managing increasing demand for hospital care

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Managing Increasing Demand for

Hospital Care

Dr Sherene DevanesenCEO

Peninsula Health

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Managing Increasing Demand for Hospital Care

Increasing Demand:

Demographic trendsChanges to social infrastructureNew technologyConsumer Expectations

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“What Americans want is quite simple; all the health care they or their doctors can imagine, virtually free, without added taxes for health care and without out of pocket costs .... That’s all. Call it part of the American Dream.”

- Professor Reinhardt, Princeton University.

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Implications of poor demand managementFinancial / economicPoor consumer outcomes

Good demand managementEffective servicesAppropriate servicesMultiple settings

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Health Care in Australia

Commonwealth (Federal) Government

- Residential Care Australian Healthcare Agreement

- Pharmaceutical Benefits Scheme

- Payments to doctors for ambulatory care States- Public hospital services

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Access to hospitals

Emergency Planned orElective

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E6 - ED Presentations – Frankston & Rosebud HospitalsPeninsula Health

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun

Actual Prev Yr

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Emergency Access

Growth in ED Presentations:OvercrowdingDysfunctionLong waiting timesDelays in admission

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Studies

Canberra HospitalDeaths in those who experienced overcrowdingIncrease in hospital mortality at 10 days

Western AustraliaDeaths of those who experienced overcrowdingLonger ED length of stayLonger physician waiting time

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Studies (cont.)

Western AustraliaStrategies

Reduce wasteReduce misuse / overuseImprove chronic disease managementMatch bed supply with demandOptimise hospital inpatient flow

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Studies (cont.)California

46% of users of EDs believed the care could have been provided by a primary care practitioner.Key factors in use of EDs by avoidable users:

Lack of access to outside EDsLack of adviceLack of alternativesPositive attitude to EDs

Chronic conditionsPopulation 32%ED users 44%

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Consequence of use of EDsfor non-urgent needs

Divert / delay resources for acute patientsMore expensive than other settings

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Control Measures

Prevention of Better care forPresentation those with acute(minimising conditions requiringAvoidable use) Emergency care

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Prevention of Presentations

Population based interventionsSmokingNutritionAlcoholPhysical activityInjuries

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Prevention of Presentations (cont.)

Provision of information

“Nurse-on-call” strategy – June 2006

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Patients referred in the following manner:

Ambulance 5%ED 19%Primary Care provider 42%Self care 33%Other 1%

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“Better Health Channel”

Health information internet site

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Primary care interventions:VaccinationsScreening, eg

Breast, colonoscopy

Acute conditions treated at home, egDehydrationCellulitisPelvic inflammatory disease

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Chronic Disease Management, egHypertensionHeart FailureDiabetesChronic Lung DiseaseSocial Issues

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Chronic Disease management (cont.)

Chronic diseases 50%

Management – requires shift from focus on acute symptoms

$515m for 5 years from Australian Government

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Chronic Disease Management (cont.)

Self Management Support

Education Plannedvisits

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Chronic Disease Management (cont.)WHO – Innovative care for Chronic Conditions Framework

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Diversion and Substitution

Multidisciplinary teams in EDs

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Diversion and substitution

Collocated GP clinics

Urgent care centres

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Better Management of Patients Requiring Emergency Care

Ambulance diversion or bypassLess than 3%

Assessment and Observation UnitsPeninsula Health – Medical Assessment Unit

Only 31% admitted to hospitalLength of stay decreased

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Better Management of Patients Requiring Emergency Care (cont.)

Information Technology Tracking systems

Workforce rolesPhysiotherapist in ED

Good outcomes

Streamlining for lower acuity patients

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Better Management of Patients Requiring Emergency Care (cont.)

Bed management practices

Better management of Mental Health patients in EDs

Triage tool at PHLength of stay decrease

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ED1 - % Time on Bypass (DHS KPI 1)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%


Actual (%) Prev Yr DHS Target

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ED2 - % Patients Admitted within 8 Hours (DHS KPI 2)

0%10%20%30%40%50%60%70%80%90%


Actual Prev Yr DHS Target

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ED3 - % Non Admitted Patients with LOS < 4 Hrs (DHS KPI 3)

0%10%20%30%40%50%60%70%80%90%

100%



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ED4 - Patients LOS > 24 Hours (DHS KPI 4)

0

10

20

30

40

50

60

70

80



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Planned or Elective Presentations

Pre and post hospital care in OutpatientsIntroduction of Allied Health practitioners in Outpatient

Clinics, egPhysiotherapists in Orthopaedic Clinic

Planned admission for medical care in stand-alone centre

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Planned or Elective Presentations (cont.)

Procedural (Surgical) ServicesCategorisationWaiting listMinimisation of cancellationsDay of surgery admissions

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Planned or Elective Presentations (cont.)

Other strategiesOther public hospitalsNew centre for State-wide accessUse of private sector“Medihotels”

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EL1 - Total Patients on Waiting List (DHS KPI 7)

2,000

2,200

2,400

2,600

2,800

3,000

3,200

3,400

Jul Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay JunActual Prev Yr DHS Target

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EL5 - Hospital Initiated Postponement (HIPs) per 100 W/L Admissions (DHS KPI 8)

0

5

10

15

20

25



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W1 - Average Waiting Time -Category 1 (Days)

0

5

10

15

20

25

30

35


Actual Prev Yr DHS Threshold

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0

50

100

150

200

250


Actual Prev Yr DHS Threshold

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0

50

100

150

200

250

300

350

400


Actual Prev Yr PH Threshold

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D2 – DOSA General Surgery

50%

60%

70%

80%

90%

100%


Actual Prev Yr PH Target

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Example of Performance thresholds used to allocate bonus funding points

Percentage of operating time on hospital bypass

Bonus Points Criteria Bonus Points

Less than or equal to 3.0% 3

3.1% to 4.0% 2

4.1% to 5.0% 1

Greater than 5.0% 0

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DHS - KEY PERFORMANCE INDICATORS & BONUS FRAMEWORK 2005/2006

TargetEmergencyED1 - % Time on Bypass (DHS KPI 1) 3%

ED2 - % Patients Admitted within 8 Hours (DHS KPI 2) 80%

ED3 - % Non Admitted Patients with LOS < 4 Hrs (DHS KPI 3) 80%

ED4 – Patients LOS > 24 Hours (DHS KPI 4) 0

ED5 – Category 1 - % Patients Seen Immediately (DHS KPI 9) 100%

Elective SurgeryEL1 – Total Patients on Waiting List (DHS KPI 7)

EL3 - % Category 2 Waiting more than 90 Days (DHS KPI 5) 0%

EL4 - % Category 3 Waiting more than 365 Days (DHS KPI 6) 0%

EL5 – Hospital Initiated Postponement (HIPs) per 100 W/L Admissions (DHS KPI 8) 15

EL2 - % Category 1 Admitted within 30 Days (DHS KPI 10) 100%

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Other StrategiesService integration to improve patient journeysGood forecasting and planningRole delineationDevelopment of clinical networksNew workforce strategies

New workforce roles

Defining a queuing strategyGood discharge planning

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Consumers - 3 segments

Healthy populationInformation or health promotion, disease preventionEarly intervention strategies

‘At risk’ populationIdentificationSelf management support

‘High acuity’ patientsAppropriate and effective hospital care

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Conclusion

CollaborationStronger relationships between sectorsChanged relationshipsShift to community models of care

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Conclusion (cont.)

Shift:

From To________________________________________Episodic care Continuums of careProvider focus Consumer focusAcute care settings Multiple care settings

managing increasing demand for hospital care

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