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Integrated Care model changing lives and reducing preventable admissions

A newly-established Wide Bay Hospital and Health Service model of care is delivering flexible and multidisciplinary care to patients – including in their own homes – while helping to reduce lengths of stay and the need for hospital admissions.

The WBHHS Integrated Care Access Team (iCAT) is using a holistic approach to providing care for patients with chronic illnesses, focusing on wellness and community management, and ending the cycle of repeat emergency admissions and hospitalisations.

iCAT is made up of work streams including nurse practitioners, Nurse Navigators, diabetes education, Aged Care Assessment, Rehabilitation Team, Hospital In The Home, medical, nursing, physiotherapy, occupational therapy, dietetics and speech pathology, to best support patients needing frequent sub-acute care.

Wide Bay Hospital and Health Board Chair Peta Jamieson said iCAT was a great demonstration of key goals in WBHHS’s strategic plan, Care Comes First… Through Patients’ Eyes, including enhancing holistic health care and early intervention.

“The iCAT model is all about providing the right care, at the right time, in the right place – acknowledging that this sometimes isn’t inside the walls of a hospital,” Ms Jamieson said.

“By delivering proactive and agile care to patients with chronic diseases, iCAT aims to reduce overall preventable hospital admissions and also manage conditions earlier so they don’t end up as acute presentations down the track.

“It’s also about encouraging people to manage their conditions better at home or in the community, and to take steps to improve their own wellness.

“Given our region has higher proportions of older people and incidences of chronic illness than state averages, modern models of care like these are crucial.”

WBHHS Chief Executive Debbie Carroll said the establishment of iCAT was part of a move to rethink the way health care was delivered.

“Up until now, we’ve probably tended to think hospital care first, community care after. But under this model, we want to be thinking of iCAT first, if appropriate, and hospital care only if it’s necessary,” Ms Carroll said.

“As well as having clinicians with different areas of expertise working together in a planned approach with the patient in their own home as much as possible, iCAT can identify other needs – especially if they are socially isolated.

“That may mean helping them to arrange appointments with their GP, checking that their social needs are being met, linking them with services that deliver scripts to their home or making sure they have the help they need to get their groceries.

“The end goal is to ensure a patient’s needs are being met in an environment where they’re most comfortable, while also maintaining our hospital capacity for more acute cases.”

One example of the outstanding work done by the iCAT team was their rapid response supporting people with Chronic Obstructive Pulmonary Disease (COPD) throughout the COVID-19 pandemic. Wide Bay has among the highest number of COPD sufferers across Australia, with rates estimated at about 25% higher than the statewide average.

“The agility of our iCAT service meant were able to contact 462 high-risk COPD patients in the Wide Bay in a two-week period which ensured their safety and wellness was supported throughout the COVID-19 pandemic,” iCAT Acting Operations Director Jacqueline Haskew said.

“Our iCAT team were overwhelmed by the grateful patient feedback they received during the phone calls.

“In addition to this work, our team also proactively supported 361 of our most chronic and complex patients in the Wide Bay region with Integrated Care management plans to support hospital avoidance.”

That support work has led to a decrease in COPD presentations to WBHHS emergency departments, when typically presentations would increase in winter.

Hervey Bay woman Margaret Anderson is among the patients to benefits from iCAT, now being managed by the team locally instead of travelling to Maryborough for her weekly treatment.

“I was diagnosed with leukemia two years ago and the only thing that keeps me alive is platelet transfusion, which I had to go every week to Maryborough Hospital to have – I found it too much,” Mrs Anderson said.

“I really did find travel difficult as I don’t have much energy as it is, and it took the complete day away from me. That flowed over to the next day because I was tired from how the trip drained energy from me.

“Now it’s just an hour-and-a-half appointment (at the iCAT clinic in Hervey Bay), which is just marvellous and I’m very grateful.

“The care I get is outstanding, it’s wonderful treatment with caring and professional staff – I’m lucky to have them caring for me.”

WBHHS iCAT is developing alternative pathways and will work in partnership with local general practitioners, aged care facilities, Queensland Ambulance Service and other health stakeholders to deliver patient-centred care.

ENDS

Last updated: 30 June 2020