20,000 Days Campaign Storyboard Learning Session 3, 11-12 March 2013 VHIU Link Team Professor Harry Rea (Clinical Lead ) Ta-Mera Rolland (Operations Manager) Nurses Pharmacists Physiotherapists Occupational therapists Social Workers Locality Coordinator Administration 20,000 project support team Links with: Cultural Support Mental Health Other Specialist teams

Aim To increase the number of patients enrolled into the Very High Intensive User programme (VHIU) from 120 cases to 600* cases by July 2013. This will result in a reduction in unplanned presentation and admission to Middlemore Hospital. *Goal of 600 includes: GP Referrals: 200 cases 5 Flag referrals: 400 cases

Driver Diagram - Include Collaborative Driver Diagram

5 Flag Process Change Packages Secondary Drivers (Theory of change) Change Ideas Tested Describe Process Screening and Triage . Process has been standardise to ensure consistent assessment and review of all patients Risk Assessment Guide (RAG) Improved the existing RAG form to include information relating to language and health literacy to enable more comprehensive and thorough assessment. Streamline Data Collection Improved the existing data sets enable process measures that facilitate the monitoring and assessment of the change ideas.

5 Flag Process Change Packages Secondary Drivers (Theory of change) Change Ideas Tested Describe Process Patient Quality of Life Assessment To demonstrate VHIU’s benefit to the patient. Standardise Information to GP’s To enable and ensure that GP’s receive clear and consistent information about what VHIU does and how they work with practices.

GP Process Change Packages Secondary Drivers (Theory of change) Change Ideas Tested Describe Process GP referral, use of triage tool. To enable GP to review their patients to identify those most likely to benefit from the VHIU programme. Partnering with GP Practices Working with Franklin, Otara & Mangere Practices, sharing expertise and information, sharing home and follow up visits. Developing a joint care plan.

Most Successful PDSA Cycles? - Include PDSA Tree diagram

Most Successful PDSA Cycles? Pt identification by GP using PARR (with High score) GP Heart sink Patients (list) Pt identification by GP using PARR (Any score) Test of 5 flag+PARR+ Heart sink pts GP identification/ Referral 5 flag generation for GP PARR & 5 Flag comparison Trigger tool Our prediction before the PDSA: GP’s can correctly identify the appropriate VHIU patients using the PARR tool. PDSA data revealed that on its own the PARR tool did not correctly identify patients for the VHIU team This PDSA led to the embedding of the trigger tool as part of patient identification

Measures Summary Outcome measures Patients enrolled from 5 flags, Primary care & Secondary care Reduction in unplanned presentations & admissions Bed days saved Patient outcome measure (pre and post VHIU programme) Process Measures Number of patients completing the VHIU Programme Number of times patients complete the VHIU Programme Time between presentations at EC & time to next unplanned presentation. Balancing Measures Numbers of re- presenting patients to the programme

VHIU Dashboard - Include Collaborative Dashboard

Changes to Support Implementation Implementation Areas Changes to Support Implementation PDSA cycles Standardisation Screening and Triage Process Documentation Process Map Training Developing training materials to support new staff. Job Descriptions Measurement Develop regular reports for outcome and process measures Resourcing Review of Job Descriptions for new Staff recruited Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.

Highlights and Lowlights The collaborative support from 20,000 days bringing focus and drive that has provided a catalyst for change and increased momentum The mutual respect within the VHIU team of our interdisciplinary skill set Recognition of the importance of a Model of Care which includes home visit and an holistic approach Lowlights Confusion due to multiple agendas within Primary and Secondary care Resistance and misunderstanding about integrated care Difficulty in breaking down silos of care

Achievements to date Do you have a change package, measurement plan? Multiple PDSA have resulted in standardised data capturing and reporting which includes monthly VHIU dashboard. What has changed and what difference have the changes made? The data has allowed us to focus on areas that make a difference and abandon those that don’t. Triage process improved to identify the patient acuity enabling the timely intervention Referral Process leading to identification of patients from across the health sector Patient identification: Increase the appropriateness of referrals received Improvements for patient and family experiences Right service by the right professional to the right patient and at right time