Respiratory Coordinated Care Program RCCP

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Respiratory Coordinated Care Program (RCCP)

• Division of Medicine
• St George Hospital
• Sydney
• Nick Spiliopoulos NUM

2
Overview

• Demographics
• COPD/Infections
• RCCP statistical outcomes from 1998 - 2007
• RCCP Costings
• Predicted Epidemiology

3
Demographics

• A 600 bed, public tertiary referral hospital
• St George catchment area comprises a population
  of 225,000
• Population density Approximately 3365 / km2
• Catchment area Approximately 67 km2
• 30 NESB
• 11.5 gt 70 years of age
• gt 380 E65A E65B(COPD) admissions pa

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COPD/ INFECTIONS 2006/7

• Cost to NSW Health for COPD DRG E65 A B,
  68m (7th costliest)
• Cost to NSW Health for Respiratory infections
  DRG E62 A, B C 89m (4th costliest)
• Affects over 1,000,000 Australians (ALF 2006)
• Every day, over 1000 COPD patients occupy
  Australian public hospital beds at an average of
  3700 per admission (ALF 2006)
• COPD is the fourth leading cause of death in
  Australian men
• COPD is the third leading cause of morbidity
  after cardiac and stroke

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Survey of Existing Services

• In 2007 the GMCT conducted a survey of 27
  greater metropolitan hospitals in NSW results
  indicated that 63 do not have a specific
  respiratory outreach service
• Of the 37 that do, only 2 facilities have
  greater than 1.0 FTE nursing staff
• 70 do not have a case management model for
  chronic patients

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HISTORY
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RCCP History

• The RCCP was established in 1995 - commenced as
  a five day per week specialised hospital-based
  community program.
• Designed to assist people with advanced COPD to
  remain optimally well at home with the goal of
  reducing hospital admission rates and LOS
• Two components- CHRONIC, long term, chronic
  patients and ACUTE, short term, early discharge
  patients
• The model of care incorporates a collaborative
  approach between health professionals i.e.
  respiratory physicians, GPs, nurses, allied
  health and community services, to help achieve
  the desired outcome
• Six RCCP staff with a 4.4 FTE , Nurse Unit
  Manager three Clinical Nurse Specialists and
  two Physiotherapists GRD 2

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RCCP Program Participants

• CHRONIC COMPONENT
• Patients recruited to the program remain on the
  RCCP until they move out of the catchment area,
  are admitted to an aged care facility, or die
• Currently, 237, Mean age 76.4 years, 110 M 127
  F
• Criteria on admission to the program
• gt 60 years
• have an established diagnosis of COPD
• reside in the St George catchment area
• psychosocially stable
• have their care optimised by a respiratory
  physician
• FEV1 lt 50 of the predicted
• GP agrees for patient to participate
• Recruitment Source
• 77 from Respiratory Ward outliers via Resp.
  Con. Reg.
• 11 from Respiratory physicians rooms
• 12 from General Practitioners, Community
  Services, ED, QRP, EMU

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RCCP Program Intervention
Each patient admitted to the program receives a
COPD information pack and an individualised
action plan
Each patient admitted to the program completes a
HAD and STGRQ annually thereafter and compared
to baseline
Home visits gt 5600 visits per year, conducted
weekly, fortnightly, monthly, or more frequently
if the patient is unwell. Average duration is 30
minutes average number of six interventions per
visit.

• Examples of interventions at each home visit may
  include-
• respiratory assessment and monitoring, oximetry,
  NIV monitoring/usage
• education about disease, treatment and self
  management, referrals
• medication review, medication delivery
  techniques, equipment check,
• physiotherapy, coping abilities regarding ADLs,
  active breathing techniques,
• home pulmonary rehabilitation, counselling and
  reassurance
• INR monitoring, ABGs, IV antibiotics,
• IV cannulation, venipuncture
• emergency calls

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RCCP MODE OF INTERACTION AND REFERRAL

• 
  
• 
  ?
  ?
• 
  
  
  
  
• 
  
• ?
  ? TEAM
  ?
• RCCP Home
  
  WARD
• 
  Visits
  
• 
  
  
  RCCP Home visits
• 
  
  
• Patient Exacerbation
  
  RCCP Early
• Infection
  
  Discharge i.e..
  INR,IV AB

OUTPATIENT PHYSICIAN INPATIENT
11
Some RCCP Chronic Component Statistical Outcomes
from 1998 to 2007
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Mean Age, Gender, number of patients living alone
and mean number using home O2 from 1998 to 2007
13
Comparison of Admissions per Chronic Patient per
Year Pre and Post RCCP recruitment 1998 to
2007 National Average for DRG E65A B 1.31
Average Admissions /patient /yr Chronic
Complex Patients (ALOS 5.3)
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Mean Number of RCCP Chronic Bed Days Saved 1998
- 2007
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RCCP Readmission Rates from 1998 to 2007
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Mean Number of Inpatient Beds Saved (based on
a five day service a National 1.31 admissions
/patient/year)
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Deaths Among RCCP Participants 1998 -2007 Mean
Annual Death Rate 18.5
18
Mean Satisfaction Survey 1998 2007 80 Mean
annual response rate
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RCCP Early Discharge Program

• ACUTE COMPONENT
• At St George Hospital, all patients requiring
  admission are seen in the ED, with a view to
  discharge within 24 hours
• A need was seen for a secondary early discharge
  program for patients requiring more than 48 hours
  hospitalisation
• In 2001, the RCCP established an early discharge
  program for patients admitted to the ward.
• Patients are referred by a respiratory consultant
  when considered stable and suitable for home
  care.
• Medical staff communicate with the home care
  team, often at the bedside
• Interventions include anticoagulant
  stabilisation, IV antibiotics and physiotherapy
• A seven day service was provided

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Comparison of RCCP Early Discharge Statistics
with Peer Group DRGs from 2001 to 2007
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Mean Number of RCCP Bed Days Saved for the
Early Discharge Component 2001 2007 In the
previous 7 years, there has been only 3 patients
that required readmission
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One Off Visits

• In addition to the 424 patients utilised by the
  RCCP (187 early discharge and 237 chronic
  participants) The RCCP also conducted 57 one off
  visits in 2007
• At the behest of ward staff
• Concerned about compliance, coping, NIV usage
  i.e. mask adaptation, 02 assessment
• These visits were not counted as part of the
  early discharge statistics.
• RCCP involvement impacts on readmission rates
• 0 of patients readmitted within 28 days

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Adjunct Pulmonary Rehabilitation

• In 2001, the RCCP commenced an exercise program,
  twice per week, away from the hospital setting,
  at the local surf life saving club, called
  Maintenance at the Beach
• Run by the RCCP physiotherapist nurse
• Attendance of 30 -45 participants at each session
• Participant criteria Anyone with COPD
• Cost 20 per participant per year
• Transport is provided
• From 2001 to 2007 there were 509 sessions
  conducted with 14,924 attendances

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Adjunct Pulmonary Rehabilitation

• Annual statistical outcomes are measured via
• Hospital admission rates
• Six minute walk test
• HAD Scale
• STGRQ
• Borg Scale dyspnoea levels pre Post exercise
• satisfaction
• Spirometry

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RCCP Clinics

• Commenced in 2000
• Run by Respiratory Registrars
• Patients targeted for review, are those who have
  not seen their Respiratory Specialist for some
  time
• Respiratory progress is reviewed and may
  include-
• spirometry
• ABGs
• Medication review
• BMD
• Psycho-social Assessment
• Psycho-geriatric review
• Community services
• Increased RCCP home visits?

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Huffers Puffers

• In 1997, the RCCP established the St George Area
  Respiratory Support Group, known as the Huffers
  Puffers - over 100 members and carers
• Meet once a month at the local leagues club
• Purpose- Increase education, interaction and
  reduce social isolation
• Outings 3- 4 times per year
• Raise money for members, outings and equipment
  for the respiratory ward, RCCP and pulmonary
  rehabilitation

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Home Oxygen and the RCCP Lending Pool

• The RCCP is responsible for organising home
  oxygen for patients being discharged from
  hospital
• We ensure patients are followed up in the
  community with regards to oximetry and arterial
  blood gases
• The RCCP has also established a lending pool,
  which includes oxygen concentrators, portable
  oxygen cylinders, conserving devices and
  nebulisers.
• The purpose of the lending pool is to ensure a
  smooth discharge process from hospital to the
  home and to allow patients to attend Doctors
  appointments and social functions.

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St George Division of General Practice

• Partnership developed with DGP
• Meetings every 3 months
• Write up in the DGP Newsletter
• RCCP within DGP Website
• If GPs require pts to be seen, or referred, they
  contact the RCCP direct
• Oxygen assessment/criteria
• Spirometry/oximetry
• ABGs
• Monitoring
• Education
• Medication management

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Costing
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Costing per RCCP Early Discharge Patient per Year
2001 to 2007
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Average Annual Cost of Maintaining a patient on
the RCCP Program from 1998 to 2007

(Includes Chronic Early Discharge Patients )
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Cost of Running the RCCP from 1998 to 2007
including the Early Discharge component
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OUTCOMES

• Reduced COPD hospital admissions LOS
• Reduced workload to A E
• Reduced workload to QRP EMU
• Reduced workload to Ambulance services
• Improved access block patient flow
• Improved bed day savings for specific DRG
• Equivalent medical outcomes

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Respiratory Inpatient Episodes SESIAHS Hospitals
St George is the only hospital with a significant
decrease in the total number of respiratory
admissions between 2000 and 2006
37
FUTURE ??
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Predicted Epidemiology

• 2020 it is predicted that COPD will be the
  leading cause of hospital morbidity
• 2030 people gt 65 will comprise 1/5 of pop.
• 2040 people gt 80 will triple (ABS)
• What can we do?

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Conclusion

• Appropriate funds, to set up or enhance existing
  chronic care programs that have a model of care
  with proven positive statistical outcomes, cost
  effectiveness, sustainability and that work in
  partnership with physicians, GPs, nurses,
  allied health and carers in order to alleviate
  the current and predicted burden to the acute
  sector..

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HOW TO CONTACT US

• RCCP, c/o Ward 5 South, Main Tower Block
• St George Hospital, Gray St. Kogarah, 2217.
  NSW
• Office Phone [phone]
• Office Fax [phone]
• EmailNicolaos.Spiliopoulos_at_sesiahs.health.nsw.gov
  .au