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Heart to Heart: Partnering Patients with their Healthcare

Blacktown Mount Druitt Hospital (Blacktown Campus)Blacktown Mount Druitt Hospital (Mount Druitt Campus)
Project Added:
5 December 2014
Last updated:
8 December 2014

Heart to Heart: Partnering Patients with their Healthcare

Blacktown and Mount Druitt Hospital, Western Sydney Local Health District (WSLHD)

Summary

The Heart to Heart: Partnering Patients with their Healthcare is a project that aims to work with acute, community and primary care services to better support patients with chronic heart failure to live well, at home.

Download a poster of this project from the Centre for Healthcare Redesign School graduation, December 2014.

Aim

To support patients (and their carers) with chronic heart failure living in Western Sydney to live well at home; and improve their health outcomes and experience of care over the lifetime of their illness.

The project objective is to reduce potentially preventable admissions of patient with chronic heart failure under the care of a cardiologist at Blacktown Hospital from 84% to 70% by October 2015.

Benefits

  • Improved co-ordination of healthcare between primary, secondary and tertiary services.
  • Improved access to healthcare that supports patients with chronic heart failure in the community.
  • Improved experience of care for patients and their carers.
  • Reduced unwarranted variations of care and increased visibility of care.
  • Enhanced secondary prevention strategies for chronic heart failure.
  • Patients connected with services relevant to their co-morbidities.
  • Make it easier for community and acute care staff to do their job.

Background

Chronic heart failure (CHF) is a complex and disabling disease with increasing prevalence in Australia, affecting 10% of people over the age of 65 and an estimated cost of $1 billion per annum (National Heart Foundation 2011). 

CHF hospitalisations are potentially preventable when patients have timely access to healthcare services; receive evidence based, co-ordinated care across the continuum of primary, secondary and tertiary services.

Data analysis at Blacktown and Mount Druitt Hospital (BMDH), Western Sydney Local Health District (WSLHD), identified 84% of 2012/13 CHF admissions were Potentially Preventable Admissions (PPA), with a 28 day re-admission rate of 28%. Activity projections for CHF admissions at Blacktown Hospital suggest a 90% increase from 2010/11 to 2026/27, which will require an additional seven beds per annum. 

Patients with CHF in Blacktown and Mount Druitt told us of their experience of living on borrowed time, that they have limited understanding of CHF and self-management and experience high levels of anxiety and frustration at limitations.

Diagnostics identified that:

  • Follow up calls 48 hours post discharge identified:
    • 80% of patients did not have general practitioner (GP) appointment
    • 80% had changes to medications, but only 40% had a supply
    • None had attended to basic self-management post discharge
  • Only 1% of discharge summaries were available to GPs electronically
  • Communication between healthcare services is fragmented and the system is difficult to navigate; care is poorly co-ordinated; and patients are inadequately supported in self-management.

Heart to Heart: Partnering Patients with their Healthcare has worked with patients, carers and healthcare staff to identify a number of strategies that will better support patients to live well at home, improve their health outcomes and experience of care over the lifetime of their disease.

Implementation

  1. Development of e-documentation and e-referrals for the chronic heart failure service that will be incorporated into the new Paperlite electronic medical record at Blacktown Hospital. It is envisaged that this will also be able to be sent to the Personally Controlled Electronic Health Record (PCeHR) into the future.
    1. Increasing the enrolment of GPs for patients known to cardiology at Blacktown Hospital from 24% to 80% by October 2015
    2. Increasing the number of CHF patients with a PCeHR
    3. Improving the processes being used to develop e-discharge summaries by Blacktown medical staff
  2. Increasing the number of e-discharge summaries being sent out to GPs from 1% to 80% by October 2015:
    1. Aim: 80% of patients with CHF discharged from Blacktown Hospital with an electronic self-management plan available to patients, carers, community and acute staff and sent with discharge summary to GPs.
  3. Electronic Self-Management Action Plan:
    1. Aim: 80% of patients with CHF discharged from Blacktown Hospital are referred to Connecting Care for a Service Needs Assessment, telephone health coaching and referral to other chronic disease services.
  4. Connecting Care referral:
    1. Aim: 95% of patients discharged with CHF from Blacktown Hospital receive a 48 hour follow up call to mitigate risk of 28 day re-admission and provide self-management support.
  5. 48 hour follow up calls:
    1. Aim: 80% of CHF patients known to Blacktown Hospital enrolled on an e-register to inform relevant healthcare staff of patient presentation, admission and discharge to facilitate better discharge planning and identify patients for appropriate early discharge.
  6. Chronic Heart Failure register:
    1. Aim: 80% of CHF patients known to Blacktown Hospital enrolled on an e-register to inform relevant healthcare staff of patient presentation, admission and discharge to facilitate better discharge planning and identify patients for appropriate early discharge.
  7. Promotions and communication: to promote chronic heart failure services to staff, community and patients; promote ‘go live’ dates for solutions; increased awareness of CHF in primary care, community and services designed to support patients and carers. 

Evaluation 

Currently, there are a number of process and outcome evaluation strategies planned for each solution. 

Early evaluation has identified clinician and patient involvement in the redesign process has facilitated local networking, development of capability in change management and redesign of clinical roles to facilitate transition of patients from hospital to primary care including increased home visits from two to nine a week. Organisational commitment of a project officer facilitates ongoing solution implementation and evaluation.

Partnerships 

  • Western Sydney Medicare Local
  • NSW eHealth team
  • Local GP practices
  • Acute and Community services within Western Sydney Local Health District
  • ACI Centre for Healthcare Redesign (CHR) Program

Lessons Learnt 

There are inherent challenges with multi-sector partnerships associated with variable funding models and resistance to change. Through early clinician and patient involvement in the redesign process, development of a shared vision, active sponsorship and a clear case for change connected to local priorities, we have been able to demonstrate the gains to be made through working in partnership to improve patient outcomes.

References 

National Heart Foundation of Australia. 2013. A systemic approach to chronic heart failure care: a consensus statement.

National Heart Foundation of Australia. 2011. Guidelines for the prevention, detection and management of chronic heart failure in Australia; updated 2011.

Acknowledgements

  • Professor Sindone and his team at Sydney Local Health District for allowing us to visit and speak with the patients and staff of the Cardiac Rehabilitation and Cardiac Chronic Care Service.
  • St Vincent Hospitals Chronic Heart Failure services for allowing us to visit and learn about their Chronic Heart Failure service and program. 
  • Project Sponsors, Andrew Newton, David Simmonds and Prof A.R. Denniss who have been truly committed to the Heart to Heart project, and incredibly supportive to the project team and stakeholders.
  • The staff of the acute, community and primary care sectors who generously offered their time, energy and enthusiasm to bring this project to life. 
  • Finally, we would like to thank the patients and carers with Chronic Heart Failure in Western Sydney for their time in sharing their personal experiences of living with Chronic Heart Failure so that we might improve how we support them to live well at home.

Contacts

Remia MoradaHeart to Heart Implementation Project Officer
Blacktown and Mount Druitt Hospital
Western Sydney Local Health District
Remia.Morada@health.nsw.gov.au

Naomi Van SteelInnovation and Redesign Project Officer
Blacktown and Mount Druitt Hospital
Western Sydney Local Health District
Phone: 0417 252 448
Naomi.VanSteel@health.nsw.gov.au

Julie JonesHealth Services Planning and Development
Blacktown and Mount Druitt Hospital
Western Sydney Local Health District
Phone: 0423 820 748
Julie.Jones@health.nsw.gov.au

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