Does readmission equate to a “failed discharge”? Helen Zisos & Kaushalya Samaraweera Social Work Department HSWDG Research Symposium 2016

Project Background Ageing Population – impact of baby boomers GEM patients are discharged home with risk Increased rate of readmission GEM LOS and patient flow

Drivers Travis Review (2015) Victorian Auditor-General’s Report (2016) Statement of Priorities (2015-16) Health Round Table Productive Ward/Lean Redesign

SVHM Strategic Direction - enVision 2025 Seamless continuum of care Person centred care Innovative and best practice models of delivery

Project Aims To identify the risk factors that may contribute to readmission Strengthen how SW can profile contribution to patient flow Inform areas of practice change to reduce rate of readmission

Evidence Demand for public hospital services is expected to increase at a faster rate than funding for capacity (Travis, 2015) Older patients aged over 65 have significantly higher rates of hospital admission and readmission and account for 52% of hospital readmissions in Australia (Courtney et al, 2009) Older Australian’s have more health conditions, more hospital separations and stay longer than younger age groups (Brown, Abello & Thurecht, 2011) The burden of ill health among older people can be reduced or prevented by adequately addressing specific risk factors (WHO, 2016)

Risk factors for older people Multiple comorbidities including chronic illnesses Multiple previous hospital admissions in the year leading up to readmission Cognitive impairment/dementia Polypharmacy Poor mobility/falls

Methodology (n = 25) Ritchie & Spencer Framework (2001) Retrospective data analysis - quantitative and qualitative Sample included patients readmitted to hospital within 28 days of being discharged home during a 6 month period from July to December 2014 Low risk ethics approval Engagement with key stakeholders

Data mining approach (Epstein 2011) Data mining tool consisted of 35 elements: Demographics Psychosocial attributes Medical issues/cognition/function Reason for readmission LOS and length of time between discharge and readmission Risk factors identified by health professionals during admission

Evaluative & Diagnostic Results (n = 25) 80% were 76 years or older 68% were CALD 44% were male 56% were female 48% lived alone 52% lived with family 44% had a carer 50% had cognitive impairment 80% had 5 + comorbidities Clear contextual information about risk factors Clinicians are working with high levels of risk Patient-centred, multi-disciplinary approach to care planning SW are exploring the least restrictive discharge plan Readmission within 28 days in not necessarily a negative thing Evaluative & Diagnostic Contextual Strategic 76% had between 1-3 previous admissions 52% had 10 days or less at home between discharge and readmission 72% had a GEM admission of 15 days or less 92% were readmitted because of an acute medical illness 100% of the time, SW completed a comprehensive assessment and d/c plan

Qualitative Results Lack of insight Cognitive impairment impacting on function Impulsivity Social isolation Refusing formal supports

Case Example 87 year old female CALD background Lives with son who has mental health issues No formal supports Deemed to have capacity - (emerging) cognitive impairment History of falls At risk of elder abuse

Social Work Intervention Suspected elder abuse – physical, financial, verbal Refusal of formal supports Acceptance of her own limitations and risk Poor home environment/hoarding/staff safety Social isolation Non-compliant with medical treatment and recommendations Longstanding family conflict Multiple presentations to ED & GEM (18+ in 2014) Least restrictive vs patient autonomy

Future Directions Further analysis of data – how can we improve? Is there a correlation between reason for admission and readmission? Readmission tool to avoid duplication of social work assessment