2. DMU - background Commenced in January 2000 Proactive rather than reactive - Program of ongoing follow-up, monitoring, education and early medical intervention post discharge Patients with complex co-morbid conditions

3. DMU - population Common co-morbidities: IHD, CHF, COAD, CRF and DM. Acute exacerbations / unstable Many problems are non medical: e.g. social isolation, lack of community supports, poverty, language, illiteracy, housing, access to (specialist) medical care etc.

4. DMU - population Psychiatric illness esp. depression, dementia and ETOH abuse are not uncommon. Poly-pharmacy with consequent drug side- effect, awareness and adherence issues are universal (admission). Equals readmissions and ED presentations

5. DMU -Aim Improve QOL of patients Reduce Admissions Reduce ED presentations Reduce Length Of Stay (LOS) Reduce total bed-days

6. DMU - How? Ongoing follow-up & monitoring through -outpatient specialised clinic reviews -care coordination activities -communication with GP -phone contact -education and self management -referrals 6 monthly Analysis

8. DMU - How? Overall key is flexible patient review. Review time based on complexity/no. of problems. Typical review time 30mins as often as required; -even weekly (initially) if necessary. -usually monthly. -discharge when >3-monthly. Follow-up of results/referrals/care plans between clinics (role of full-time nurse coordinator & dedicated registrar) Care coordinator contact prior to review

9. Clinics Alfred: mon, wed, fri Caulfield: mon Sandringham: fortnightly thurs Inner South: fri Eduction classes, library, patient newsletter

10. DMU - How? Utilize allied health/educators: address anxiety, depression, energy conservation, nutrition Realize sometimes inpatient Rx is unavoidable. Admit at an early stage of disease relapse to; (i) reduce LOS (“turn-around”) (ii) maintain performance status (avoid placement). (iii) Avoid ED by direct admit if possible.

11. “Self management” DMU style - Past Monthly group sessions Anxiety and depression, energy conservation, nutrition, relevant topic eg sleeping well At The Alfred, lunch provided Greek, Russian Care co-ordinators invite patients Patient response Transport, commitment

12. Self management DMU style - Now Psychologist leading group support and information sessions “Sick and tired of feeling sick and tired” Monthly, lunch provided Not at Alfred (Inner South, Caulfield and Bentleigh Bayside) Community health centre staff and DMU staff Care co-ordinators approach patients Evaluation

13. DMU team 7 Consultants, Registrar and Residents (renal, general medicine, endocrinology, cardiology, geriatrics, rheumatology, respiratory) 4 Nurse Care Coordinators, Manager PTE Pharmacist Allied health educators Need: psychologist

14. Results Comparative analysis of healthcare utilization of all patients 6 months pre and post enrolment. - 6 months prior to enrollment date - 6 months post enrollment date - 7-12 months post enrollment date Each patient acts as own control. Data analysis is done every six months

15. Demographic Data* Male/female %50.7%/49.3%  2 co morbidities100% 1° diagnosis CHF28% 1° diagnosis COAD30% Lives alone48% Lives with family/carer42% Lives in Hostel/NH8% Lives in supported accom.2% *random cohort of 50 patients enrolled last 6 months of 2001.

16. Outcomes 2002-2006 n=1305 patients Total admissions reduced by 54% 12009 potential beddays saved ED presentations reduced by 59%

17. DM critical factors Clinical leadership, enthusiasm, vision Team members Communication: team meetings, electronic Patient telephone contact – care coordinators GP liaison Education Measuring results

18. The Alfred DMU-Future Directions Expand clinics and staffing including psychology Increasingly become a community-based service and avoid patients coming to the “physical” Alfred at all. Nurse Practitioner ? Health coaching Assess clinical outcomes in the patient group Expand electronic medical record

19. Acknowledgements Dr Marco Bonollo, Renal Consultant, General Physician, DMU leader Care Coordinators: Jo Butler, Jo Harris, Belinda Ryan, Fiona Vaular, Juliet Ward Drs Laila Rotstein, Solomon Menehem, Harvey Newnham, Livia Rovera-Wall, Annie Fung, Su Hii, Ronald Leong, Yuben Moodley, Juan Aw, DMU Registrars Pharmacists Robyn Stell, Susan Fisher Community Health Centres allied health Inner South, Caulfield, Bentleigh Bayside