1. The Health Roundtable Implementing Systems Change in Chronic Disease in the Illawarra Shoalhaven Presenters: Paul van den Dolder & Franca Facci ISH LHD Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1

2. The Health Roundtable KEY PROBLEM  Increase in chronic disease (Aust and world wide)  Increase in hospitalisations for chronic disease (NSW and Aust)  Patients and carers confused in trying to navigate care, and:  Frustrated that health care providers don’t work collaboratively (Garling)  Costs increasing  Local ‘solutions’ focussing on single disease e.g. cardiac rehab  Need for increased engagement with GPs 2

3. The Health Roundtable AIM OF THE INNOVATION A coordinated, integrated service system  Prevent avoidable presentations and admissions  Reduce duplication of diagnostics e.g. in ED  Reduce LOS  Improve patient self management and quality of life  Not create an additional ‘service layer’ but ‘fill the gaps’ in care  Enhance GP capacity to better manage their CC pts 3

4. The Health Roundtable BASELINE DATA  Analysing a cohort of 368 people 90 days prior to their entry in the program  average admission rate 2.0  total bed days 3901  Referrals to outpatient rehabilitation programs for COPD, CHF and CR at approximately 27%  Attendance at outpatient rehabilitation programs poor – e.g. for cardiac rehab it was 5%  Re-admission rates higher than NSW overall rates for COPD (13.6 v 13.0) per 100 and CHF (8.8 v 9.2 per 100)  GP referral into chronic disease programs low *Butler L, Furber S, et al Effects of a pedometer based intervention on physical activity levels after cardiac rehabilitation: a RCT. Journal of Cardiopulmonary Rehabilitation Prevention 2009:29:105-114 4

5. The Health Roundtable KEY CHANGES IMPLEMENTED Objectives  Improving disease management in primary health care settings through strategic partnerships – key partnership - implementation arm through the Medicare Local  Improving self management support – workforce development, telephone health coaching  Improving knowledge base and information sharing across the health system – providing shared access to electronic medical records  Sustainable infrastructure – embedding new approaches in existing structures to facilitate change  Capturing and disseminating innovation 5

6. The Health Roundtable KEY CHANGES IMPLEMENTED Strategies  Targeted enrolment – identifying patients in real time  Timely referrals to Care Coordinators working in the Medicare Local  Comprehensive assessment, shared care planning, continuum of care coordination & self management support  Scheduled monitoring and review  Underpinned by shared decision making 6

7. The Health Roundtable OUTCOMES SO FAR From Jan 2011  > 1800 people enrolled and accessed care coordination From May 2011  > 600 people received telephone health coaching for ~ 6 months on their chronic condition Analyzing data of 368 patients  Emergency admissions decreased by 420 (61%)  Bed days decreased by 2045 (52%)  LOS no significant change noted 7

8. The Health Roundtable OUTCOMES SO FAR 8

9. The Health Roundtable LESSONS LEARNT  Existing systems resistant to change  V Hard to integrate new models into usual care – proliferation of add-on programs and hard not to fall into this  Engagement with outside agencies viewed with caution and will take years of relationship building  Health care services and staff are not engaging with patients and carers – (but we really think we are!)  Adequate funding is a prerequisite  Change will take time but our reporting systems are not conducive to this  In panic mode we revert to old patterns of service delivery 9