Access block and inefficiencies in the organization and funding of rehabilitation services in Australia

Transcription

1 Access block and inefficiencies in the organization and funding of rehabilitation services in Australia Dr Peter W New* 1, 2, 3, A/P Christopher J Poulos 4, 5 1. Head, Acute Rehabilitation, Continuing Care Program, Southern Health, Victoria 2. Head, Spinal Rehabilitation Unit, Caulfield General Medical Centre, Bayside Health, Victoria 3. Departments of Medicine and Epidemiology & Preventive Medicine, Monash University, Monash University, Victoria 4 Network Clinical Director (Medicine, ED, Cardiac Services, Neurosciences and Rehabilitation), Southern Hospitals Network, South Eastern Sydney and Illawarra Area Health Service. 5 Clinical Associate Professor, University of Wollongong, NSW

2 OVERVIEW Introduction: population issues hospital demand & patient flow disability & rehab Current rehabilitation services Vic & NSW Problems current organization & delivery rehabilitation services + case studies Proposals improve organization & delivery rehabilitation services

3 INTRODUCTION: Population Issues Acute inpatient beds 1990s Living longer Ageing population Pop n > 65yo 13% % 2051 Australian Bureau of Statistics. Population Projections, Australia, Canberra: ABS 2006, (ABS cat. no ) Chronic diseases : 80% burden costs Australian Institute of Health and Welfare. Chronic disease and associated risk factors in Australia, Canberra: AIHW, 2006 (AIHW Cat No. PHE 81) Health workforce shortage

4 Hospital Demand: increasing Hospital admissions 3% = 2x rate pop n A&E 34% cf State of Our Public Hospitals Report 2008 Hospital delays ambulance bypasses double 35% A&E needing admit >8/24 wait bed 25% semi-urgent elective surgery wait >90 days Your Hospitals Vic Gov report 2008

5 Hospital Demand: Response Response focused acute esp A&E A&E attendances Post-acute support Chronic disease Mx community Cameron PA. Med J Aust 2006; 184: Braitberg G. Med J Aust 2007; 187:

6 Patient Flow Theory Natural variability flow Artificial variability flow Manage flow important quality & safety patient care resource efficiency / costs right patient, right place, right time, right care Managing Patient Flow: A focus on clinical processes. Joint commission Resources (

7 Patient Flow: Natural Variability Random - cannot be eliminated Vary arrival rates But seasonal/weekend variation Vary LOS Vary staff expertise Vary severity/complexity patients BUT: patient streams specialisation Acute A&E: Admit vs non-admit Rehab: stroke, SCI, amputee etc

8 Patient Flow: Artificial Variability Identify & Inflow & outflow barriers Benchmarking: eg AROC Larger units > ability tolerate & Mx variability Acute: elective admissions greatest contributor Rehab No W/end admit / therapy Late in day admissions

9 Demand response & rehabilitation Rehab (sub-acute) seen separate from acute Little attention in acute to secondary / tertiary prevention to optimise rehab outcomes Relatively little focus patient flow in/out IP rehab Quality and Care Continuity Branch, Acute Health Division. Sub-Acute/Acute Interface Project: final report. Melbourne: Victorian DHS, 2001 Poulos CJ et al Aust New Zealand Health Policy 2007; 4: 3

10 Disability in Australia Disability: with age 20% population disability 6% pop n profound or sever core-activity limitation Australian Bureau of Statistics. Disability, ageing and carers, Australia: summary of findings, Canberra: ABS, (ABS Cat. No ) older pop n live alone Australian Bureau of Statistics. Household and family projections, Australia, 2001 to Canberra: ABS, (ABS Cat. No ) Ability remain community more dependant functional independence cf medical factors role rehabilitation

11 Rehabilitation a health strategy.. that aims to enable people with.. disability to achieve and maintain optimal functioning in interaction with the environment Stucki G et al. J Rehabil Med 2007; 39: multidisciplinary, medically directed services that aim to improve the functioning of an individual after illness or injury and that are evidenced by comprehensive assessment of function and realistic and negotiated goals Australasian Faculty of Rehabilitation Medicine. Rehabilitation service categories BA4AFB9155AE86F

12 OVERVIEW REHAB SERVICES 2006 Rehab Australia >53,000 IP (78%=NSW & VIC) 20% < 65 yo Private > public BUT public disability cf private Most D/C community rehabilitation glue b/n acute & community Simmonds F et al. Aust Health Rev 2008; 32: Simmonds F et al. Aust Health Rev 2007; 31 Suppl 1: S31-S53

13 Supply rehabilitation physicians: 2008 AFRM

14 Rehabilitation Facilities Victoria All major public IP stand-alone V good ambulatory most metro areas NSW centre & community: goal directed Home based rehab: some time limits (2-6 weeks) collocation with acute trend to re-allocate small hospitals rehab Relatively poor access ambulatory rehab

15 PROBLEMS CURRENT ORGANISATION & DELIVERY REHAB SERVICES Systems issues Funding issues Workforce constraints State-Federal & aged care-disability Lack evidence-based health care management Lack evidence-based health care (rehab) policy Paterson J. National healthcare reform: the last picture show. Melbourne: Victorian Government Department of Human Services, 1996 Willcox S et al. Revitalising health reform time to act. Melbourne: Australian Institute of Health Policy Studies, 2007

16 Hospital-based care: functional decline Acute hospitals: function patients b/c inactivity prolonged recovery & LOS Clinical Epidemiology and Health Services Evaluation Unit, Melbourne Health. Best practice approaches to minimise functional decline in the older person across the acute, sub-acute and residential aged care settings. Melbourne: Victorian DHS, 2004 Preventable complications outcomes: function, QoL, legal LOS length of stay pressure ulcers, falls, malnutrition & contractures Stacey MC. Preventing pressure ulcers. Med J Aust 2004; 180: 316 Middleton MH et al.prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals. Intern Med J 2001; 31:

17 Acute rehabilitation hospital Rehab not engaged early Delays rehab referral & assessment Delay referral >> delay assessment Poulos CJ et al. Managing the interface between acute care and rehabilitation can utilization review assist? Aust Health Rev 2007; 31 Suppl 1: S129-S140 After accepted rehab (subacute) allied health discharge planning Functional decline + preventable complications + LOS

18 Public rehab hospitals Older/sub-optimal physical environment Lack single rooms Privacy Infection control risk eg viral gastro ability admit VRE+ Lack ceiling track hoists OHS & nursing burden care Design not conducive independence & non-therapy physical activity

19 Rehab hospitals Private rehab capacity less disabled Public rehab More disabled Sicker / comorbidity??? Location public rehab as stand-alone Efficiency, safety, workforce Transfer patients: elective & non-elective After-hours rostering

20 Rehab hospital: admission times Admission times to rehab wards Site A (n=1405) 49.3% Site B (n=1012) 37.0% % 52.9% % 10.1%

21 Rehab hospital: transfer costs to acute Costs Site A: 28 beds $41,000=$56/bed/week Site 76 beds $192,000=$49/bed/week Reasons Elective investigations Elective specialty consultations/reviews Emergency medical/surgical

22 Ambulatory Rehab rehab consultants cf IP NSW cf Vic V poor centre-based specialist & community rehab Little Domiciliary rehab Medicare access to community allied health via GPs BUT NOT Rehab specialist!

23 Exit block: Younger adults disabilities Current situation Severe, persisting, acquired disabilities No longer need IP rehab Not covered compensation barriers to aged care Current options Wait months unnecessarily in hospital AFTER need IP rehab finishes NSW: Lifetime Care & Support only motor vehicle Vic: My Future My Choice wait 4-8/12!!!

24 Exit block: Funding for carers Lack funding paid carers Bureaucratic processes restrict/delay access 5-7 hours/week BUT if need more: Younger age: stuffed! Older: EACH & Linkages: BUT Wait times: >6 months post DC Limit hours

25 Aids & equipment Inadequate system provision Long wait: > 30 days post D/C 6-9/12 Variation between regions Orthosis (mobility) or projective footwear (diabetic) months preventable complications: falls, amputations cf prosthetic limb schemes equitable, responsive, $ responsible

26 Equipment & home mods Equipment: eg wheelchair Max funding $6,000 (electric) cf top $15-20,000 Stairs2.jpg some patients need multiple w/chairs! Home mods: $4,400 x 1/lifetime cf bathroom: $15-20,000 cf ramp: $10-20,000 cf cost care in hospital: $3,500/week

27 Interface aged-care services Current improvements focused aged-care care & support not disability Transitional Care Program >65 yo & risk of HLC 8-12/52 support + limited therapy = restorative care Concerns cost-effectiveness cf alternative eg rehab Australian Government Department of Health and Ageing. Transition Care Program guidelines Canberra: Department of Health and Ageing, 2005 Gray LC et al. Transition care: will it deliver? Med J Aust 2008; 188:

28 Rehabilitation exit block project 2 IP rehab units Melbourne (2008): 48 beds neuro (40%) + ortho (30%) + general (30%) Prospectively document all admissions Document causes and LOS exit block 6/12 and 4/12: total bed days=11,602 n=233, male=female Age: median 48 (IQR 58 69) LOS: 32 (IQR ),

29 Rehabilitation exit block results Patients with barriers 15.6% 1/3 multiple barriers Beds blocked 2,082/11,602 bed days 5.0 beds/day=10.3% Internal 61% NWB 27.8% Family 13.5% Clin psych 6.1% Med unstable 5.2% External 39% Home mods 14.6% Carer funding 12.2% HLC/LLC 4.2%

30 Rehab patient flow mapping AcrobatDocument

31

32 Rehab patient flow simulator Quicktime movie simulation

33 Simulation of Acute to Sub-acute Flow Scenario Request to Admit (days) Wait List to Admit (days) Occupancy (%) Avg Queue Max Queue Base Long stay fall* Long stay miracle** Movers LOS fall^^ Medi-Hostel 70% Medi-Hostel 100% Med/Long LOS Rise^ * 25% Medium Stayers LOS reduced by 7 days, 25% Long Stayers LOS reduced by 14 days ** 100% Medium Stayers LOS reduced by 7 days, 100% Long Stayers LOS reduced by 50 days ^^ 50% Movers (under 30 days) LOS reduced by 2 days ^ 20% Medium Stayers LOS up by 14 days, 20% Long Stayers LOS up by 14 days

34 Pilot Non Weight Bearing TCP in Orthopaedic Rehabilitation Unit Aim: to provide a suitable environment for patients during the NWB period low level care facility or at home n=18, age 71yr (range 46-91)-no min age LOS: Acute (mean 10, 0-83), Rehab (mean 19, 1-49), TCP NWB (33, 8-95), Read rehab (rehab 11, 6-16) Cost saving: $2,145/patient

35 PROPOSALS & OPPORTUNITIES IMPROVE ORGANISATION & DELIVERY REHAB SERVICES Improve rehab organisation & delivery patient flow & outcomes acute & sub-acute State-Federal Health departments Hospital networks

36 Rehab team processes: opportunities Role monitor and RV exit block Internal vs external factors Improve team meeting and DC planning Improve patient centred goal setting

37 National Rehabilitation Strategy No current Federal body role rehab NHHRC No current rehab consideration Bennett C. Beyond the blame game. MJA 2008; 189: 31-2 National Rehab Strategy (AFRM) Policy, Planning, Service provision, Research Workforce A C34069AA

38 State rehab strategy State-wide reviews to complement National Qld Health review community rehab-finished Vic DHS review subacute services-started Need consider specialist streams: Vic DHS/TAC: Vic SCI Action Group? Others eg TBI

39 Acute subacute community Service review & redesign Organisation-system approach Manager patient flow ± team review LOS =5.5/10 Buy-in, engagement, collaborative, non-confrontational Systematic Evidenced-based

40 Acute subacute community Resources assist improvement clinical redesign principles Phillips PA Med J Aust 2008; 188 (6 Suppl): S7-S8. http DHS resources: service redesign Engineering-health care partnership systems design, analysis & control tools (eg queuing theory) Proctor P et al. Building a better delivery system: A new engineering/health care partnership. Committee on Engineering and the Health Care System. Institute of Medicine & National Academy of Engineering.

41 Rehab & Aged care Many principles & issues discussed also apply to aged care services Cooperation & collaboration b/n rehab & aged care programs Overlap some aspect Avoid duplication similar services Limit delays parallel assessment

42 Prevent disability & complications activity levels hospital patients functional decline acute & subacute Chen CC et al. Arch Phys Med Rehabil 2002; 83: Jones CT et al. Australas J Ageing 2006; 25:

43 Prevent disability & complications Early referral rehab patients-esp severe disability Start rehab early: in acute Systems for early identification and referral of appropriate patients for rehab Poulos CJ, et al. Aust Health Rev 2007; 31 Suppl 1: S129-S140 Poulos CJ, et al. Aust Health Rev 2007; 31 Suppl 1: S79-S85. outcomes & LOS ± avoid IP rehab Maulden SA, et al. Arch Phys Med Rehabil 2005; 86 (12 Suppl 2): S34-S40 Munin MC, et al. JAMA 1998; 279: Scivoletto G, et al Arch Phys Med Rehabil 2005; 86:

44 Redesign IP rehab delivery intensity efficiency & outcomes Stroke: Kwakkel G, et al. Stroke 2004; 35: Chen CC et al. Arch Phys Med Rehabil 2002; 83: Sub-specialisation: hub & spoke model Esp SCI, stroke/abi, amputee, burns access beds: eg non-traumatic SCI unit acute rehab: median 35 (IQR 22-63) acute ready rehab TF: median 14 (IQR ) Role changes / substitution eg early OT home visit & rapid mods team

45 Improve ambulatory rehab Centre + community + home-based Closer to home: patient centred Cheaper cf IP rehab relevance to lived reality Meet demand Funding issues growth not just substitution Role rehab in community allied health via Medicare

46 access aids, equip & home mods $$$ Streamlined Accessible Equitable Economic & QoL benefits

47 Support younger patients disability Range suitable accessible accommodation options to aged-care based high-level care Smaller group residential Adequate $ home-based carers Senate Community Affairs References Committee. Chapter 4. Young people in residential aged care facilities. In: Quality and equity in aged care. Canberra: Commonwealth of Australia, 2005: /aged_care04/report/c04.htm TCP ± intensity allied health

48 Broader range IP rehab & subacute services efficiency if stratify: based on care needs acute =intensive less acute =more supportive Poulos CJ et al Aust New Zealand Health Policy 2007; 4: 3 holding units Waiting home mods, carers etc Non-weight bearing LL #

49 CONCLUSIONS Current sub-acute reforms focus aged-care Clinical Epidemiology and Health Services Evaluation Unit, Melbourne Health. Best practice approaches to minimise functional decline in the older person across the acute, sub-acute and residential aged care settings. Melbourne: Victorian Government Department of Human Services, Continuing Care Section, Programs Branch, Metropolitan Health and Aged Care Services Division. Improving care for older people: a policy for health services. Melbourne: Victorian Government Department of Human Services, Need include focus on rehab specific reforms in current wave of health system changes

50 CONCLUSIONS Addressing presented issues needs buy-in: Federal /State Regional health authorities local effectiveness & efficiency health care system by implementing changes suggested access to IP beds: acute & sub-acute outcomes costs

51 ACKNOWLEDGEMENTS New PW, Poulos CJ. Functional improvement of the Australian health care system can rehabilitation assist? MJA. 2008; 189: Monash Institute Health Services Research Keith Stockman & Fiona Dickson Data access: CGMC & KC Southern Health Senior Medical Staff research grant 2008 Rehab exit block

52 QUESTIONS?