Integrating Hospital, General Practice and Community Health - ABHI initiative in association with Sydney West Area Health Service
WentWest in association with the clinical redesign of Sydney West Area Health Service (SWAHS) is achieving continuity of care for chronic cardiac, chronic respiratory and aged care patients in the Blacktown area by integrating hospital, general practice and the community health centre services.
Micheal Kundukulam (Integration Coordinator) at WentWest has been working closely with the hospitals and community health centres to develop processes for shared care between the health care providers in the region.
Measuring the baseline for integration
The program began in June 2008 by identifying the gaps to continuity of care. Several meetings and focus group discussions were held with the hospitals, GPs, and community health to identify the issues the care providers faced in managing patients with chronic conditions. Based on these issues solutions were developed and prioritised in consultation with the stakeholders.
Some of the general issues faced by the stakeholders included:
- Discharge summaries not sent directly to GPs, not legible and changes to treatment not recorded in the summary
- Information and access to the right kind of service is not always available
- GP is not approached pre-admission, on admission or through admission to develop plan of care that meets all the patients needs
- Community nurses who support the patient in the community do not have any clinical background information of the patient and are unaware of the GPs management plan
- Hospital does not have information about the patient’s management plan and support in the community
The solutions:
Based on the issues the following solutions were prioritized, designed and implemented by WentWest in association with SWAHS.
- Admission and Discharge Notifications: When patients present and are discharged from the Emergency Department (ED), the GP receives a fax of the clinical summary and any assessments and reports documented for the patient.
- Case conferencing with the hospital: For patients who get admitted into the inpatient wards and are about to get discharged, a case conference is organised. The patient’s treatment at the hospital is discussed with the GP through the teleconference and a summary of the conference faxed to the GP.
- Collaborative care planning in the community: GPs, register into the ABHI program and fax the clinical background along with a care plan for patient with chronic conditions to the community nurse. Community Nurse continues with the care, and supports the GP with information for team care arrangements and necessary referrals to support the patient. A written feedback is provided to the GP and links with the GP Liaison nurse who supports the GP to organize a community case conference. The GP is further updated on the progress of the patient through community nurse visits and written feedbacks.
The outcomes:
- Notifications of Admission and Discharge: The process began in September 2008 and more than 340 notifications have been sent from ED until August 2009.
- Case conferencing with the hospital: The process began in January 2009 and more than 40 discharge case conferences have been conducted until August 2009.
- Collaborative care planning in the community: 30 GPs have been registered into the program and are using the community integration process to collaborate care. The number of GPs participating is limited due to the capacity of resources in the community.
Testimonial:
“As a GP, receiving information or coordinating care for my patients with the Hospital, or community health had been a challenge until WentWest began its Australian Better Health Initiative project. Based on the concerns that we raised at a focus group discussion, WentWest in association with Sydney West Area Health Service provided us with a few solutions, which include notifications from ED, Discharge teleconferences, and the support of Community Nurse and GP Liaison Nurse to coordinate care in the community. This level of integration has provided us with very good support to assist our patients with chronic conditions to regain their health”
(Dr Michael Tan, local GP)
For more information about this project please contact Micheal Kundukulam on ph: (02) 8833 8000 or email at: mkundukulam@wentwest.com.au