IMPACCT- A needs-based, solutions-focused community service

Aim

Develop and implement a needs-driven, community-based interdisciplinary service to enable earlier hospital discharge, reduce non-acute hospital usage, and improve coordinated, holistic care for high-needs patients.

Outcomes

Earlier Hospital Discharge

• 3,987 patients discharged earlier from hospital - each with an average service length of stay of ~5.8 days, releasing a potential 23,125 beds days.

Reduced Non-Acute Hospital Use

• Hospital alternatives resulted in 62 patients not admitted to hospital, nor re-admitted within a 28-day period.
• 162 patients were referred for hospital avoidance intervention.
• Hospital length of stay post intervention has decreased from an average of 30 days to 21 days.
• 119 Emergency Department (ED) presentations were avoided.
• Improved Care Coordination - average increase from 195 to 496 patients/month now receiving care in the community through onward referral.
• Patient Satisfaction - 92.4% to 100% patient satisfaction rate with the service.

The prevalence of neurodevelopmental (ND) disorders among children continues to increase and there is a growing need for early identification and assessment that can best inform intervention and promote future outcomes. Most children require comprehensive multidisciplinary developmental assessments due to the severity, complexity and/or diagnostic uncertainty (Bentley et al., 2024). More than 85% of children diagnosed with Autism have mention of developmental concerns before 36 months of age when accessing medical supports. Unfortunately, far less than half receive an evaluation by that time. This contributes to an average age of diagnosis above four years of age (Hine et al., 2020).

Further, children from disadvantaged backgrounds including socioeconomic and diverse ethnicities are disproportionately affected (Hine et al., 2020). There is a significant need for review of current developmental assessment procedures, along with identification of novel systems in triaging and caring for neurodiverse (ND) children and their families at the right time (Hine et al., 2020). The journey to assessment and diagnosis from parent perspectives is well understood--parents report it takes an average of three to five professionals, with significant time commitments that result in stress and frustration. Families also report barriers to diagnosis such as false reassurance or dismissal from health care providers, lack of expertise by those they consult with, and their own lack of developmental knowledge and awareness that can also be influenced by cultural differences.

Families spend a lot of time waiting to reach experts, experience misdiagnosis and need for further assessment resulting in more wait times (Makino et al., 2021). Expensive private assessments were sometimes more favourable as they had shorter wait times but can result in disproportionate access to care. Interestingly, no significant differences in parental satisfaction, perceptions of family centred care, or shared decision-making were reported between a Paediatrician-led model and an allied health clinician-led model. There were also no significant differences in delivering care via in-person clinic appointments only versus mixed mode delivery with telehealth supports (Makino et al., 2021). Complex developmental and behavioural concerns must be understood at several diagnostic levels including behavioural, neuropsychological, biological and environmental and is understandably demanding of clinicians' time (O’Keeffe & Macaulay, 2012). This, however, means that health services face challenges in balancing significant demand as well as provision of timely care that meets best practice standards.

Due to the significant demand for developmental assessment, lengthy waitlists are a serious and ongoing battle for healthcare providers. MDT child diagnostic services are the best practice for evaluating children with complex ND disorders however major barriers exist to accessing publicly funded paediatric developmental clinics in a timely manner. The literature addressing this is limited. Therefore, new and more streamlined approaches that maintain quality and best practice standards are required.

Background

Globally, the costs of hospital care are rising, and concentrated on a minority of high-needs patients and increased non-acute healthcare utilisation1. High-needs patients are diverse, and no single care model can address all their needs.

However, effective strategies include:

• engaging external services with patient and care partner-specific care plans
• coordinating healthcare that also considers social, economic, and behavioural factors
• identifying and targeting high-needs patients earlier and more intentionally.

Locally, population growth is significantly increasing demand for health services, which will further accelerate in the coming decade, adding pressure to our health system. Demand is not only growing due to population growth but also because people are using hospitals more frequently. Nearly a third of hospital admissions could be avoided or shortened with access to community services. Local community services are difficult to navigate and are challenged by fragmented and duplicative offerings across primary, secondary, and tertiary care. Internally, our Hospital and Health Service operational areas often work in silos, leading to service duplication and fragmented care pathways. Entry into community services is hindered by narrow inclusion criteria and inefficient goal setting, resulting in reduced program flow and poorly defined length of stay (LOS) Key Performance Indicators (KPIs). Enhanced healthcare navigation, wrap-around support, inter-agency cooperation, and one-stop-shop health services have been highlighted as models to mitigate and manage demand.

To address these issues, the IMPACCT Services project aimed to determine if a community-based, multi-disciplinary service providing needs-driven rather than criteria-based interventions for adult patients on the Gold Coast would:

• sustain earlier hospital discharge and integrate access to health services across sectors
• reduce non-acute hospital or emergency department utilisation
• enable reablement and access to an individual’s community
• proactively identify and manage risks for high-needs patients
• improve health literacy for patients, families, and carers
• develop care plans that are safe, flexible, practical, and sustainable, considering the combination of physical, social, economic, and behavioural factors contributing to patients’ unique needs.

Discussion

What was necessary for the project to succeed?

• Adoption of a Solutions-Focused Mindset:  Emphasising practical, needs-based interventions over rigid criteria and an emphasis on interdisciplinary assessments to address the challenges of community-based interventions.
• Expanding Inclusion Criteria: Broadening the scope to include more patients.
• Non-Labour Budget: Allocating funds for minor equipment and emergency supplies to promote hospital avoidance.
• One-Stop-Shop Phone Line: Providing a single point of contact for referrals, streamlining the process and reducing barriers.
• Integrated Care Services: Promoting a multi-disciplinary, innovative approach to community service provision.

Lessons Learnt and Limitations

• Developing Strong Links with GPs: Challenges in advertising, promotion, and the number of available services.
• Difficulty with QAS links: Initial challenges in establishing connections, improved more recently.
• Discrete Program Funding: Programs often funded as stand-alone initiatives, limiting integration.
• Change Management: Resistance within existing teams.
• Geographical Limitations:  Expansion hindered by infrastructure and lack of funding for capital works, particularly in the northern corridor of the Gold Coast.

Strengths, Weaknesses, and Opportunities

Strengths:

• recruitment of a flexible, engaged, and senior team
• multi-disciplinary model of care
• solutions-focused, needs-based intervention rather than criteria-led, profession-specific model of care.

Weaknesses:

• resistance to a multi-disciplinary response from existing teams
• initial challenges in developing strong links with Primary Care providers and QAS
• overcoming historical perceptions of inclusion criteria.

Opportunities:

• adoption of the QAS Falls Co-response program.
• robust linkages with the Complex Management Unit and Aged Care inpatient services, providing innovative ideas
  for supporting internal patient flow
• Integrated Care-led Community Services Redesign
• HHS focus on relational coordination
• opportunity to develop a true multi-disciplinary model of care, contrasting with profession-specific teams.

What would you do differently?

• Advocate earlier for an IMPACCT-specific coordinator position, which is still awaiting permanent funding.
• Advocate for a northern hub at the point of implementation. Where Else in Queensland Health Can You See This Project Succeeding?
• This model of service could be implemented in any HHS, both metro and rural. The needs of the Gold Coast community are not isolated and reflect the growing need to remain flexible to meet the needs of Queenslanders across all stages of their healthcare journey.

Next Steps

• Complete evaluation of the IMPRINT service.
• Evaluate the QAS Falls Co-response program’s effect on HHS patient outcomes.
• Continue advocating for the expansion of the service into the northern corridor of the Gold Coast.
• Further improve avenues for earlier hospital discharge by providing an Allied Health discharge-to-assess model as a future arm of MAPS.
• Expansion of MAPS to provide a rapid GP response service with 12 hours referral response.

References

1. Pashchenko, Svetlana, and Ponpoje Porapakkarm. "Medical spending in the US: facts from the Medical Expenditure Panel Survey data set." Fiscal Studies 37.3-4 (2016): 689-716.

2. Long, Peter, et al. "Effective care for high-need patients." Washington, DC: National Academy of Medicine (2017).

3. Loeb, Danielle F., et al. "Primary care physician insights into a typology of the complex patient in primary care." The Annals of Family Medicine 13.5 (2015): 451-455.

4. Blumenthal, David, et al. "Caring for high-need, high-cost patients—an urgent priority." n Engl j Med 375.10 (2016): 909-911.

5. State of Queensland (Queensland Health). “Gold Coast Health Local Area Needs Assessment 2022-2025.” December 2022. https://www.publications.qld.gov.au/ckan-publications-attachments-prod/resources/7b79e26e-49db-4ae1-b198-efd7761e7f6c/pub.0313_lana-report-a4-2022-final-v6-web-friendly.pdf?ETag=047ce3306df12bf04e481bbdd6899779

6. Primary Care Gold Coast. “Gold Coast Primary Health Network Needs Assessment 2023”. 2023. https://gcphn.org.au/wp-content/uploads/2024/04/2023-Health-Needs-Assessment-Final-V3.pdf

7. Gold Coast Health. “Appropriateness Evaluation Protocol 2021”. November 2021. http://gcmis.sth.health.qld.gov.au/QvAJAXZfc/opendoc.htm?document=QVDocs/Appropriateness%20Evaluation%20Protocol%20Summary%20Nov%202021/AEPSummary.0.0.03_20211103.qvw 8. Gold Coast Health. “Community Services Redesign”. November 2021. https://gchweb.sth.health.qld.gov.au/documents/COM001349