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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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