Chronic Condition Hospital Avoidance Management Program (CHAMP) Northern Adelaide Local Health Network Presenters: Emma Elix, Mirella Kakogianis HRT 1721‘Allied Health Improvement Group’ 25-26 October 2017 Adelaide

Key Problem Chronic conditions are the leading cause of illness, disability and death in Australia (Australian Institute of Health and Welfare 20141) Within NALHN there is a significant cohort of clients who have multiple chronic diseases , complex psychosocial issues and socio-economic disadvantage, increasing their burden of disease, vulnerability and likelihood of presenting to hospital The underlying triggers of hospital admissions are often not only medical and relate to unhealthy lifestyle behaviours, social isolation and financial difficulties In 2015 there was a NALHN executive decision that more needed to be done to assist patients and families to better manage chronic conditions, improve quality of life and overall health and reduce the pressure placed on inpatient occupancy levels and bed flow Source: 1. Australian Institute of Health and Welfare 2014. Australia's Health 2014. Australia's health series no.14. Cat.no.AUS 178.Canberra:AIHW © 2017 Confidential Draft Discussion Document

Aim of this innovation The Chronic Conditions Hospital Avoidance Management Program (CHAMP) was established in 2015 The program was designed to better meet the needs for clients with complex multiple chronic diseases like diabetes, chronic respiratory illnesses and cardiac conditions The program was designed to reduce the costs and burden on the hospital system through: reductions in hospital admissions, reduced LOS, shifting client care to more appropriate community services and increased engagement with General Practice   What were you aiming to achieve? What was the improvement you were seeking? One slide The Chronic Diseases Management Unit (CDMU) was established in 2015 to bring together the work done by nursing, allied health and medical leads to help people manage conditions like diabetes, chronic respiratory illnesses, and viral hepatitis and cardiac/heart conditions. The coordination of services aims to reduce unnecessary hospital admissions and reduce the length of stay where a hospital admission is required. © 2017 Confidential Draft Discussion Document

Baseline Data In 2014 the admission rate of preventable admissions in NALHN was 13.2%, with a 6.7% proportion linked to chronic diseases1 Current LHN Target: Potentially preventable admissions target 8.5%3 Sources: 1. NALHN 2014-15 Potentially Preventable Admissions (PPAs) 2014-15 Casemix Funded Activity (FINAL as of 27/07/2015) 3. NALHN Service Level Agreement 17/18 © 2017 Confidential Draft Discussion Document

Key Changes Implemented The Chronic Condition Hospital Avoidance Management Program (CHAMP) provides direct therapy service, disease management and self-management support to clients who have chronic diseases and are at high risk of hospital admission The LACE Index scoring tool was introduced to determine the level of risk for hospital readmission post discharge in order to prioritise referrals based on risk of readmission CHAMP patients are linked with a case manager– who is responsible for assisting the patient to identify self management needs/goals, overcoming barriers, assist with improving self management skills, maintain motivation, and helping to link the patient into other services as needed The LACE index scoring tool is a validated means to determine the level of risk for hospital readmission post discharge. The LACE index identifies patients that are at risk for readmission or death within thirty days of discharge. It incorporates four parameters. “L” stands for the length of stay of the index admission. “A” stands for the acuity of the admission. Specifically, if the patient is admitted through the Emergency Department vs. an elective admission. “C” stands for co-morbidities, incorporating the Charlson Co-Morbidity Index. “E” stands for the number of Emergency Department visits within the last 6 months. LACE scores range from 1-19 and as mentioned above predict the rate of readmission or death within thirty days of discharge. Below is an example of how to calculate the LACE index. A score of 0 – 4 = Low; 5 – 9 = Moderate; and a score of ≥ 10 = High risk of readmission. © 2017 Confidential Draft Discussion Document

Outcomes so far A client centred, self management program can reduce occupied bed days and reduce length of stay Champ hospital avoidance outcomes (Clients from July2016-June2017) Pre Champ Data No. Post Champ Data Difference Pre and Post Champ % Difference % Pre Champ Admission OBD days 502.3 Post Champ Program Admission OBD days 105.72 Difference in OBD for pre and post champs 396.58 Percentage Change in OBD 79% Number of patients for these admissions 30 Number of Patients for these admissions 15 Difference in number of patients admitted Percentage change in number of patients admitted 50% Number of admissions 143 37 Difference in the number of admissions pre champ and post champ 106 Percentage of change in the number of admissions pre champ and post champ 74% Total Number of Champs Patients in reporting period 36 Bed Days Saved: 396.6 Beds Saved @ 100% Occupancy: 1.09 Hospital separations and LOS are counted up to 12 months prior to start date of CHAMP (except for patients where Report Date is less than 12 months following program end). For these patients, separations are counted for the same time period before as in after. Separations After Program counted up to 12 months following end date. Approx. cost saving $250 000 + Hospital separations and LOS are counted up to 12 months prior to start date of CHAMP (except for patients where Report Date is less than 12 months following program end). For these patients, separations are counted for the same time period before as in after. Separations After Program counted up to 12 months following end date. © 2017 Confidential Draft Discussion Document

Outcomes so far – cont. The Flinders Program PIH and K10 initial and discharge scores are currently being captured with a view to analyse outcomes of client behaviour change CHAMP won the 2016 SA Health Awards for Out of Hospital Strategies and Care © 2017 Confidential Draft Discussion Document

Lessons Learnt Development of a clear care plan based on PIH and initial K10 is important to ensure goals established are client directed and ensures client has clear understanding of service scope / timeframes Robust engagement and referral pathways are essential with external service providers to facilitate timely and appropriate access to community health and support services To ensure validity of outcome measures sophisticated data capture systems, clear business rules, staff education and compliance monitoring are required For more information Contact: Mirella Kakogianis or Emma Elix Tel: 0477343632 (Mirella), 0466397663 (Emma) © 2017 Confidential Draft Discussion Document