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: 1. Identify and manage individuals at high risk of hospitalisation2. Improve primary care responses to acute events 3. Enablers of better individual care – pathways, and e-tools (e.g. Shared Care)4. Child health – aligns with Work Streams and NRHP

High Risk Individuals

Identify

• Algorithm run in 3 DHBs monthly

• ROC = 0.72

• Combined algorithm

• ROC = 0.79

Provide

• List to practices, score >30% risk readmission in 12 months

Review

• List must be considered by a clinician

Triage

• Which patient could we make a difference

• “Ammenability”

Connect

• 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

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

Contact details

Full name – GAIHN Title DDI: 09 Mobile: 02Insert email address

www.gaihn.health.nz