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Overview. Policy directions NPA:Sub-acute COAG Long Stay Older Patients’ Initiative Sub-acute Services Planning Framework HIP Guidelines Right care/Right time/Right place FIM across Rehab, GEM and Restorative Care Improved pathways and models of care Acute GEM Restorative Care

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Overview

Overview

  • Policy directions

    • NPA:Sub-acute

    • COAG Long Stay Older Patients’ Initiative

    • Sub-acute Services Planning Framework

    • HIP Guidelines

    • Right care/Right time/Right place

    • FIM across Rehab, GEM and Restorative Care

  • Improved pathways and models of care

    • Acute GEM

    • Restorative Care

    • Residential In Reach

    • HARP: Better care for older people (HARP BCOP)

  • Innovative resources

    • Best care for older people everywhere: The toolkit


Sub acute planning framework

Sub-acute Planning Framework


What drives demand

What drives demand?


Forecasting for sub acute services

Forecasting for Sub-acute Services


Sub acute service system

Sub-acute Service System

Sub-acute bed based services

Rehabilitation (adult and paediatric)

Geriatric Evaluation and Management/Restorative Care

41 facilities – 23 in metro/18 rural region

Over 1800 beds

50% rehabilitation and 50% GEM

75% in metro/25% in rural regions

Substitution and diversion services

Hospital in the Home

Post Acute Care

Sub-acute Ambulatory Care Services

Chronic and Complex Care Services: HARP, Family Choice Program, Victorian Respiratory Support Service

Transition Care Program

Facility and Home based packages


Integrated guidelines

Integrated guidelines

Enable better client journey across the care continuum

Patient flow unhampered by program boundaries

Right care, right place, right time


Impact of ageing on acute care

Impact of ageing on acute care

  • People over 85 years will increase from 1.6% of the population to around 5 – 7%

  • In the next 20 years

    50 % of acute care beddays will be used for patients over 70 years

  • Patients over 85 years will utilise 14.5 % of the acute care beddays


The people who use or service our patients are older and frailer

The people who use or service:Our patients are older and frailer

52% of people admitted to sub-acute services are 80 years or older

40% patients in rehabilitation are >80

Frailer on admission

and discharge


Older people use hospitals differently

Older people use hospitals differently

More complex needs

Multiple diagnoses

Increased risk areas


Sub acute and residential aged care access indicator project

1. Number of patients within the health service (acute & subacute beds) awaiting a residential care or TCP placement.

An indicator to reflect patient flow

2. Average inpatient length of stay (LOS) in subacute care per month

An indicator to reflect efficiency

3a) Average Admission Barthel score per month

b) Average discharge Barthel score per month

c) Average Barthel improvement per day

An indicator to reflect effectiveness, complexity and measure improvement but not necessarily access

4. Formal separations per subacute bed per month

An indicator to measure efficiency

5. Number of subacute referrals accepted per bed per month

An indicator to reflect the demand on the system

6. Number of people in acute beds waiting for subacute beds

An indicator to reflect patient flow

Sub-acute and Residential Aged care Access Indicator Project


Geriatric medicine patient journey

Geriatric medicine patient journey

Sub-acute Inpatient (GEM)

35 days

Acute Inpatient

25 days

ED

Usual care pathway: 57 inpatient days

Better care pathway: 14 inpatient days

Transition Care Program

56 days at home

GEM Plus

14 days

APU


Residential aged care journey

Residential Aged Care journey

Sub-acute Inpatient (GEM)

35 days

RACS

Acute Inpatient

25 days

ED

20 hrs

Usual care pathway: 57 inpatient days

Better care pathway: HITH/HARP In reach

HITH or HARP In-reach

RACS


Resources to support improved care

Resources to support improved care


Move to functional improvement measure fim

Move to Functional Improvement Measure (FIM)

  • Health service driven revisions to VAED to incorporate FIM measures

  • Movement away from data based on diagnosis/acute focus, to patient focus

  • GEM uses Barthel Index, move to FIM to align service reporting

  • Incorporate measures of frailty


What will we achieve

What will we achieve

  • Improved access and equity of services

  • Improved consistency of service quality

  • Better patient journeys

  • Avoidance of unnecessary hospital admissions

  • Prevention of functional decline

  • Minimised long term care needs

  • Avoidance of premature entry into RACS

  • Better patient experience


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