Need to do better;

1. Need to do better; Relevance of electronically coordinated care between providers to reduce avoidable admissions for over 65 year olds Trudy Yuginovich

2. This paper; • findings from phase 1 of a current ARC-funded project: ‘Minimising the inappropriate and unnecessary hospitalisation of frail older people (over the age of 65)’. • This research addresses a need for formative evaluation of process, impact and outcomes.

3. Issues • At any given time people accessing health services can have up to 9 different records (hospital, primary care, dental, community health, mental health and others). • Result from the lack of a unique patient identifier and results in services using their own separate identifiers which is a barrier to sharing of patient information between providers and better coordination of care • Globally this is reflected in poor communication between providers, duplication and gaps in services.

4. Aims: • develop, trial and evaluate a tool that enhances the continuity of patient care and patient safety • provide a single point of access to data that identifies and provides information to all clinicians involved • evaluate the perceived need for an e-communities of care

5. Literature; • In Australia, a number of persons over 65 years are admitted to or remain in hospital because they are unable to access community-based supports • cannot be discharged as medically safe until either these supports become available or until they have spent longer recovering in hospital • people utilising hospital-based health care could remain at home if alternative supports were made available (Metropolitan Health Division Department of Health 2004)

6. literature (cont) • variety of new aged care models emerging which aim to provide appropriate collaborative aged care services; • in Australia change has been slow

7. Other current models of care; • Program of All inclusive Care for the Elderly (PACE), • the Systeme de SoinsIntegrés Pour PersonnesAgees (SIPA) • Program of Research to Integrate Services for the maintenance of Autonomy (PRISMA) in Quebec and France (Kodner and Kyriacou 2000; Hébert, Durand et al. 2009) • In the Northern Territory in Australia, the HealthConnect Northern Territory (HCNT) Shared Electronic Health Record Service (SEHR) was implemented

8. Approach: • Fourth Generation Collaborative Evaluation (FGE) • theoretical framework has been used extensively in nursing research since the 1980’s • uses a constructivist, inquiry paradigm to provide a shared process of accountability (Guba and Lincoln 2003).

9. Method; • Purposive sampling • A Project Steering Committee of key stakeholders • The Project Team of the researchers and project staff • A Site Management Group (SMG) • Stakeholders • semi-structured interviews (n-7)

10. findings • A need for the ‘right information at the right time and place • approved health care providers should be able to ‘download relevant information from a GP’ for other relevant services to coordinate care for the frail over 65years olds • A Coordinated approach to care was seen as potentially reducing avoidable admissions for this age group

12. Themes; • interconnectivity between providers • communication, For a fast contact with a [General Practitioner] GP, the caller must be at least an RN. • access to resources and avoidable hospitalisation. • major difficulties exist with networking services within the health sector. Waiting for a doctor is a major reason for unnecessary time spent in hospital. ..Assessment teams are often unavailable.

13. Themes(cont..) • difficulties retrieving information out of systems • problems linking directly with other providers for cross sector information • The least effective communication mode was identified as being email. • Most common means of communication-Phone and fax in all cases. Some respondents indicated that sometimes fax is useful only as a follow up

14. themes • significant numbers of people at risk of avoidable hospitalization • A need for the ‘right information at the right time and place’ • approved health care providers should be able to ‘download relevant information from a GP’ for other relevant services to coordinate care for the frail over 65years olds

15. Value of an e-community • overnight hospital stays were seen by all respondents as being a result of poor coordination and/or inability to communicate leading to delays in finding needed information. • Better connectivity between GPs and other service providers would make a big difference. • A common waiting list would help a lot. • At least we could do a better job of coordinating information exchange with the hospitals-so much time and effort wasted on this that adds to length of stay

16. Value of e-community of care • No respondents suggested that they were aware of any options for linking between departments providing services to the aged care community • all agreed that this was an optimal solution thus reflecting comments by others

17. conclusions • The main at-risk group for avoidable admission to hospital was seen as being people with poorly managed chronic conditions who need extra services not easily available in the community. • A free-flow of information, between providers is imperative to streamline care for the frail elderly. • Currently there is no facility to generate an electronic discharge summary and/or provide a linked approach to care in the region • A linked approach to care is seen as crucial to coordinated approaches to care to reduce avoidable admissions.