We have managed to reduce our no show rate for outpatient care with a multi pronged approach
1. Combination of the telephone reminder calls, text messages and e-mail dependent on the patients preference for communication
2. Follow up by clinic clerk or social worker (general outpatients) or psychiatrist (this is mandated under the Mental Health Act) if the patient does not show
3. Identification of root cause of no shows and implementation of a free local patient transport service.
4. Implementation of a policy that means all patients except mental health are formally discharged after two consecutive no shows. This has been a difficult transition for our very caring staff but does mean our resources are being used to provide care to the greatest number possible.
Give the size of WA and the remoteness of many communities telehealth had been used effectively for chronic disease management for many years. In recent years however there has been utilisation of the medium in acute care setting’s also. Dr Fiona Wood heads up the State Burns Unit for WA and has been a passionate driver of the use of telehealth for acute burn assessment and early intervention either prior to the patients transportation down to Perth or to enable the patient to receive appropriate care in their local community. On the back of this the State implemented an emergency telehealth service to support rural hospitals and remote nursing posts. Over a period of 2 years all of these facilities were equipped with camera’s that enable the emergency telehealth consultant to zoom in and out of the patient cubicle and provide real time advice to the local team on patient management. There have been a number of high profile cases where nurses have been coached to provide life saving interventions by an emergency consultant thousand of km’s away. Both of these services have been effective in reducing resistance to using Telehealth on the back of Consultant preference to be in the same room as the patient to provide quality care. Funding for telehealth consultations in an activity based model remains an ongoing challenge. Currently the site where the patient presents receives the funding rather than the site where the medical expertise and advice is being delivered from.
We also implemented a combination of the telephone reminder calls, text messages and e-mail dependent on the patients preference like many others on this discussion but were finding we could not drop our no show rate below 20%. Armadale also provides care to a low social economic population group and often our outpatient clerks were unable to contact the patient prior to or after a missed appointment. We ran a service improvement project for 6 months to map out the reasons why patients did not show and were able to reduce the no show rate to 10% with a free patient transport service. The reality was though that for many of these patients there were daily life challenges that were of a higher priority that attending an outpatient appointment so whilst it has been a difficult transition for our very caring staff we now formally discharge people after two consecutive no shows to an outpatient clinic.
Last winter our PT also experienced increased referrals from our acute medical teams for a just in case check prior to a decision being made regarding the patients discharge. The just in case check added no value in many cases to the patients care plan or outcome. This increase in referrals appeared to be two fold a) there had been a spike in inpatient falls on medical wards b) the acute medical model meant that more than 60% of patients were being discharged within 72 hours. The medical team became increasing concerned that early discharge would also lead to increased falls at home and re-admissions. The PT team were unable to cope with the increased demand resulting in many medically well patients experiencing an increased LOS waiting for a mobility assessment and others experiencing an increased LOS due to limited access to value add interventions such as chest physiotherapy. Data on readmission rates and LOS was effective in managing the perception and concerns of the medical teams but like Sharon the most successful strategy was the implementation of standardised care protocols and a decision by the MDT at the daily journey board meeting if a request was made to deviate from the standardised protocol. The transparency of the MDT discussion was a powerful tool for team education around appropriate referrals to PT but also served as an informal, real time forum for peer review of patient management approaches across the team.
The National Emergency Access Target (NEAT) has meant there has been a sustained focus on discharge before 10am across WA hospitals. Many of the strategies outlined by Brian have been implemented and providing national benchmark data to Heads of Dept has been effective in engaging medical teams and developing a shared understanding about hospital priorities and drivers. The strategies that have made the biggest difference on a day to day basis however have been
1. Implementation of a Nursing Coordinator: Patient flow role. This person leads daily bed meetings at 10am and 3pm with Heads of Dept, Nurse Unit Managers of wards, ED and allied health. Information from the morning and afternoon ward round underpins a shared understanding of planned discharges for the day and ensures the MDT is focused on tasks required to safely achieve the discharge.
2. Implementation of Care Coordination team: comprised of 3 allied health and 1 nurse, the CC team is responsible for implementing and coordinating care plans for frequent presenters to the hospital and receives referrals for discharge coordination for complex cases on day 1 of their admission.
3. Long Stay patient committee – Chaired by the Director of Nursing and meets weekly to oversee care coordination of patients whose LOS is above the national benchmark target. The Director of Clinical Services and Director of Allied Health also attend this meeting to ensure decisions regarding a patients care can be made in a timely fashion.