“CHAMP” Collaborative chronic disease hospital avoidance pilot in Northern Adelaide Anna Brennan, Senior Manager of Physiotherapy, Northern Adelaide Local Health Network.

We would like to acknowledge this land is the traditional lands for Kaurna people and that we respect their spiritual relationship with their country. We also acknowledge the Kaurna people as the custodians of the Adelaide region and that their cultural and heritage beliefs are still as important to the living Kaurna people today. Physio – as student placement at Arth F with Arthritis Self Help Course – first lightbulb moment Kidney Disease Education day in 2004 – Mignon presented on Flinders Model – C of C AT in 2005, courses at work with dialysis and respiratory staff FHBHRU 2007-2010 including ABHI and management since – 2 years ago Potentially Preventable Admissions Directors

NALHN Location Multiple sites including 2 hospital and 2 GP Plus Sites with staff involved in this program (N and NE)

Collaborated with Medical and

… “reduce the PPA’s” … People with Diabetes, cardiac and respiratory disease Reduction in preventable admissions Use of redistributed resource (including redistributed staff) 12 months to determine if endorsement would continue

Cardiac/Heart Failure Services Respiratory Services -Medical -Nursing -Pulmonary Rehab -Allied Health discipline 1:1 and group intervention Direct interface with tertiary services eg. Resp Nursing, Home O2, PFT. Diabetes Services -Nursing -Allied Health discipline 1:1 and group intervention Direct interface with tertiary services eg. Hospital Diabetes Centre, Endocrinology, Multi-disciplinary High Risk Foot Clinic Cardiac/Heart Failure Services -Medical -Nurse Practitioner -Exercise Physiology -Allied Health discipline 1:1 and group intervention Direct interface with tertiary services eg. Cardiology, Chest Pain Assessment Service Hep C Services -Nursing -Allied Health discipline 1:1 and group intervention Direct interface with tertiary services eg. Gastroenterology, Infectious Diseases. CHAMP Case management and self management support for ‘high admission risk’ disease service clients (plus ‘vulnerable people’ with other Chronic Disease) Collaboration with AH, Med and Nursing to develop plans – staff from dissolved Primary Health Care Directorate (AH and N) working with existing disease management teams, and plans for a new Physician rapid access clinic ?CHAMP

Original aim 6-12 weeks as per org expectation

Implementation: Challenges and Enablers Workforce Skill mix Continual change Cross network services Data collection Workforce- some permanent re-deployees or those who had ‘hospital takeover’, majority of staff on rolling 3 monthly contracts Skill mix– many with skills from ABHI/DIFL etc, but not complex disease management and vice versa, Continual change Cross network services Data collection

What we really did…

Early Outcomes 60 patients (mean age 64) Comparison of equivalent period pre and post program (median 5 months) Admissions Admissions dropped from 135 to 64 (53% reduction) Occupied Bed Days 518 days pre to 345 post program (33% reduction) First 60 patients completed the program Av age 64, ranging from 45% between 40-65, age range from 31-84, median 57.5) Pre –post ranged from 3-7 months Most common primary diagnosis COPD 67%, diabetes 21%, heart failure 5% but 76 had multiple comorbidities identified PIH – not all data available, 26% had all low scores – issues with use – but – of a group with high scores 45% (5) improved to 4 or below for all questions, 45% (5) in some but not all and 9% (1) did not improve

“It was very beneficial, very useful, I learned how to deal with asthma and diabetes management better and am now I’m looking at building my life by addressing my relationships, depression, self esteem and life ahead in general”

What’s next? Staff recruitment and training Review of service – including consumer involvement Efficient client identification process Better outcome collection & analysis Service Integration

CDMU Proposed Service model

Reflections… Mirrors SMS process Even if things don’t change this time, is it a waste of time? Taking action to move towards achieving the goal is important- even if you can’t achieve it all now. Use of the Flinders Program forced better practice (even when not perfect)

Thankyou Anna.Brennan@sa.gov.au Mirrors SMS process Even if things don’t change this time, is it a waste of time? Taking action to move towards achieving the goal is important- even if you can’t achieve it all now. Use of the Flinders Program forced better practice (even when not perfect) Anna.Brennan@sa.gov.au

Champ Activity