High Risk Individuals Dr Harley Aish, Clinical Champion 18 April 2013

GAIHN Greater Auckland Integrated Health Network Partners: DHBs: Auckland, Waitemata, Counties-Manukau PHOs: Auckland, East Health, Procare, Total Healthcare GAIHN Objective: To reduce acute/avoidable hospital admissions. Aim: To improve integration between primary and secondary care, and to strengthen the regional capacity of primary care. GAIHN’s role: To lead and coordinate collaborative processes to develop initiatives which are then implemented across the region by the partners. Four Work Streams: Identify and manage individuals at high risk of hospitalisation Improve primary care responses to acute events Enablers of better individual care – pathways, and e-tools (e.g. Shared Care) Child health – aligns with Work Streams and NRHP

High Risk Individuals A: Identify HRI B: Provide C: Review D: Triage E: Connect Also known as PARR tool, patients at risk of readmission, Predictive Risk Modelling

Identify Algorithm run in 3 DHBs monthly ROC = 0.72 Combined algorithm A: Identify HRI Current tool in DHBs increase frequency Ideal = primary data algorithm continue to validate reliability B: Provide C: Review D: Triage E: Connect Combined = date of admission + primary care data

Provide List to practices, score >30% risk readmission in 12 months A: Identify HRI B: Provide User-centred design Useful info Individual messages and list C: Review D: Triage E: Connect Monthly lists to practices, score >30%, patients admitted in last month All three DHBs for some practices Next Sending patient individual messages to practices, i.e. straight to PMS inbox Running algorithm in practice, ?monthly review of enrolled population, ?patient by patient, like a CVD risk assessment

Review List must be considered by a clinician A: Identify HRI B: Provide C: Review A regular new process D: Triage E: Connect List Review by nurse? By GP? Making it happen consistently

Triage Which patient could we make a difference “Ammenability” A: Identify HRI B: Provide C: Review D: Triage Consistent evaluation “Amenable” E: Connect Exclude Transferred Deceased Self-limiting Credibility: GPs expect this list to be those who things can be changed, but requires clinician who knows patient, more than an algorithm, to evaluate Difficulty: “amenability” is a function of GP’s confidence, experience with tools and interventions

Connect We are on the journey, testing these interventions A: Identify HRI B: Provide C: Review D: Triage E: Connect Home visits E-shared care, careplan goals Multi-discipline team meeting Medication review Mental health screen Self Mgmt = health literacy Whanau Ora = Social determinants, home environment Pneumovax, fluvax Palliative care, advanced care plans We are on the journey, testing these interventions

47y Maori F, Diabetes, nephrotic synd, CHF, starting dialysis 39y Samoan F, SLE, nephropathy, invasive aspergillous, lung cavities, lobectomy 73y Cook Is, M, IHD, Diabetes, HTn, renal impairment, “perfect compliance” 47y Samoan F, Obesity, Anxiety, gout, hard to engage

Lessons learnt “not our problem” “the list is rubbish” Timeliness of reports Does your DHB want to reduce (re)admissions? Proof of efficacy vs. Plan-Do-Study-Act vs. viewing admissions as system failures “I know who is at risk” Poor correlation between clinician judgement and actual readmission

Lessons learnt (cont.) Start with a funded package Allocate Nurses, don’t wait for GPs! Importance of supportive Senior General Physician reviewing complex cases Complex environment, multiple stakeholders, needs strong clinical champion and experienced project manager , don’t expect more from same resources

Contact details www.gaihn.health.nz Full name – GAIHN Title DDI: 09 Mobile: 02 Insert email address www.gaihn.health.nz