1. Making Numbers Real: The discharge journey Tania Geyer, Di Norris, Liz Prowse Noarlunga Health Services (now part of Southern Mental Health, SA)

2. NUMBERS… (blah blah blah) KPI #5 = N/A KPI #9 =KPI #12 = 65% KPI #3 = 27% KPI #7 = 5% KPI #2 = KPI #8 = 50% KPI #11 = mc 2

3. KPI # 12: Follow-up within 7 days of discharge Why focus on this indicator? An across service indicator (involves inpatient and community) Clinical relevance We didn’t seem to be very good at it Tapped into a number of processes around discharge and transfer of care

4. Baseline Rates of Follow-up Us: 48%

5. Identified Need of Attention from Benchmarking Results It’s a clinical problem not just a number! High time of risk Consumers falling through the gaps Missing link between inpatient and community follow-up Communication issues Links with other KPI’s – length of stay and 28 day readmission

6. What did we do? Discussion/communication with Team Leaders and clinicians Working group with significant buy-in from inpatient and community with project support – Recognition and understanding of the KPI and clinical implications – Focus on the KPI measuring the consumer experience of discharge

7. Development of procedure Developed by working group – high level of engagement from teams Move into line with general health follow-up, e.g. phone call day after surgical discharge Examples of procedure points: Inpatient – Confirm follow-up with consumer – Document actions on discharge checklist and journey board – Make contact and complete documentation Community – Inpatient admission report become part of morning handover – Confirm nature of discharge contact

8. Implementation and Roll-out of procedure Paper based collection initially Enhancement of computer system to collect contacts made by inpatient staff to discharged consumers Training Recommendation to change the KPI to collect any contact made within 7 days Examining and improving discharge/transfer of care practice – inpatient Journey Boards

9. Journey Board - Goals Make the Consumers Journey visible to the whole team by using visual management techniques Introduce a standardised communication tool in all Southern Mental Health units Improve communication between inpatient wards and the community teams Facilitate making barriers to the journey visible Collect data regarding real barriers rather than perceived barriers to improve treatment and discharge plans

10. Baseline Rates of Follow-up

11. Referral Triangles 1. When SW/Psychologist/OT was needed 2. When referred to SW/Psychologist/OT 3. When the Psychologist, SW or OT has seen the Consumer 21/7 23/7

12. Process:Only rub out referral triangle if you need to re-refer. Green – good to go Yellow – more to do Red – not good to go Referral Triangles - System

13. A total of 133 surveys were distributed to both inpatient and community staff SMH, 81 surveys were returned for a 61% response rate. Evaluation Summary

14. (95% of the general hospital staff surveyed were enthusiastic about encouraging other areas to implement journey boards only 2% disagreed 9% were unsure) Evaluation cont.. SMH staff showed a positive response with 65% agreeing that they would encourage other areas to implement journey boards, 23% were unsure or stated the question was not applicable and only 12% disagreed.)

15. Comments from General and MH Staff Easy access to information Keeps control of work load Gives a snapshot and an overall picture of journey Identifies the allocation of workload Evaluation cont..

16. 3 Year Comparison Us: 48% to 59% to 68%

17. And… Monthly monitoring, by each site and as a region Adding collection to residential rehab. centre Closing the loop/following up Further system enhancements, e.g. new discharge screen

18. Journeyboarders – particularly Anna Szynkar and Denise Wright (Flow Coordinators) Inpatient and community staff of Southern Mental Health, in particular those based at Noarlunga Information and project staff Consumers and carers of our service All Adult Benchmarking participants Acknowledgements