GOLD COAST INTEGRATED CARE PROGRAM Dr Graham Wright G.P. Gold Coast GP Super Clinic Integrated Care Program

PURPOSE OF THE PROGRAM

• Can improved integration of care between General Practice and Hospital Care improve provision of care AND be cost effective?

• Improve communication between G.P.s and Hospital • Reduce duplication of investigations • Identify risks and intervene early to reduce the rate of hospital admissions,

particularly in high risk patients with chronic disease. • Establish out patient specialist clinics with short wait times for rapid access

• This would be studied as part of a Griffith University research program, under

Prof Paul Scuffham • The final report on the program after 3 years is due in 2018

GOLD COAST INTEGRATED CARE PROGRAM

• The development of the program started in 2013 • The first patients were enrolled in March 2015 • Target population of 1500 patients enrolled was reached by September 2016

and more patients are still ‘on-boarding’

• A detailed assessment for all patients was developed and data collected. • Further study developed an index, the “Biarri” score – expressed as a

percentage, for Risk of Hospitalisation in the next 12 months (RoH) • Patients identified with a score > 65% to be targeted to improve care and

reduce their risk of hospitalisation

WHO IS INVOLVED?

• 15 G.P. practices are involved in the program • 112 G.P.s are taking part

• As of April 2016, there were 131,000 patients registered at these practices

• The total Gold Coast population at last count was 530,000

• Approximately 25% of the Gold Coast population are registered with

practices taking part in the program.

WHO / HOW WERE PATIENTS SELECTED FOR THE COHORT?

• Gold Coast University Hospital data was analysed for admissions and diagnosis.

• Initially, “The Big Four” diagnosis were selected • Diabetes • Heart Disease • Chronic Respiratory Disease • Renal Disease

• Disease registers were created for these four groups • Patients were identified who were admitted with a chronic disease. The

disease registers were then matched at each practice to identify mutual patients and their G.P.

• G.P.’s then reviewed the list of patients for entry to the program

THE COHORT VS. HSS TOTAL - ROH

0

50

100

150

200

250

0-10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100Risk of Hospitalisation

Cohort

0

5000

10000

15000

20000

25000

30000

35000

40000

0-10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100Risk of Hospitalisation

HSS

“ON-BOARDING” • This is the initial phase of a patient being enrolled into the program • Patient is selected by chronic disease and admission (hospital) or by G.P. • Patient is invited by the G.P. practice to join the program • Patient agrees and consents to join the program • An initial telephone interview is carried out and data entry started • The patient attends the practice for an assessment with a “nurse navigator” who is

embedded in the G.P. practice. • The nurse navigator identifies patient health and social issues which may addressed

to reduce the risk of hospital admission • The patient, nurse navigator and G.P. then consult and complete a management

plan based on the patients needs and risk prevention. • This may involve a G.P. management plan and EPC team care referrals to allied

health team members as well as accessing services provided by the program

THE SHARED CARE RECORD • The program developed a “shared care record” which is accessible via a

web portal by the patient, members of their care team and hospital if admitted acutely.

• An initial summary for the patient containing information from the G.P. practice was uploaded, containing investigations, correspondence, medications and previous consultations.

• An interface “Record Connect” was developed to link the major G.P. medical software ( Best Practice, Medical Director, Zedmed, Practix ) to the shared care record which uploads details of all G.P. consultations with a patients enrolled in the program.

• As of 31.10.16 10,543 event summaries have been entered by general practice

OUT PATIENT CLINICS

• Integrated care is running out patient clinics for cohort patients, identified as needing additional specialist management.

• The intent is to avert an admission by initiating management advice from a specialist and actioning it by their G.P. in the community

• The clinics have a short (no) wait time for access

“VALUE ADDING” TO THE G.P.

• The program is to install a server in each of the participating practices to provide analysis of both cohort and non cohort patients of that practice. The first went live 2.11.2016

• It shows admissions to hospital for cohort and all of the practices patients

APPOINTMENTS

• It also shows out patient appointment details for all the practices patients and elective bookings for surgery.

CHRONIC DISEASE REGISTERS

•The software allows a rapid review of chronic disease patients, identifying those with higher risk of hospitalisation.

• It shows information on each patient

PATIENT SUMMARY

• From each disease register item, you can click and drill down to get more detail on an individual patient and their Risk of Hospitalisation (RoH)

OTHER BENEFITS TO THE G.P.

• Cohort patients have a shared care entry when they are discharged from hospital. Even if there is no discharge summary, the G.P. can see details on the shared care record.

• An entry made to the shared care record generates a message sent to the G.P. which appears in their incoming results with a hyperlink to the shared care record.

• Out patient clinic letters will be in the shared care record