Helping High Risk Patients
20,000 Days Campaign Learning Session 3
11-12 March 2013
Clinical Champion:
Dr Harley Aish
Team Members:
Damien Hannah (Localities); John Streeter (ProCare); Josey
Lawrence (ProCare); Kate Moodabe (Localities); Keith Crump
(ProCare); Nick Swain (ProCare/GAIHN); Pauline Sanders-Telfer;
Louise McCarthy (GAIHN); Sharon Pearce
20,000 Days Support:
Ian Hutchby (Improvement Advisor)
Monique Davies (Project Manager)
Our project will….
We aim to provide coordinated planned management of our identified high risk primary care patients
reducing the demand for unplanned hospital admissions and bed days by 10% (1625 bed days)
Our targeted intervention is the development of a locality based primary /secondary physician role
based in primary care with a focus of supporting general practitioners to improve the management of
high risk medical patients with long term conditions. This is underway through the Localities initiatives
via our Strategic Project Management Office.
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Long term goal of each primary care locality having a designated medical team with a
primary/secondary care physician working between the services so that the clinical network
relationship is built around the patient journey not dislocated at the point of admission and
discharge
•
Improved management of patients identified with the PRM tool, who are at high risk of
readmission as measured by reduction in predicted bed days
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The development of physician clinics within primary care whereby the physician can review
patient management with the primary care team and review specific patient care if appropriate
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Improved and more appropriate referral to secondary care specialist services
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Development of targeted continuing professional development for primary care teams
Who are High Risk Patients?.....
 Patients discharged from Counties facilities are allocated a risk score. The PARR
algorithm looks at discharges in the previous month and uses criteria such as age,
gender, ethnicity, deprivation score, distance to hospital from the home, and the
number of admissions in the last 12 months as well as the associated principal and
secondary diagnoses. Based on these criteria, a risk score is allocated. This score
gives a percentage chance, or probability, of an unplanned readmission for that
particular patient within 12 months.
 The PARR scores for patients discharged in the previous month are sent to PHOs on
the 5th day of each month. PHOs and practices then use the lists to identify patients
who are both at high risk of readmission to hospital, and are amenable to treatment
or other intervention. The cut-off score is currently nominated as 30%.
 Patients with a score of 30% or higher are classified as high risk.
High Risk Patients - Their GP’s Location
The following table groups high risk patients according to where their GP is located:
High Risk Patients
**Total Enrolments
% of All High Risk
Patients
% of Total Enrolments
in Locality
Manukau
2,728
164,284
36%
1.7%
Mangere/Otara
2,218
141,331
30%
1.6%
Eastern
1,028
107,111
14%
1.4%
Franklin
609
46,098
8%
1.3%
Enrolled
elsewhere
933
TOTAL
7,516
12%
**Enrolments per PHO register as at 30 September 2012
Sharon Pearce: Counties Manukau Decision Support
Ethnicity of our High Risk Patients
Ethnic Group
High Risk Patients
%
European
3,172
42%
Pacific
2,185
29%
Maaori
1,437
19%
Asian
571
8%
Other/Unknown
151
2%
TOTAL
7,516
100%
48% of HR
patients are of
Maaori or Pacific
ethnicity
Sharon Pearce: Counties Manukau Decision Support
Driver Diagram
Change Packages
Secondary Drivers
(Theory of change)
Change Ideas Tested
(describe process)
Communication of HRI lists to
GP Practices
Individual patient lists or combined HRI practice lists?
Working with GPs to gauge their preference for patient
individualised reports or combined HRI Practice lists
Practice Readiness for HRI
interventions
Practice Readiness Survey (selected Manukau GP Practices)
Survey of ProCare practices to gain an understanding of their
use of the risk reports and how they are focusing care on
HRIs, what additional resources they would find useful and if
they wished to take part in further PDSA testing
Automation of risk score from
DHBs to be provided monthly
Manual process at present, Waitamata DHB automating and
CM and ADHB to follow
Predictive Risk Modelling Flow Chart
Categories for Triage of HRI
Most Successful PDSA Cycles?
•
PDSA: Otara GP Practice
The Otara GP practice nurses completed a (VHIU) RAG assessment with 11 of the 23 HR
patients identified for their practice in the previous month. The PDSA prediction found to be
correct, 50% of patients were amenable to an intervention.
Next PDSA: to repeat using the Trigger Tool in conjunction with the RAG form. Ask if VHIU
for assistance with training in methodology for the nurses
•
PDSA: GPs doing the Identification of Contributors (Condition complexity, self
management, palliative care, social determinants, mental health, other)
Measures Summary
-
Measures related to Aim
Graphs of key measures
Which of your run charts would you give to senior leadership to use?
Include Collaborative Dashboard
Ian?
Primary Care Interventions for
High Risk Individuals – Pilot
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Primary Care Interventions for High Risk Individuals – Pilot
•
Summary
This pilot is intended to support Primary Care in the management of High Risk Individuals through a suite of
extended interventions and when required, co-ordination with secondary support and allied health services. The
intention is to strengthen Primary Care as a patients ‘home-base’ where required services outside of a practices
resource can assist in the management of care. Locality SMO’s and MDT expertise will be available for case
conferences on a regular basis. There will be funding and invoicing support to assist in the process of care
planning.
Pilot Practices – TBC
HRI Definition
20,000 per locality
≥ 30% risk of re-admission (PARR
Report)
Pilot Purpose
To increase management capability of HRI’s in the Primary Care setting.
To develop an HRI intervention tool with GP’s to include services outside what available in the current funding
structure
Increased access to services in a timely manner, which is appropriate for HRI care planning.
To provide funding support and management mechanism for invoicing.
Pilot Objectives
To develop an intervention tool appropriate to the HRI needs.
To strengthen Primary Care as the ‘home’ healthcare provider with patients.
Increase access to necessary services in a timely manner with funding support.
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•
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Start Date: March, 2013
Timeframe: 12-18 months
Achievements to date
Now meeting weekly at ProCare, Grafton
The group have been meeting weekly since the last learning session and this has enabled us to
progress our work and PDSA cycles
Better management of high risk individuals (HRIs) –the current situation?
A Predictive Risk Algorithm (PRM) tool has been developed for patients at high risk of admission to
hospital. Phase 2 which is underway at present, is looking to revise the algorithm incorporating
primary care data which has shown to improve its predictive power
The monthly PRM risk stratification reports are being sent from the three DHBs to all PHOs and
reports of High Risk Individuals (HRIs) are delivered monthly to Procare Practices. The group are
working on PDSAs on the formatting of the reports (i.e. individual vs practice lists) possible
interventions areas and practice acceptance and readiness for provision of interventions for HRIs
Next Steps?
Work with Decision Support Services to establish automation processes
Enhanced integrated care for high risk individuals - developing the intervention model
Progressing HRI pilot development with the Strategic Project Management Office, 2 GP practices per
locality, practices have been identified via the locality managers and DHB for implementation of
prototype service, with project brief completed