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

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

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

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  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

  4. Identify • Algorithm run in 3 DHBs monthly • ROC = 0.72 • Combined algorithm • ROC = 0.79

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

  6. Review • List must be considered by a clinician

  7. Triage • Which patient could we make a difference • “Ammenability”

  8. Connect

  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

  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

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

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