant reduction in the
probability of at least one hospital admission among patients receiving self-management education
compared to those receiving usual care”(44).
Where appropriate, Educators facilitate discussion on advanced care planning.
Additionally, the roles and responsibilities of specialist Educators include the provision of education
and training for staff in hospitals and the community, including retirement and aged care facilities,
thereby building specialist capacity in clinical settings.
Smoking Cessation
SCRCCP patients are provided with specialist smoking cessation counselling and medication support
services.
Reviews of the evidence demonstrate the significant value of individual behavioural counselling and
NRT for smoking cessation.(64-68)
Monitor
Moderate to high-risk patients are routinely monitored in the home / community to prevent avoidable
disease exacerbation and facilitate early detection of the deteriorating patient.
27
FINAL DRAFT
Figure 8: Schematic Representation of an SCRCCP Model of Care
Severe Chronic Respiratory & Cardiac Care Program Model of Care
EARLY IDENTIFICATION
ASSESSMENT & RISK STRATIFICATION
STRATIFIED COMMUNITY MANAGEMENT
Hospital in the Home
SITES
Very
High Risk
ƒ
General Practice
ƒ
Community nursing
ƒ
CAPAC Services
ƒ
Aged Care teams
ƒ
Other Community
Healthcare
Case Management
High Risk
Moderate / Lower Risk
Supported SelfManagement
At Risk / Undiagnosed Population
Primary & Shared Care
Components of a Severe Chronic Respiratory & Cardiac Care Service
Monitoring &
Early Detection
Express
Medical Review
Pulmonary &
Cardiac
Rehabilitation
Self-Mx
Support &
Education
Smoking
Cessation
Early
Discharge
Direct Phone
Line Support
28
FINAL DRAFT
Early Detection
Early detection of the deteriorating patient facilitates early intervention by the SCRCCP team. Patients
and carers are encouraged to telephone the on-call team member. Early intervention may avoid the
need for a triple-0 call*, an emergency department presentation via ambulance, and an unplanned
hospital admission.
Alternatively, early detection will facilitate planned clinical assessment and/or review and/or admission.
*
Early detection strategies do not replace the need for triple-0 / emergency ambulance services.
Direct Communication
SCRCCP-enrolled patients are provided with direct telephone communication to their local clinical
teams via a rapid-advice phone line, providing anxious and/or breathless patients with an alternative
option to a triple-0 call*.
In a significant proportion of cases it is possible for an experienced specialist clinician (allied health
practitioner, nurse or doctor) to provide remedial on-call advice over the telephone to an anxious and/or
breathless patient, thereby obviating the need for a triple-0 call*.
There are certain requirements for the success of rapid advice phone line services, some of which are
listed below:
1. The patient must be known to the clinical team.
2. The clinical team must be known to the patient.
3. Advice line calls from patients must go directly to the patient’s local clinical team. The call can then
be answered in person, by an on-call team member, with whom the patient is familiar.
4. To attract patient referrals to the clinical team, the referring clinician must have confidence in all
members of the team.
*
Rapid advice lines do not replace the need for triple-0 / emergency ambulance services.
Intervention
SCRCCP interventions are variable and multi-faceted according to the stage and acuity of disease.
They encompass the above strategies in an overall program that is early and anticipatory rather than
last-minute and reactionary.
Interventions are evidence-based and multi-disciplinary and include: supported self-management,
smoking cessation counselling, case management, hospital-in-the-home, pulmonary or cardiac
rehabilitation and planned hospital admission where required.
The use of existing treatment guidelines(34, 39, 59, 69), and the development of clinical protocols and other
decision support tools, adapted at the local level to suit local resources, will facilitate:
ƒ
best clinical practice in the provision of medical services such as administration of intravenous
antibiotics, lung assessment, spirometry, oxygen saturation, ECG, daily weight monitoring for signs
of early fluid retention, surveillance for pulmonary and hepatic congestion and peripheral oedema,
and assessments of nutritional and psychosocial status
ƒ
event-driven hospital discharge with transitional support into the community
ƒ
planned admissions where an admission to hospital is necessary.
Care plans, developed by the multidisciplinary team using, if necessary, ‘telehealth’ or virtual case
conferencing incorporate regular medical review and action planning.
Action plans will facilitate organised, rapid responses to exacerbations by the patient’s local clinical
team with management in the community as an alternative, where appropriate, to admission via ED.
29
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Respiratory Toolkit
The ACI Rural Respiratory Advisory Group has suggested the development of an evidence-based
‘Respiratory Toolkit’ comprising a set of clinical tools / forms / protocols / flow charts to aid the delivery
of specialist respiratory care in non-metropolitan healthcare settings or those managed predominantly
by generalist clinicians.
The toolkit will include standardised information on patient assessment, treatment, risk factor
management, event-driven discharge, care planning and patient information.
Existing tools such as the COPD-X Guidelines, the Pulmonary Rehabilitation Standards, the Pulmonary
Rehabilitation Toolkit, and patient booklets developed by the Australian Lung Foundation will be used.
Heart Failure Guidelines
The Heart Foundation is developing a position statement on chronic heart failure.
The developers of this proposal have been advised that the position statement is highly compatible with
the proposal.
The statement is scheduled for release in August 2010.
Assessment
Local SCRCCPs would undergo continuous outcomes assessment facilitated by routine collection and
analysis of a minimum data set.
[See Key Performance Indicators, following page]
Links
Wherever possible, links are established with existing services including:
9
General Practice (general practitioners and GP practice nurses)
ACAT and aged care teams
CAPAC / PACS
ComPacks
Community nursing
Emergency Departments
Medical Assessment Units (MAUs)
Care Coordinators
Retirement and Aged Care Facilities (RACFs)
Exercise maintenance programs such as ‘Lungs in Action’ and ‘Heart Moves’ following
pulmonary and cardiac rehabilitation.
Care organisations and NGOs
9
Meals on Wheels
9
9
9
9
9
9
9
9
9
9
SCRCCP teams provide both clinical services to patients and training to other clinicians. A requirement
for information sharing and skills transfer between clinical teams has the potential to boost overall
services capacity and assist with integration of clinical services.
Skills transfer from specialist SCRCCP teams to generalist clinicians facilitates, where appropriate,
shared care options and is important for SCRCCP service sustainability.
To maximise service quality local SCRCCP teams develop strong links with established centres of
excellence which provide specialist clinical support and training. This may include a program of
rotational staff training between the hospital and community sectors.
30
FINAL DRAFT
3.3.3
ƒ
Reduced Hospital Admissions
KPI:
ƒ
% reduction in chronic respiratory and heart failure admissions (target: 25% reduction)
1.
% reduction in ALOS for the DRGs E62, E65 and F62 (target: 20% reduction)
2.
Reduction in variance in ALOS between peer sites (target: <10% variance)
Equivalent Medical Outcomes
KPI:
ƒ
1.
Reduced Length of Stay in Hospital
KPI:
ƒ
Key Performance Indicators
Equivalent mortality rates from COPD, pneumonia and heart failure for patients
participating in the program (being treated at home) to those non-program patients being
treated in hospital.
Improved Patient Quality of Life
Improved patient quality of life as measured by pre- and post-program administrations of the St
George’s (UK) Respiratory Questionnaire(18) or Minnesota Quality of Life Questionnaire
KPI:
ƒ
Improvement in quality of life as determined by a comparison of scores pre- and
post-entry to the SCRCCP program.
Pulmonary Rehabilitation
Increase in proportion of SCRCCP-eligible patients offered pulmonary rehabilitation and an
increase in completion rates of pulmonary rehabilitation programs
KPI:
% increase in the number of patients attending and completing pulmonary rehabilitation
(targets: 100% of SCRCCP-eligible patients, who have not completed a rehabilitation
program within the last 18 months, to be offered pulmonary rehabilitation
30% of SCRCCP-eligible patients to commence pulmonary rehabilitation
70% of commencing patients to complete their program
ƒ
Cardiac Rehabilitation
Increase in proportion of SCRCCP-eligible patients offered cardiac rehabilitation and an increase in
completion rates of cardiac rehabilitation programs
KPI:
% increase in the number of patients attending and completing cardiac rehabilitation
(targets: 100% of SCRCCP-eligible patients, who have not completed a rehabilitation
program within the last 18 months, to be offered cardiac rehabilitation
60% of SCRCCP-eligible patients to commence cardiac rehabilitation
70% of commencing patients to complete their program
ƒ
Education and Smoking Cessation
Increase in proportion of SCRCCP-eligible patients offered respiratory or cardiac education
including smoking cessation support.
KPI:
% increase in the number of SCRCCP-eligible patients receiving education and
smoking cessation support
(target: 75% of SCRCCP-enrolled patients to receive self-management education).
31
FINAL DRAFT
3.4
SCRCCP Experience - Existing ‘SCRCCP-type’ Services in NSW
In NSW there are a handful of existing ‘SCRCCP-type’ services - developing and established - which
are similar in their objectives, methods and outcomes. These services have developed independently in
different healthcare settings, driven by local teams to suit local environments.
To date all commenced services have made significant inroads in terms of their common goals to
improve patient care and reduce the burden on the hospitals in their areas. Together they provide a
track record of demonstrated success.
The salient features and outcomes of these programs are highlighted in brief below.
3.4.1
The Respiratory Coordinated Care Program at St George Hospital, Kogarah NSW
Description
Established over a decade ago (1997) and enhanced by the Chronic Care Program in 2000, the St
George Respiratory Coordinated Care Program (RCCP) comprises a multi-disciplinary team of
specialist respiratory clinicians. The team is based in St George hospital but delivers over 95% of it’s
services to patients in the community(70).
Offsetting the costs of RCCP staff, whose positions were re-allocated from the respiratory ward to the
RCCP, the hospital closed five inpatient beds over the three months of summer and did not require
winter surge beds.
The service has two components:
1. An acute component facilitating early, protocol-driven discharge with follow-up care delivered in the
home by a specialist multidisciplinary outreach team.
2. A chronic component consisting of coordinated case management delivered in the home by the
specialist outreach team, featuring action plans and home management rather than ED attendance
and hospital admission.
Outcomes
The service has been an outstanding success(70). The average number of admissions per patient per
annum for the pool of chronic and complex patients in the program has decreased from over four
(average = 3.11) per annum to less than one (average = 0.63) per annum (see Figure 9), giving an
estimated annual saving of 3373 bed days* or 9.2 beds.
Figure 9: Average admissions (chronic patients) / year pre- and post-RCCP enrolment
7
6
Pre Enrolment
No. Admissions
5
Post Enrolment
4
3.11
3
2
1
0.63
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Av.
19982008
* Av adm rate 3.11 – 0.63 = 2.48 admissions saved per patient per year x av 200 patients/yr x NSW ALOS of 6.8 = 3373 bed days saved.
32
FINAL DRAFT
The readmission rate for acute patients in the acute program is virtually nil(70). With an average
number of patients of 140 per year, this confers a further saving of approximately 364 bed daysŧ.
The average length of stay (ALOS) for the acute component of the program (commenced 2001) to
2008 is 4.2 days(70) compared with a state average of 6.8 days (see Figure 10) giving a further saving
of 270 bed days∆.
Figure 10: Average Length of Stay: Acute / Early Discharge Component
8
6.8
7
6
Days
5
4.2
4
3
2
1
0
2001
2002
2003
2004
ALOS NSW (peer DRGs)
2005
2006
2007
2008
ALOS St George RCCP
Av.
20012008
In total, the reductions in hospital admissions and length of stay for both the acute and chronic
components of the program confer an average annual savings of approximately 3966 bed days, or
10.8 inpatient beds.
Approximate savings, St George RCCP
Program
Component
Chronic
Acute
Total Savings
Approx No. Bed Days Saved
(average / yr)
Approx No. Inpatient Beds
Saved (average / yr)
3332
9.1
(364 + 270) = 634
1.7
3966
10.8
The St George RCCP has influenced the development of similar - though newer - programs and pilot
services in NSW including the RCCP based at Prince of Wales Hospital, the Sutherland RCCP, the
Orange/Bathurst RCCP, and the ‘Respire’ program based at Royal Prince Alfred Hospital. A similar
service, the Respiratory Ambulatory Care Service, has been commenced at Westmead-Blacktown-Mt
Druitt Hospitals. The early outcomes of these services demonstrate reductions in presentations to
emergency departments, reductions in admissions, reductions in length of stay in hospital and
reductions in overall costs.
ŧ
State ALOS of 6.8 – St George RCCP ALOS (2006) of 4.2 = saving of 2.6 days per stay x 140 patients = 364 bed days
∆
6.8 (Av State ALOS for peer DRGs) - 4.2 (RCCP ALOS) = 2.6 x 104 patients = 270 bed days
33
FINAL DRAFT
3.5
Cost-Benefit Analysis
3.5.1
Savings
Table 1 below demonstrates that full implementation of this program at an institution with no existing comparable service and approximately 1500 SCRCCP-eligible
admissions per annum would result in potential gross savings (before costs) of approximately 15 inpatient beds. It is acknowledged that there may be some overlap of
benefit inherent across component estimations. Nonetheless, care has been taken to provide conservative estimates of overall benefit.
Table 1: Potential Savings (gross / before costs) for a hospital with approximately 1500 SCRCCP-eligible admissions* per year
Bed Day No. Inpatient
Savings /yr Beds Saved
Intervention Strategy
Target Outcomes
Early Discharge with Transitional Support
Reduced ALOS by 1.0 day for one third of SCRCCP-eligible
admissions
(St George RCCP reduced ALOS by 2.6 days/adm - data on
file 1998 - 2008)
1.7
615,000
II
1750 †
4.8
1,750,000
II
Heart Failure Patients
Reduced admission rates for a group of 100 (St George HF Service)
case-managed patients by at least 1.0 adm/pat/yr
(McAlister et al 2004(15) & Taylor et al 2005)(15, 17)
800 ¥
2.2
800,000
I
Pulmonary Rehabilitation
Increase in the number patients completing PR
from 5% to 20% (an overall factor of 15%)
75% reduction in admission rates (Puhan et al 2009)(43)
1181
3.2
1,181,000
I
Cardiac Rehabilitation
Increase in the number patients completing CR
from 25%(71) to 40% (an overall factor of 15%)
25% reduction in admission rates (Davies et al 2010)(62)
450
1.2
450,000
I
Self-Management Education and Smoking
Cessation Counselling
75% of SCRCCP-enrolled patients receiving education
(and, where necessary, smoking cessation intervention)
1 hospital admission saved for every 10 patients educated
(44)
(Effing etal 2007)
969
2.7
969,000
I
5765
15.8
5,765,000
Routine monitoring facilitating early detection
and intervention in the community setting
Respiratory Patients
Reduced admission rates for a group of 250 case-managed
patients by at least 1.0 admission/pat/yr
(St George RCCP reduced adm rates by 2.5 adm/pat/yr - data
on file 1998 - 2008)
Total Gross Savings
◊
Level of
Evidence
615 ŧ
Stratified Hospital in the Home / Case Management
*
ŧ
†
¥
Savings◊
($)
A list of SCRCCP-eligible admissions (DRGs) is given in Appendix A. For full details of the following calculations refer to spreadsheets (Appendix B).
33.3% of 1850 admissions = 615 bed days
250 respiratory patients x ALOS of 7.0 (actual 7.68) = 1750 bed days
100 heart failure patients x ALOS of 8 (actual 8.8) = 800 bed days
Standard medical bed cost (POWH Finance Dept) = $800 + $220 for path etc = $1020 /day or $372,300 /yr (a figure of $1000/day has been used in the above calculations)
34
FINAL DRAFT
3.5.2
Costs
Staffing Costs
Medical specialist involvement is required to provide dedicated support to the service, establish an
ambulatory clinic for rapid and appropriate medical review and undertake home visits if required.
Nurses and allied health staff with experience in managing patients with severe and complex
disease are required to cope with specialised testing and equipment (eg spirometry, NIV, CPAP,
oxygen, ECG analysis, auscultation of heart and lung sounds etc).
The RCCP at St George monitors about 250 chronic patients and provides an early discharge
program for both acute and chronic patients. It operates 7 days a week (0800 - 1630 hrs). Current
staffing for this patient load is as follows:
FTE
Position
1.0
Nurse Unit Manager
1.9
Clinical Nurse Specialists
1.2
Physiotherapists
4.1
Total
Other services such as social work, clinical
psychologist, dietician, etc are utilised as needed
(approximately 0.4 FTE in total).
However, given the increasing disease burden, the St George RCCP is under-resourced and
unsustainable. New patients are not admitted to the service until a vacancy arises; usually through
the death of an existing patient (the death rate for this high acuity group is about 25% per annum).
Services such as this require augmentation if they are to remain safe and effective alternatives to
in-hospital care.
Table 2 indicates the staffing and equipment levels required for a 5 day-a-week service with no
current staff / equipment available for deployment. As discussed above, most institutions have a
small nucleus of staff running their Chronic Care Program. Most of these units would need
additional funds to reach the level of staffing listed below, which is required to provide a sustainable
service. The staff budget listed below would enable most institutions to run a seven day service.
The full time equivalent (FTE) staffing rates have been estimated according to the patient volume
associated with the SCRCCP-eligible diagnosis related groups.
Table 2: Cost of a 5 day per week service for a hospital with approximately 1500 admissions per year
with no current staff / equipment available for deployment (or a 7 day service for those
services with existing resources)
Resp Cardiac Total
FTE
FTE
FTE
Position
Physician** (specialist or general
with interest), GP, CMO or
registrar with interest
Nurse Unit Manager / CNC
or Nurse Practitioner (add $10,000)
Award
Award
+18% on($)
costs
Revenue
218,300
174,640
64,000
110,640
Total
Cost
0.6
0.2
1
1
2
95,000
112,100
224,200
0
224,200
1
1
2
80,000
94,400
188,800
0
188,800
Registered Nurse
(>8th year)
2.4
1
3.4
69,000
81,420
276,828
0
276,828
Physiotherapist*
(outreach, level 4)
2.5
1
3.5 106,000
125,080
437,780
0
437,780
Occupational Therapist
(level 4)
0.6
0.2
0.8 106,000
125,080
100,064
0
100,064
Clinical Psychologist
0.4
0.2
0.6 101,000
119,180
71,508
0
71,508
8.5
4.6
Clinical Nurse Specialist
Totals
0.8 185,000
Costs
(Resp +
Cardiac)
13.1
$1,409,820
*
In some settings - particularly non-metropolitan NSW - certain allied health disciplines (eg physiotherapy) may not be represented in
the local clinical team. Instead, a generic allied health equivalent is recommended in these situations.
**
Costed at the level of Consultant Physician (Senior Staff Specialist)
35
FINAL DRAFT
Ancillary Costs
Item
Cost ($)
6 Leased cars (including running costs for 12 months)
90,000
Mobile phones (purchase + running costs for 12 months) @ $100/m x 12 FTE
14,400
Computers / printer / fax / equipment @ $3,000 x 12 FTE
36,000
Medical equipment (O2 monitors, portable spirometer, PEP devices, cardiac
stethoscopes, ECG machine, blood glucose monitors, portable weighing scales etc)
20,000
Consumables/stationery/etc
4,000
Total
$164,400
Total Staffing and Ancillary Costs for a hospital with approx 1500 admissions per year:
Total Staffing
1,409,820
Total Ancillary
164,400
TOTAL COST
$1,574,220
3.5.3
Cost-Savings Equation
A comparison of the total annual costs and potential savings of a fully funded SCRCCP at a hospital
with approx 1500 SCRCCP-eligible admissions per year is provided in Table 3. Conservative
calculations suggest that a properly funded and staffed Severe Chronic Respiratory & Cardiac Care
Program has the potential for substantial net savings.
Table 3:
*
Financial equation for a hospital with approx 1500 chronic SCRCCP-eligible
admissions per year:
TOTAL COSTS
1,574,220
TOTAL (POTENTIAL) SAVINGS*
5,765,000
NET GAIN
$4,190,780
It is acknowledged that potential savings only become actual savings when the costs of
providing prior services are removed from the overall budget of a hospital / health service. The
costs of the Respiratory Coordinated Care Program at St George Hospital were met by closing
5 inpatient beds over the summer months.
The experience of the St George RCCP, and other more recently established services in NSW, is
that projected savings are realised within 6 to 12 months of program implementation. This assumes
recruitment of all staff and full service deployment within that timeframe.
An estimation of the potential financial impact on individual hospitals in NSW, according to their
current admission rates, is provided in Table 4 below.
36
FINAL DRAFT
Table 4:
Financial Equation for Severe Chronic Respiratory & Cardiac Care Program for
NSW Public Hospitals with the Top 40 number of SCRCCP-Eligible Admissions*
Hospital
Number of
Separations
Bed Days
Saved
Number of
Beds
Saved
Total Gross
Savings
($)
Total Costs
($) (Sep
weighted)
Potential Net
Savings
($)
5,003,635
Gosford
1791
6,883
18.9
6,883,253
1,879,619
Theoretical Hospital (1500 adm / yr)
1500
5,765
15.8
5,764,869
1,574,220
4,190,649
St. George
1488
5,719
15.7
5,718,750
1,561,626
4,157,124
Royal Prince Alfred
1452
5,580
15.3
5,580,393
1,523,845
4,056,548
Blacktown
1441
5,538
15.2
5,538,117
1,512,301
4,025,817
Westmead (all)
1384
5,319
14.6
5,319,052
1,452,480
3,866,572
Prince of Wales
1216
4,673
12.8
4,673,387
1,276,168
3,397,219
Wyong
1215
4,670
12.8
4,669,544
1,275,118
3,394,426
Wollongong
1183
4,547
12.5
4,546,560
1,241,535
3,305,025
Liverpool
1173
4,508
12.4
4,508,127
1,231,040
3,277,087
John Hunter
1138
4,374
12.0
4,373,614
1,194,308
3,179,306
Nepean
1109
4,262
11.7
4,262,160
1,163,873
3,098,286
Bankstown/Lidcombe
1014
3,897
10.7
3,897,051
1,064,173
2,832,879
Campbelltown
1014
3,897
10.7
3,897,051
1,064,173
2,832,879
Theoretical Hospital (1000 adm / yr)
1000
3,843
10.5
3,843,246
1,049,480
2,793,766
Concord
955
3,670
10.1
3,670,300
1,002,253
2,668,046
Royal North Shore
929
3,570
9.8
3,570,375
974,967
2,595,409
Newcastle Mater
805
3,094
8.5
3,093,813
844,831
2,248,982
Mount Druitt
761
2,925
8.0
2,924,710
798,654
2,126,056
St. Vincents - Public
751
2,886
7.9
2,886,278
788,159
2,098,118
Tweed Heads
729
2,802
7.7
2,801,726
765,071
2,036,655
Canterbury
695
2,671
7.3
2,671,056
729,389
1,941,667
Sutherland
688
2,644
7.2
2,644,153
722,042
1,922,111
Fairfield
681
2,617
7.2
2,617,250
714,696
1,902,555
Shellharbour
626
2,406
6.6
2,405,872
656,974
1,748,897
Shoalhaven
617
2,371
6.5
2,371,283
647,529
1,723,754
Coffs Harbour
613
2,356
6.5
2,355,910
643,331
1,712,578
Ryde
607
2,333
6.4
2,332,850
637,034
1,695,816
Mona Vale
606
2,329
6.4
2,329,007
635,985
1,693,022
Wagga Wagga
591
2,271
6.2
2,271,358
620,243
1,651,116
Hornsby
583
2,241
6.1
2,240,612
611,847
1,628,766
Dubbo
576
2,214
6.1
2,213,710
604,500
1,609,209
Tamworth
553
2,125
5.8
2,125,315
580,362
1,544,953
Manly
538
2,068
5.7
2,067,666
564,620
1,503,046
Children's Hospital Westmead
537
2,064
5.7
2,063,823
563,571
1,500,252
Lismore
517
1,987
5.4
1,986,958
542,581
1,444,377
Port Macquarie
501
1,925
5.3
1,925,466
525,789
1,399,677
Theoretical Hospital (500 adm / yr)
500
1,922
5.3
1,921,623
524,740
1,396,883
Manning
484
1,860
5.1
1,860,131
507,948
1,352,183
Maitland
473
1,818
5.0
1,817,855
496,404
1,321,451
Orange
447
1,718
4.7
1,717,931
469,118
1,248,813
Auburn
441
1,695
4.6
1,694,871
462,821
1,232,051
Bowral
438
1,683
4.6
1,683,342
459,672
1,223,669
Data Sources:
(72)
Admissions data obtained from Health Information Exchange (HIE), May 2007
Bed costs obtained from POWH Finance Department
(73)
Data on average number of admissions / patient / yr (n=1.23) was obtained from the Health Round Table database .
For full details of calculations refer to spreadsheets (Appendix B).
* SCRCCP-eligible admissions are listed in Appendix A
37
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3.6
Workforce Education and Training
There are several options available to assist with the training requirements of an enhanced
SCRCCP workforce. Briefly, the existing training programs available include:
ƒ
Specialist education programs through the College of Nursing
ƒ
The College of Nursing also offers a dedicated distance education course for respiratory
nursing, and a number of other respiratory-specific modules.
ƒ
The NSW Respiratory Nurses Special Interest Group offers hospital-based respiratory nursing
courses and on-going education.
ƒ
The Cardiovascular Health & Rehabilitation Association of NSW and Australia provide on-going
education and collaboration for all health professionals.
ƒ
The Australasian Cardiovascular Nursing College provides on-going education for nurses
working in all settings of cardiac nursing in Australia.
ƒ
The Cardiac Society of Australia and New Zealand provides ongoing education for all health
professionals working in cardiology areas.
ƒ
The National Heart Foundation of Australia provides on-going education such as workshops
specific to understanding and managing depression in cardiac patients.
ƒ
The Smoking Research Unit of the Brain Mind Research Institute, University of Sydney, offers a
three day training course for healthcare clinicians with an interest in smoking cessation, nicotine
addiction and evidence based smoking cessation techniques.
ƒ
The Asthma and Respiratory Educators Association offers educational workshops
ƒ
The University of Sydney’s Discipline of Physiotherapy offers an undergraduate or graduate
entry Masters program which includes cardiopulmonary components.
ƒ
Cardiorespiratory Physiotherapy Australia (Part of the Australian Physiotherapy Association)
conducts on-going professional training and education
ƒ
The Thoracic Society of Australia and New Zealand offers educational workshops
ƒ
Charles Sturt University offers distance learning modules
ƒ
The Lung Health Promotion Centre conducts continuing education accreditation: CPD points
with RACGP, CPE points with Pharmacy Assoc, CEP points with AAREA
ƒ
The Pulmonary Rehabilitation Toolkit (http://www.pulmonaryrehab.com.au) provides web-based
training modules in pulmonary rehabilitation.
ƒ
Through their ‘Lungs in Action’ and ‘Heart Moves’ programs the Australian Lung Foundation and
the Australian Heart Foundation sponsor training and accreditation of local professional fitness
instructors and exercise physiologists to offer community based exercise classes. Community
based exercise programs are tailored for people with chronic disease and provide a local
referral destination for patients to extend the benefits of pulmonary and cardiac rehabilitation by
maintaining levels of physical activity.
38
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3.7
Implementation
3.7.1
Specialist Services
Existing services operating successfully as single-specialty entities (that is, as respiratory or cardiac
services alone) should be encouraged to continue unchanged and, if insufficiently resourced,
remain eligible for enhancement funding that may ensue from this submission. Whilst combined
care (cardiac + respiratory) and shared care (specialist + generalist) models may be suitable for
patients with lower-level acuity illness, patients with severe and complex disease - particularly those
enrolled in hospital outreach programs - are ideally managed by, or in close conjunction with,
specialist clinical teams.
The implementation process can be achieved efficiently because most hospitals in the state have
already established a nucleus of multidisciplinary respiratory and cardiac specialist clinicians as a
result of the Chronic Care Program (CCP). The allocated funding for the CCP was sufficient for
most institutions to employ one or two staff and to implement limited pulmonary rehabilitation
services. However, such services are substantially under-resourced and unsustainable at current
staffing levels.
Wherever possible, the proposed service enhancements outlined in this document would be
undertaken by an expansion of the existing chronic care teams.
3.7.2
Combined Care and Shared Care Services
The model recognises and accepts wide variation in resources and clinical care across NSW and is,
therefore, flexible so that it may be adapted by local clinical teams to suit existing service
configurations and population need. In practise this will mean different things in different clinical
settings. In some settings, synergies and efficiencies may be achieved by funding and delivering
respiratory and cardiac failure services ‘together’; that is, side-by-side.
Joint models may help to avoid duplication of services and allow sharing of common resources
such as, for example, occupational therapy, dietetics, clerical staff etc. In some sites gym space
and equipment might be shared.
Variations of the model will have potential application in settings where the majority of patient care
is provided by generalist clinicians, such as in much of non-metropolitan NSW.
39
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3.7.3
Implementation of New Services
In settings where established respiratory and cardiac-specific services have not been developed,
employment of a temporary project officer to assist with the development of local protocols, creation
of links with centres of excellence, and organise training opportunities etc, in conjunction with local
clinicians, may assist the set-up phases of program implementation.
For new services, local implementation could proceed according to the following phased approach:
Phase 1:
Development, where necessary, of the following service prerequisites:
ƒ
local clinical protocols and tools (adapted from existing if feasible)
ƒ
links with established centres of excellence
ƒ
access to clinical training programs
ƒ
information management system to facilitate the collection, storage, and
analysis and of program-related data
A temporary project officer - preferably a local clinician - could be seconded from
their substantive clinical role to undertake these tasks.
Phase 2:
Seeding funding for staffing and equipment to facilitate the commencement of local
services across NSW
Phase 3:
Program / local service evaluation after 12 months of operation
Phase 4:
Outcomes-based program refinement
3.7.4
Virtual Units
It is envisaged that variations of the model will have potential application in settings where the
majority of patient care is provided by generalist clinicians, such as in much of non-metropolitan
NSW.
In this regard it is thought that, in some instances, SCRCCPs may function as ‘virtual units’, a
concept introduced by commissioner Garling in his report(2). Virtual respiratory units may consist of
a multidisciplinary team of three to four clinicians, each based at different sites, rather than the
traditional model of a physical unit in a fixed location with dedicated staffing and beds etc.
In these settings the development of local clinical tools and protocols is particularly important.
Equally, strong links with established centres of excellence are necessary so that specialist and
sub-specialist input can be provided or arranged as required. Additionally, improved access to
clinical training programs for non-metropolitan and other generalist clinicians will be needed.
40
FINAL DRAFT
4.
CONCLUSION
Chronic respiratory and cardiac diseases are responsible for a large and increasing burden of
disease in NSW. To cope with this problem clinical management practices should become less
reactive and more anticipatory.
This proposal provides best-practice advice to the NSW Department of Health and the NSW
Area Health Services on an adaptable model of care; a Severe Chronic Respiratory & Cardiac
Care Program (SCRCCP), as described in this paper. The proposal points to a more productive
approach in the determination to find a balance between specialist and generalist services by
promoting integrated hospital and community care, and integrated specialist and generalist
clinical teams.
The SCRCCP model described in this proposal recommends the transfer, where appropriate, of
specialist care out of hospital and into the community. The model shifts the management of
patients with known progressive disease towards regular, community-based monitoring,
facilitating early detection of disease deterioration and pre-emptive intervention strategies. A
range of coordinated strategies encompassed in the SCRCCP comprise a seamless interface
between in-patient and community services, linking with GPs and other services where
appropriate.
The SCRCCP model recognises and accepts wide variation in resources and needs across
clinical settings in NSW and is flexible in order that it may be adapted by local clinical teams to
suit existing service configurations and population need.
An implemented SCRCCP has the potential to improve patient outcomes, significantly reduce
presentations to hospital emergency departments, reduce hospital admissions, reduce the
length of stay for those who are admitted to hospital, and achieve substantial savings in both
bed days and overall costs.
41
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45
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6.
APPENDICES
APPENDIX A: SCRCCP-Eligible Diagnosis Related Groups (DRGs)
Code
Description
E40Z
Respiratory System Diagnosis W Ventilator Support
E60A
Cystic Fibrosis W Catastrophic or Severe CC
E60B
Cystic Fibrosis W/O Catastrophic or Severe CC
E62A
Respiratory Infections/Inflammations W Catastrophic CC
E62B
Respiratory Infections/Inflammations W Severe or Moderate CC
E62C
Respiratory Infections/Inflammations W/O CC
E65A
Chronic Obstructive Airways Disease W Catastrophic or Severe CC
E65B
Chronic Obstructive Airways Disease W/O Catastrophic or Severe CC
E69A
Bronchitis and Asthma Age >49 W CC
E69B
Bronchitis and Asthma Age >49 or W CC
E71A
Respiratory Neoplasms W Catastrophic CC
E71B
Respiratory Neoplasms W Severe or Moderate CC
E74A
Interstitial Lung Disease W Catastrophic CC
E74B
Interstitial Lung Disease W Severe CC
E74C
Interstitial Lung Disease W/O Catastrophic or Severe CC
F62A
Heart Failure & Shock W Catastrophic or Severe CC
F62B
Heart Failure & Shock W/O Catastrophic or Severe CC
46
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APPENDIX B: Admissions and Cost-Savings Analysis: Data and Calculations
by Hospital
[Data available on request: [email protected]]
47