1 / 14

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

karim
Télécharger la présentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related