high risk individuals dr harley aish, clinical champion 18 april 2013
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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 - PowerPoint PPT PresentationTRANSCRIPT
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