A model of access combining triage with initial management reduced waiting time for community outpatient services: a stepped wedge cluster randomised controlled trial.

BACKGROUND: Long waiting times are associated with public community outpatient health services. This trial aimed to determine if a new model of care based on evidence-based strategies that improved patient flow in two small pilot trials could be used to reduce waiting time across a variety of services. The key principle of the Specific Timely Appointments for Triage (STAT) model is that patients are booked directly into protected assessment appointments and triage is combined with initial management as an alternative to a waiting list and triage system. METHODS: A stepped wedge cluster randomised controlled trial was conducted between October 2015 and March 2017, involving 3116 patients at eight sites across a major Australian metropolitan health network. RESULTS: The intervention reduced waiting time to first appointment by 33.8% (IRR = 0.663, 95% CI 0.516 to 0.852, P = 0.001). Median waiting time decreased from a median of 42 days (IQR 19 to 86) in the control period to a median of 24 days (IQR 13 to 48) in the intervention period. A substantial reduction in variability was also noted. The model did not impact on most secondary outcomes, including time to second appointment, likelihood of discharge by 12 weeks and number of appointments provided, but was associated with a small increase in the rate of missed appointments. CONCLUSIONS: Broad-scale implementation of a model of access and triage that combined triage with initial management and actively managed the relationship between supply and demand achieved substantial reductions in waiting time without adversely impacting on other aspects of care. The reductions in waiting time are likely to have been driven, primarily, by substantial reductions for those patients previously considered low priority. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615001016527 registration date: 29/09/2015.

Are wait lists inevitable in subacute ambulatory and community health services? A qualitative analysis.

Objectives Wait lists are common in ambulatory and community-based services. The aim of the present study was to explore managers' perceptions of factors that contribute to wait times. Methods A qualitative study was conducted using semi-structured interviews with managers and team leaders of ambulatory and community health services within a large health network. Interviews were transcribed and coded, and the codes were then grouped into themes and subthemes. Results Representatives from 26 services participated in the project. Four major themes were identified. Three themes related to reasons and factors contributing to increased wait time for services (inefficient intake and scheduling processes; service disruptions due to human resource issues; and high service demand). A fourth theme related to staff attitudes towards wait times and acceptance and acknowledgement of wait lists. Conclusions Service providers perceive high demand to be a key driver of wait times, but a range of other factors also contributes and may represent opportunities for improving access to care. These other factors include improving process efficiencies, greater consistency of service delivery through more efficient management of human resources and shifting to more consumer-centred approaches in measuring wait times in order to drive improvements in patient flow. What is known about the topic? Wait times are common in out-patient and ambulatory services. These services experience high demand, which is likely to continue to grow as health service delivery shifts from hospital to community settings. What does this paper add? Although demand is an important driver of wait times, there are other modifiable factors that also contribute, including process inefficiencies and service disruption related to human resource issues. An underlying staff attitude of acceptance of wait times appears to be an additional barrier to improving access. What are the implications for practitioners? The findings of the present study suggest that there are opportunities for improving access to ambulatory and community health services through more efficient use of existing resources. However, a more consumer-focused approach regarding acceptability of wait times is needed to help drive change.

Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial.

BACKGROUND: Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional "waitlist and triage" model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction. METHODS/DESIGN: A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12 weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial. DISCUSSION: This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12615001016527 . Approved 15/9/2015.

Evaluation of a transition care cognitive assessment and management pilot.

This paper describes the evaluation of the Transition Care Cognitive Assessment and Management Pilot (TC CAMP) at a residential care facility in Victoria, Australia. Transition care aims to provide a goal-oriented, time-limited service to older people at the conclusion of an episode of hospital care. The TC CAMP was established to specifically meet the needs of people with cognitive impairment. The purpose of this study was to evaluate the implementation and effectiveness of the TC CAMP. The evaluation sought to explore the perceptions of staff and family carers, and outcomes for the person with dementia. Methods consisted of file audits, focus groups and individual interviews with nursing staff and carers. This evaluation found that it was possible to provide appropriate transition care to people with cognitive impairment who exhibited behavioural and psychological symptoms of dementia. The TC CAMP achieved length of stay and readmission rates that were comparable with transition care for cognitively intact people. The role of the Clinical Nurse Consultant was highly valued by staff and families involved in TC CAMP. The findings from TC CAMP suggest a suitable environment, availability of trained and resourced nursing and clinical staff and clear roles and expectations for all stakeholders should be considered in implementation of this model of care.