The Transitional Aged Care Program (TACP) in Hunter New England Local Health District (HNELHD) is a holistic home-based therapy and nursing program. The program is designed to help people over the age of 65 years, and Aboriginal and Torres Strait Islander people over 50 years, to regain their functionality at home after a hospital admission. The program also works to limit their entry into residential aged care following an admission to hospital.
TACP uses a multidisciplinary team approach to provide patients with person-centered holistic care for up to 12 weeks. An in-hospital Aged Care Assessment Team (ACAT) review is performed in conjunction with a TACP case manager assessment, to determine whether the patient will benefit from the individualised support and therapy provided through the program.
The TACP program captures feedback from patients via patient-reported measures (PRMs) surveys. This includes patient-reported outcome measures (PROMs) that help to inform consultations and care planning, response to treatment regimens and when patients require referrals to the multidisciplinary team and other services.
Patient-reported measures workflow
-
As part of onboarding eligible patients to the TACP program, the case manager discusses PRMs and registers patients in the Health Outcome Patient Experience (HOPE) platform.
-
Patient receives a paper-based PROMIS-29 survey to complete at home within the first two weeks of TACP enrolment.
-
TACP nurse discusses survey results with patient.
-
The TACP nurse gives completed survey to the case manager who transcribes survey into HOPE portal.
-
PROMIS-29 results shared during daily handover and during scheduled allied health case conference.
-
Surveys are completed on entry to the program, prior to discharge, and as clinically indicated.
-
Survey completion tracked on spreadsheet and daily nurse scheduler advises staff on when clients need to do surveys.
Consumer story
Pamela, a 79-year-old female, lived alone with support from services to assist her with cleaning, meals, and lawn maintenance, and was able to drive. Following a stroke, Pamela had a complicated, six-month hospital admission, experiencing multiple health issues including a right shoulder dislocation, autoimmune neutropenia and thrombocytopenia, a skin tear haematoma requiring surgery, urinary tract infection and exacerbation of her pre-existing severe rheumatoid arthritis.
Following her discharge from hospital and participation in the TACP program, Pamela’s initial PROMIS-29 survey results showed moderate pain interference partially due to a fall the day prior to survey completion, severe physical function limitations and severe inability to participate in social roles and activities. Pamela received extensive multidisciplinary intervention from TACP including wound care, participation in balance and strengthening program, mobility practice, personal care enablement, nutrition education and home modifications.
Pamela’s second PROMIS-29 results, prior to discharge from the TACP program, demonstrated improvements in anxiety, depression, pain interference and her ability to participate in social roles and activities. Pamela achieved her goals of returning home (with ongoing long term assistance), increased mobility and balance, and the ability to care for her dog.
Even though she has significant physical limitations, results of the second PROMIS 29 identified that she can continue to stay at home with appropriate supports in place and care for her dog.
*Name has been changed for patient privacy.
Benefits of patient-reported measures
Benefits for the patient
- Surveys help to guide discussions with patients and highlight shared care planning for internal and external service referrals and treatment options.
- PRMs help patients and service providers to set realistic goals, and understand the patient input required to achieve these goals.
- PRMs validate the use of holistic care within TACP, and show that individual needs are met when the results of the follow-up survey are reviewed.
Benefits for the service
- Data demonstrates that most clients enrolled in TACP show outcome improvements in the PROMIS-29 domains from program commencement through to program completion.
- As the TACP operates in rural and remote areas, PRMs helps to identify referral gaps as support services are less available.
- SPRMs ensure that assessors are making appropriate and timely referrals. PRMs assist less experienced clinicians to identify at assessment which referrals need to be made.
Benefits for the organisation
- PRMs are a standing agenda item at the HNELHD TACP Managers bi-monthly meeting, encouraging managers to discuss any issues, barriers to implementation and team education.
Helpful tips for other services
Review survey responses with the patient to initiate open discussion and helps to identify areas of concern for the patient.
Engage the whole team in the ‘Why?', 'How?’ and ‘benefits’ of using PRMs, rather than leaving it to a few people to drive.
Keep an updated database of patients on TACP to ensure follow-up surveys are not missed close to discharge.
Clinical engagement approach
The Executive Director, Clinical Governance, Operational Directors and Network Manager, Aged Care & Rehabilitation Services HNELHD supported the implementation of Patient Reported Measures (PRMs) as a priority for each of the TACP services across the Hunter New England Local Health District (HNELHD).
The district PRMs leads provided the following support to the TACP service:
- presenting to TACP managers at their bimonthly meeting, covering general information about the purpose and benefits of PRMs; an introduction to the PROMIS 29 Quality of Life tool and how responses can be used at the individual level for care planning; and the requirements from TACP managers to support implementation.
- working with each of the TACP services and managers individually to map out a tailored workflow process and education plan
- a combination of face-to-face training and online training which included nursing and allied health staff.
- ongoing support for staff and TACP managers through regular check-ins and troubleshooting during implementation.
Organisational structure
Governance
- A PRMs Governance and Management Policy Compliance Procedure outlines the organisational structure, role responsibilities and reporting expectations for all PRMs collected within the district.
- The Executive Director Clinical Governance chairs the Patient Advisory Group, which meets every two months, and is the Executive Sponsor for the PRMs Program in HNE LHD, and communicates PRMs clinical cohorts and surveys to operational executive directors.
- Operational Executive Directors and Sector General Managers endorse PRMs collection in their clinical portfolio areas.
- Clinical Networks and Stream Coordinators, Service Managers and PRMs Improvement Program Facilitators work together to support PRMs implementation in endorsed clinical services.
- Local services report to their Sector Partnering with Consumers / Clinical Safety and Quality Committees on PRMs activity.
- PRMs issues that cannot be resolved at a local level are reported via an exception report to the District Partnering with Consumers Committee.
- Sector Partnering with Consumers Committees/Clinical Safety & Quality Committees include PRMs activity in their annual report to District Partnering with Consumers Committee.
- PRMs Improvement Program Facilitators provide an annual report to the Board Community and Patient Partnership Committee.
Acknowledgements
We acknowledge and thank the following for their participation in this project:
- Liana Hancock, Case Manager, Transitional Aged Care Program
- Matthew Jones, Manager, Transitional Aged Care Program
- Melissa O’Brien, Executive Director, Clinical Governance
- Lisa Shaw, Improvement Program Facilitator, Patient Reported Measures Improvement
- Maeve Barron, Improvement Facilitator, Patient Reported Measures Program
- Mary Bond, Manager, Health System Improvement, Clinical Governance
- Rebecca Francis, Project Officer, Patient Reported Measures