Winter Strategy care for high risk patients; 2017 and beyond

A joint Primary Care and Hospital Sector program for heightened care for high-risk patients through the 2017 influenza season in Northern NSW has led to ongoing refinement for 2018 and beyond.

The full 2017 evaluation report and 2018 program details can be found here

In February 2017 a joint project between Northern New South Wales Local Health District and North Coast Primary Health Network was conceived to develop a more integrated strategy to better respond to increased risk to patients’ and their healthcare demands over winter (WS17). Aims and strategies were developed through a co-design process with managers, clinicians and patients.

Methods for Implementation and evaluation
Self-selected practices were provided with $225.70 per patient for additional nurse-led proactive care for their frail/vulnerable patients for a 17 week program covering the influenza season in 2017. Practices were asked to identify their “at risk” cohort who would benefit from the program and register patients through a website within the LHD data system so they were flagged in both the general practice and hospital/Community Health systems. This clinician-driven patient selection process had been successfully used in a previous Integrated Care Collaborative program, showing general practice could select patient cohorts with a high risk of hospitalisation while supporting clinician engagement.

The evaluation sought to capture the feasibility and acceptability of the approach and gather improvement ideas for subsequent iterations. Mixed methods were used to evaluate the patient and clinician experience.

There was strong interest in the program from primary care teams, and high completion rates for general practice teams and patients. Clinicians reported improved patient care and demonstrated improved professional satisfaction. A global patient reported measure of health (PROMIS-10) failed to show any significant change. A locally developed patient reported experience measure showed very high patient engagement and satisfaction at the start of the program and no significant change at the end in the limited sample with paired data.

The Winter Strategy 2017 program demonstrated the ability to generate public-private cross sector progress on health system integration. It showed that clinicians and managers will engage around this well recognised point of patient care. The primary care clinicians valued the program, generally believing it improved patient care and professional satisfaction.

Clinician driven patient selection is likely to be an important ingredient for clinician engagement however it is prone to generating selection bias toward those patients who are regular attenders and well engaged with the general practice. This is reflected in the very high patient experience baseline scores.

Use of Sick Day Action Plans was continued beyond the conclusion of the program in some practices. The program also helped to establish practice nurses as chronic care coordinators in a number of sites.

The program had relatively low costs with qualitative reports of improvement in patient and clinician experience. Though not measured in this program, it is plausible that an improvement in patient health outcomes and hospital utilisation was likely.

The Winter 2017 program paved the way and generated many improvement ideas for a subsequent iteration in 2018. Demonstrating the feasibility of the program and gaining clear clinician and management support has added to the culture of readiness for further programs to improve the integration of the health system. Other Local Health Districts and Primary Health Networks have been interested in replicating or adapting the Winter Strategy program. Meaningfully measuring the effectiveness of future Winter Strategies will be an ongoing area of learning. Insights gained from 2017 assisted with improvements in the 2018 iteration.

Key words: Integrated care, winter planning, chronic disease management in general practice, community aged care

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