Western Healthlinks – Implementation of a Priority Assessment Service within Health Navigation

Introduction:

The Emergency Department is often the first place patients go to when they are feeling unwell. Whether this is due to low health literacy, a lack of social support, poor discharge planning or difficulty in navigating the healthcare system, the result is an increased cost and burden on our Emergency Departments and hospitals.

Silver Chain are working in partnership with Western Health to deliver the Western Healthlinks program. It is a three-year pilot which commenced in 2016 and aims to reduce the number of unnecessary hospital admissions through Health Navigation and access to the Priority Response Assessment (PRA) Service.

A 24-hour central phone number is available for patients to contact if they feel unwell and a Registered Nurse conducts an initial nursing assessment over the phone.  If assessed as a non-emergency, a nurse will attend the patient’s home and conduct a home nursing assessment (PRA service) between the hours of 7am and 10pm.

Based on the patient’s presenting symptoms, nursing assessment, and liaison with the patient’s GP, a PRA can take different pathways. These include, but are not limited to, the patient staying at home with GP follow up within 24-48 hours, an outpatient review at Western Health’s Specialty or Rapid Access Clinic after discussion with the Registrar of the patient’s discharging medical treating team, or an admission to the Emergency Department if assessed as medically necessary.

Medical Governance is provided by the patient’s GP during business hours. Our Silver Chain GP is available to provide advice on the best way to manage the patient after-hours.

Aim and theory of change:

Not all hospital admissions can be avoided, but for those that are at-risk for frequently re-presenting to hospital, it is through a thorough nursing assessment in the home and collaboration with the client’s GP and the other health services involved in the patient’s care, can the option of staying at home or need for attending ED be truly explored.

Targeted population and Stakeholders

Melbourne’s west is one of the most linguistically and culturally diverse areas. Through collaboration with patients and their GPs, other health providers involved in the patient’s care and Western Health, our Navigators are delivering Western Healthlinks to patients who are highly vulnerable and most at-risk of presenting to hospital.

Timeline

Since commencement of Western Healthlinks in November 2016, we have had 3159 active patients in our program. Of those, 1801 PRA visits have been attended.

73% of patients remained at home.

Highlights

Western Health Data collected over 24 months shows that average bed days per patient was reduced from 6.03 to 4.55. This represents a reduction of 9556 bed days over 24 months, or 13.8 beds per day (↓ 24.5%) (p<0.001)

Discussions:

The results have shown that PRA has been beneficial in keeping patients at home through assessment, collaboration with GPs and coordination of services in the community.

An increased prevalence of mental health presentations, however, has made accessing community mental health support challenging and often results in an ED admission.