15-16 June - Broadbeach

1. “FREQUENT-FLYERS” PROGRAM“Disease Management is a system of coordinated healthcare & communications for populations with conditions in which patient self-care efforts are significant”Dr Marco Bonollo FRACPThe Alfred, Prahran, Victoria (Cougar) 15-16 June - Broadbeach

2. “Frequent-Flyers” disproportionately use valuable inpatient resources • Elderly, with multiple co-morbidities e.g. IHD/CCF, COPD, DM, CRF. • Frequent admissions & ED presentations, with long LOS – “repeat offenders”. • Many “non-medical” problems e.g. psychiatric illness, ETOH abuse, chronic pain. • CALD • Live alone or supported accommodation. • Poly-pharmacy.

3. “Frequent-Flyers” - a system of uncoordinated healthcare… • Care transferred from general medical outpatient clinics to GPs - false economy? • GPs vary in their ability to meet their complex needs  referred to ED. • Attend multiple specialist clinics/rooms. • Benefit less from invasive interventions. • Admitted with specialty problems under general medical units due to co-morbidities.

4. “Frequent-Flyers” need a counter-intuitive approach… • Broad vision – to become a community provider of tertiary hospital care. • CHS, local hospital & GP co-located clinics avoid patients attending tertiary institution. • Specific reportable benchmarks. • “Skill-sharing” relationship with GPs as cornerstone of care. • Patients with multiple problems attend one general unit not multiple specialist units. • Self-management incorporating allied health, especially psychology. • Pro-active admission (substitution) policy.

5. DMU is virtual unit utilizing work practise change across traditional demarcations in (aged) care. • Mapped target population with total numbers minimized. • Care Coordination • Flexible clinic review • Craft group expertise & “skill-sharing” including advanced Rx e.g. EPO • Minimize inappropriate referrals & invasive investigations. • Electronic medical record • Independent pharmacy review

7. Electronic DM record

8. Total admissions reduced by 56%ED presentations reduced by 55% 1/1-30/6 2003

9. Total Bed Days Reduced by 1681 or 72% at a Potential Cost Saving of $1,008,600 1/1-30/6 2003

10. ALOS Reduced by 2.4 days or 36% 1/1-30/6 2003

11. Implementation of modest outpatient resources results in liberation of considerably more valuable inpatient resources. • Project Started: 2001 • Staffing: 1.2 EFT Physicians, 2.5 EFT nurses, 0.1 EFT Pharmacist • Funding: HARP (DHS) $375 000 p.a. • Estimated savings: $3.5 million p.a. • Duration: mainstreamed

12. Lessons Learnt Recommendations; • Share skills and resources (including human) across silos of care rather than develop another silo. What we would do differently; • Greater initial communication with (division of) GPs. • Minimize hospital-based clinics earlier. • Develop a DM focus in all units at outset. • Establish service guidelines to avoid first admission. • Earlier development of nurse practitioner/outreach.

13. Acknowledgements • DHS, State Government of Victoria (HARP) • Bayside Health Executive • Ms Joanna Butler • Ms Kaylene Fiddes (k.fiddes@alfred.org.au) • A/Prof. Lexie Spier • Phillip Cornish (HARP, CGMC) • Prof. Napier “Nip” Thomson Contact Details • Marco.Bonollo@med.monash.edu.au