Outpatient Reform: Summary of Studies

Modes of Outpatient reform Cross References to Studies

This article summarises published and quasi-published studies into more efficient models of outpatient care delivery. There appear to be six generic modes of reform. These are summarised in the table above which also cross references the 19 studies outlined below.

1.  Brooks, E & Younce, J. (2007). A Case Management Model for the Ambulatory Care Patient Experience Chronic Pain. AAACN Viewpoint.

This article describes the development and implementation of a nurse-led clinic which can perform pain assessment and evaluation. Patients can submit tests by post and nurse can coordinate the reissuing and filling of prescriptions delivered to the pharmacy for certified mailing. Face to face interviews with the nurse take place every six months and any change in condition triggers escalation referral.

2.  Moore, K., Johnson, G. Fortner, B.V. & Houts, A.C. (2008). The AIM Higher Initiative: New Procedures Implemented for Assessment, Information, and Management of Chemotherapy Toxicities in Community Oncology Clinics. Clinical Journal of Oncology Nursing, 12 (2), 298-238.

The Assessment, Information, and Management (AIM) Higher Initiative, a quality improvement program undertaken at 15 community oncology practices, was initiated to improve the AIM of chemotherapy-related toxicities in patients with cancer.  Led by a nurse champion at each of the clinics, a variety of new procedures, processes and tools were implemented to improve quality of care. Nurses and practice administrators can use the quality improvement processes to generate changes in procedures and practices.

3.  Australian Agency for International Development (2001). HIV/AIDS Treatment and Care Evaluation of the Thailand-Australia HIV/AIDS Ambulatory Care Project. Quality Assurance Series, No. 28, December. 

According to the authors, it is likely that greater satisfaction leads patients to become (1) more involved in their care, (2) increase adherence to recommended treatment protocols and follow-up, (3) which may contribute to improved health status. This Australia/Thailand HIV study found that there are four major factors underlying satisfaction:

•  Communication skills
•  Clinical effectiveness
•  Waiting time
•  Information

4.  De Vries, B., Darling-Fisher, C., Thomas, A.C., Belanger-Shugart E.B. (2008). Implementation and Outcomes of Group Medical Appointments in an Outpatient Specialty Care Clinic. Journal of the American Academy of Nurse Practitioners. 20(3), 163-169.

Study of a nurse practitioner-facilitated group medical appointment (GMA) intervention for COPD clients in a pulmonary practice. Receiving care in a group format, it was found that NP-facilitated GMAs are feasible and can help improve health outcomes. Both patients and provider response to the GMA were very positive. The GMA is described as an innovative solution for the management of chronic disease patient that is comprehensive, time efficient, reimbursable and well suited to NP practice which can be implemented in most practice settings.

5.  Pearson, M.L., Mattke, S., Shaw, R., Ridely, M.S. & Wiseman, S.H. Patient Self-Management Support Programs: An Evaluation. Final Contract Report (Prepared by RAND Health under Contract No. 282-00-0005). Rockville, MD: Agency for Healthcare Research and Quality; November 2007.

Self management support programs aim to change patients’ behaviour by increasing patients’ self-efficacy and knowledge. Pearson et al suggested that improved behaviour is likely to lead to better disease control which would in turn, lead to better patient outcomes and reduced utilization of health care services, particularly preventable emergency room visits and hospitalizations, and ultimately to reduced costs.

6.  Meates, M. (1997). Personal Practice. Ambulatory Paediatrics – Making a Difference. Archives of Disease in Childhood, Vol. 76 (5), 468-476.
See also: Paediatric Ambulatory Care Unit, Victoria Hospital

www.fifefire.gov.uk/orgs/

Based on the philosophy that ‘children should not be admitted to hospital unless absolutely necessary’, Victoria Hospital provides home visit service that offers nursing care to children to support ambulatory care (following brief episodes of hospital care) and to facilitate early discharge for the child and family.

7.  Lorfallah, H., Farag, K., Hassan, I. & Watson, R. (2005). One-stop Hysteroscopy Clinic for Postmenopausal Bleeding. J Reprod Med, Vol. 50(2), 101-107.

The report evaluated the role and feasibility of the one-stop clinic for management of postmenopausal bleeding, based on the use of transvaginal ultrasound and hysteroscopic examination under local anaesthesia. Based on analysis of 308 patients referred to the clinical between October 2000 and May 2002, the study concluded that the one-stop clinic is effective in reducing the number of hospital visits per patient as well as hospital admissions and the waiting list.

8.  Pottle, A. (2005). A Nurse-led Rapid Access Chest Pain Clinic – Experience from the First Three Years. European Journal of Cardiovascular Nursing, 4, 227-233.

The Rapid Assess Chest Pain Clinics (RACPCs) are designed to provide prompt cardiological assessment of new onset chest pain in patients without known coronary disease. The service is aimed at ambulatory patients. This particular research has demonstrated that nurses can successfully run RACPCs without an increased risk of incorrect diagnosis. These clinics offer patients timely access to assessment of their chest pain and facilitate early diagnosis of cardiac disease. They are also well accepted by the patients attending the clinic.

9.  Humphreys, K. & Moos, R. (2006). Can Encouraging Substance Abuse Patients to Participate in Self-Help Groups Reduce Demand for Health Care? A Quasi-Experimental Study. Alcoholism: Clinical and Experimental Research, Vol. 25(5), 711-716.

This study evaluated whether patients treated in 12-step programs rely less on professionally provided services and more on self-help groups after discharge, thereby reducing long-term health care costs. Their finding shows that professional treatment programs which emphasize self-help approaches increase patients reliance on cost-free self-help groups and thereby lower subsequent health care costs.

See also follow up study: Humphreys, K. Moos, R.H. (2007). Encouraging Posttreatment Self-Help Group Involvement to Reduce Demand for Continuing Care Service: Two-Year Clinical and Utilization Outcomes. American Psychiatric Association, Vol. 5, 193-198.

10.  DeCoster, V.A. & George, L. (2005). An Empowerment Approach for Elders Living with Diabetes: A Pilot Study of a Community-Based Self-Help Group – The Diabetes Club. Educational Gerontology, Vol. 31(9), 699-713.

This project sought to develop and pilot-test a peer-led community-based, self-help intervention for elders with diabetes – the Diabetes Club. The intervention targeted diabetes self-efficacy, seeking to empower elders then increase diabetes self-care behaviour targets, resulting in improved glycemic control. Club members and social workers collectively developed, implemented, tested intervention protocols. Findings showed significant improvements in diabetes self-efficacy, self-care behaviours and reduction of glycosolated haemoglobin. The results are promising, demonstrating the benefits of social-work involvement in diabetes and the potential of elders helping themselves and each other.

11.  Ickovics, J.R., Kershaw, T.S., Westdahl, C., Magriples, U., Massey, Z., Reynold, H. & Rising, S.S. (2007). Group Prenatal Care and Perinatal Outcomes: A Randomized Controlled Trial. Obstet Gynecol, Vol. 110 (2), 330-339.

This study aimed to determine whether group prenatal care improves pregnancy outcomes, psychosocial function, and patient satisfaction and to examine potential cost differences. Results suggested that women in group sessions were less likely to have suboptimal prenatal care, had significantly better prenatal knowledge, felt more ready for labor and delivery, and had greater satisfaction with care. Breastfeeding initiation was higher in group care. There were no differences in birth weight nor in costs associated with prenatal care of delivery.

12.  Outpatient Anticoagulation Service, Gloucestershire Health Community.

http://www.gloshospitals.org.uk/ppi/leaflets/pdf/GHPI0563.pdf

A nurse-led clinic aims to monitor treatment and adjust the dose of anticoagulant. Clinics are held twice a week where blood test will take place. Patients will be discharged from the clinic once the correct dose of anticoagulant is found. Home visits can be arranged for those who are unable to attend their blood test at the clinic.

13.  Bradford Haematuria Pathway, Reducing Outpatient Appointments.

http://www.nhsbenchmarking.nhs.uk/docs/HICpresentation11.pdf
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ImprovementStories/PursuingPerfectionAViewfromAcrossthePond.htm

At Bradford Health and Social Care Community, patients are not passive recipients of care but more like collaborators for change, for example, patients are invited to multidisciplinary team meeting and their viewpoints are taken into account. As a result, patients who are tested negatively for pathology would receive a letter rather than waiting for a follow up outpatient appointment.  They still have the choice of meeting their consultant if they wish, but most people prefer to receive a letter. This is a saving of 300 clinic slots a year that can be reallocated.

14.  Golden Jubilee National Hospital: Introducing Patient Focussed Booking to reduce DNA rates.

http://www.nodelaysscotland.scot.nhs.uk/CaseStudies/CaseStudyItems/Pages/GoldenJubileeNationalHospitalIntroducingPatientFocussedBookingtoreduceDNArates.aspx

In order to improve the average DNA rate (7.7%) within the outpatient department, the hospital adopted the Patient Focussed Booking (PFB) approach to arrange appointment. PFB clinic held in October 2007 for minor procedures has seen DNA rates drop to 1.7%; while dermatology PFB clinic’s DNA rates have dropped to 1.8%. PFB clinics can better utilise clinical sessions, improve patient satisfaction and improve quality of care.

For more information on PFB, please visit: http://www.scotland.gov.uk/Resource/Doc/89501/0021443.pdf

15.  Best Practice in Radiology to Reduce Outpatient Activity and Manage Flow.

http://www.natpact.nhs.uk/demand_management/downloads/BigWizard_1.2_step3.pdf

Radiology departments produce X-rays for emergency patients, inpatients and outpatients through the same facility. Staff manages the workload by prioritising patients according to clinical need. This often means that emergency patients are seen first and outpatients typically face long waits. Some units have redesigned their service into three separate processes for the three patient groups.

16.  Virtual outpatient clinics in sleep services, Aintree University Hospitals NHS.

http://www.skillsforhealth.org.uk/workforce-design-development/workforce-design-and-planning/competence-based-workforce-design/New-and-innovative-ways-of-working/Virtual-outpatient-clinics-in-sleep-services.aspx

Virtual clinics in outpatient setting to improve outpatient capacity and improve patient care. A consultant respiratory physician undertakes virtual clinics from his computer by reviewing all the referrals and arranging for any relevant sleep studies to be done prior to the first clinic appointment. Treatment for sleep problems can be initiated even before the patient is seen in clinic. This includes life style changes such as losing weight and reducing alcohol and caffeine intake. Specially trained clinical physiologists can interpret sleep studies and instruct patients in the use of domestic CPAP (Continuous Airways Pressure) treatment for sleep apnoea even before attending the outpatient clinics.

17.  Ohio Health’s Outpatient Clinics.

http://www.allbusiness.com/health-care/medical-practice-family/14560393-1.html

In the 1980s, outpatient and ambulatory care made up about 20 percent of hospital revenue in America, but now, it’s more like 45 percent.  At Ohio State, outpatient services make up 36 percent of the system’s $1.5 billion in annual revenue, and in response over the past five years, the system has added 10 outpatient centres to deal with this demand in a more cost effective community setting away for acute hospitals.

18.  Wandsworth Community Virtual Ward.

http://www.kingsfund.org.uk/document.rm?id=8621&lt

Introduced with the aim of replicating the multi-disciplinary approach of the hospital ward, but in a community setting. Uses predictive risk modelling that was developed by the King’s Fund to target patients with a 70% chance of admission to hospital in the next 12 months. But this model could be adapted to encompass patients who have a history of high outpatient usage e.g. patients with long-term conditions. Weekly multi-disciplinary team meetings; daily activity rounds with GP; community matrons and ward clerks; information entered directly into GP’s computers via direct access. All necessary outpatient investigations, visiting schedules, and information flow between all services co-ordinated by ward clerk.

19  Managed Care Model in Southwark PCT.

http://www.southwarkpct.nhs.uk/documents/5281.pdf

In Southwark PCT and Acute Trusts, the whole health economy has been responsible for implementing a range of initiatives for long term conditions in order to help reduce outpatient activities, these include:

• a managed care model, with patients stratified according to their risk and then managed on a self care, disease or case management basis with each patient receiving a personal care plan.
• community based service alternative where appropriate, including specialist community nurse led services, chronic illness clinics in primary/community settings with supporting diagnostic services.
• self-care programmes for patients, including the Expert Patient Programme

20. Loxford Polysystem.

http://www.redbridge.nhs.uk/loxford/1-1polysystems.asp

Polysystems include GP surgeries, pharmacies, dental services, community and voluntary services and more. What these services have in common is a local focus on healthcare provision, with a drive to promoting well-being and keeping people healthy.  Polysystems are a collaborative approach to joined-up services will enable patients to experience a seamless service without delays as they move through and around the system, independent of where they access it.