Integrated Care for Emergency Medical Patients - Irish Acute Medicine Programme

Abstract

Background: GPs experiencing access difficulties for medical patients in all hospitals. Hospitals only accepted admission referrals to ED Department, long waits experienced , admitted patients waited lengthy periods on trolleys. Patients most affected were older patients with co morbidities, delays resulting in unsafe practice and poor outcomes. Description of Programme: National Acute Medicine Programme established with the Royal College of Physicians. Objective to integrate Primary and Secondary care for emergency medical patients. Programme linked local General Practitioners and local hospital, redesigned medical flow, streamed acute patients away from ED to Acute Medical Assessment Units, to improve access. The programme also focussed on intense early treatment, shortening LOS, enabling early discharge. This resulted in more beds available to meet access demand and reduce trolley waits. Aim and theory of change: Triple Aim; Quality – patients were seen by senior doctor within 1 hour, direct access by GP. Patient Experience – patient journey shortened, trolley waits reduced. Value – increased ambulatory care, reduced admissions, shortened LOS, bed savings. Strategy for change; Governance Group; Local General Practitioners, specialists, managers formed. GPs referred directly to Acute Medical Assessment Unit (AMAU). Rapid assessment by senior clinicians in AMAU, “investigate to discharge” not “admit to investigate”. Detailed analysis of GP demand, hospital flows, capacity, discharge to general practice, rapid diagnostics, access to rapid OPD. Performance improvement cycles, monthly performance feedback workshops, coaching. Targeted population and stakeholders: Targeted population 250,000 medical admissions to the 33 Irish Hospitals. Stakeholders; GPs, medical consultants and hospital managers. Timeline: Programme designed 2010, ramped up over 7 years, now operational in each of the hospitals. Highlights: - Patient experience time reduced, 67% of hospitals now meeting target. - LOS reduced 1.6 days, freeing over 1000 medical beds. - Trolley waits reduced 17%. - GPs report improved access, GPs and patients report improved experience. - Improvements against a background of 30% increase in demand. Sustainability and Transferability: Programme ramped up to each hospital. Hospitals implementing the programme reliably achieved improvements, which were transferable to other hospitals. Discussion: The Programme demonstrated a national evidence based programme implemented across a whole health system, beneficial results aligning to the triple aim; improved quality, improved patient experience and improved value. Efficiencies gained allowed Irish Health Service to cope with the austerity measures successfully between 2010 and 2016 (34% reduction in hospital resources) and large increase in demand. Conclusion: Redesigned model between General Practitioners and acute services resulted in reorientation to ambulatory care and early discharge. This has allowed improved access for patients, improved patient experienced times, improved quality of service and improved value. Lessons Learned: - Importance of clinical leadership. - Critical local health network governance by General Practitioners, hospital clinicians, managers. - Analysis of each eco system flow model and capacity requirement. - Demonstration of power of data to change practice, regular feedback and coaching.