Background/Introduction:
Through partnership with Western Health Service, Silver Chain Group are delivering the Western Healthlinks program, an innovative, 3-year pilot which aims to reduce the number of unnecessary hospital admissions. The Silver Chain Group is a not-for-profit organisation with a proven record of delivering quality community health and aged care services across Australia.

The Silver Chain group provides Health Navigation and access to a Priority Response Nursing Assessment (PRNA) Service for Western Health Links patients in the community.

These patients are identified by the Department of Health as being eligible for the program if they frequently are admitted to hospital with multiple co-morbidities and chronic or complex health conditions.

Practice Change Implemented:
24/7 Phone Support
7 days per week 6am - 10pm Priority Nursing response Service
System Navigation
GP connection
Telehealth
Clinical portal

It was thought that through this change patients will receive a cohesive and integrated response, to reduce siloed health and social care and subsequent need to go to hospital. As well as experiencing an improved quality of life at home.

Highlights
Patient experience at 18 months continues to be extremely positive
A lower than projected 30 day readmission rate
A high percentage of patients with an active GP
73% patients who called the Priority Nursing Assessment response remained at home

Sustainability
Sustainability is dependent on ongoing funding, workforce and system change management that supports integrated and collaborative care.

The model of care is transferable with committed funding and partnerships.

Key findings and results to date clearly demonstrate an improved patient experience, reduction in hospital admissions and length of stay. As well our workforce reflects the health professional reward of supporting patients to achieve their personal goals.

For discussion, the role of the inpatient setting, Silver Chain group, other community settings and providers and the importance of GP led care.

Lessons learnt include:
Recruitment, the Workforce soft skills are as important as clinical competency
Challenge of system integration between acute, community and GP and other service providers
Risk stratification does support management of high volume and complex patients
Complex patients can make change

Introduction: Western Health Healthlinks is a chronic illness management programme providing support for high-risk patients with chronic and complex conditions in the community in partnership with the Siverchain group (SCG). Launched in November 2016, Healthlinks is funded by the Department of Health and Human Services (DHHS) in Victoria, Australia. It evolved as a means of addressing integrated care for chronic and complex patients utilising the most hospital resources.

Description: Wesern Health Healthlinks explores how flexible funding for the chronic illness group can facilitate changes in service delivery. The model of care has been formulated through an extensive literature review, benchmarking and consultation process.

Aim: The primary aim of the evaluation of this programme is to determine if the model of care affects the number of days admitted to hospital, healthcare costs, service use and patient experience.

Targeted Population: Western HealthLinks programme was established to ensure a more supportive, cohesive and integrated model of care for WH’s chronic and complex patient group with the goal of improving the care experience and providing more healthy days back in their own homes.

Timeline Data presented is from November 2016 to October 2018

Highlights: Total beds saved 9556 over 23 months.
Total beds saved per day over 23 months was 13.8.
Reduction in bed days by 24.5% (p<0.001).
20% reduction in WIES utilisation equivalent to $10M AUD.
Paient experience improved on qualitative analysis.

Sustainability: Australia uses an activity-based funding model to support the provision of public hospital services. Activity-based funding (ABF) pays hospitals based on the number and mix of patients they treat. While ABF is an effective funding model for short-term episodic care, it’s less effective for supporting the delivery of long-term, proactive and systemic care approaches. With patients challenged with chronic and complex illness identified as being at risk of poorer outcomes and being a greater healthcare burden, health systems are recognising the need to provide additional support and alternative models of care. This flexible funding model is key to the sustainability of this program.

Transferability: To be transferrable there would need to be strong commitment from Hospital executive and board and the funding health department to deliver non-ABF funding.

Conclusions: The first 23 months of the Western HealthLinks programme has resulted in an increase in the time that qualifying patients are spending in their own homes and away from hospital, in addition to realising improvements in their overall healthcare experience.

Discussion: Implementing the programme during the first 23 months has not been without its challenges. As the Western HealthLinks programme developed, so did the need for new systems and processes, the redesign and augmentation of existing services, and the establishment of new collaborative arrangements, such as the one established with SCG.

Lessons Learned: Although WH recognises further development is required to embed the model of care, the 23 months of the Western HealthLinks integrated care programme has provided a solid foundation for further development and improvement over the coming years.

Introduction:
The over-use of hospital Emergency Departments (EDs) for non-urgent health conditions is a world-wide phenomenon. In Victoria, approximately 45% of ED presentations to Melbourne’s metropolitan hospitals are for conditions that could be treated in more accessible and less costly community-based primary health services. These type of presentations increase service delivery costs, lead to longer ED waiting times and divert critical resources from patients that require urgent medical attention.
This project sought to better understand how and why people are electing to be treated in the Austin Health ED for non-urgent conditions. A behavioural and education-based intervention was developed and trialed with people who had attended the ED for non-urgent respiratory-related conditions.
Theory/Methods:
The project was grounded in behavioural insights research. The Behaviour Change Wheel (BCW) approach to changing behaviour developed by UK researchers was adopted. The project also employed an action research methodology within two main phases of research.
The first phase involved interviews and focus groups with staff and recent patients of the Austin Health ED.
The second phase trialed a face-to-face education-based intervention. Surveys were conducted with all research participants including those in the control group. Tracking of the re-presentation rates among study participants were also undertaken.
Results:
Qualitative data from the interviews and focus groups were used to construct four typical patient and carer 'personas' to illustrate the motivations behind people’s ED presentations.
Forty-three education sessions were conducted with predominantly parents (mothers) of young children with respiratory-related illness. While the education sessions were rated as beneficial by attendees, the tracking of re-presentations to the ED indicated the education session did not have any statistically significant influence on the probability of re-attending ED for non-urgent respiratory conditions.
Discussions:
The findings from this research produced further evidence of the system factors that are encouraging concerned consumers to present at ED for non-urgent health conditions. With these factors at work, it is difficult for any alternative message to gain traction with consumers and to become front-of mind when they are considering attending an ED.
Conclusions:
Any attempt to change behaviour is difficult and complex. Based on the results that were achieved, it is difficult to envisage that an education-based intervention will produce the type of reduction in the overuse of EDs that is sought by the health system.
Lessons Learned:
A key implication for public sector planning is that rather than put considerable resources into attempting behaviour change, effort may be better concentrated on re-designing the way services are delivered to reflect the way consumers are accessing the health services.
Limitations:
The main limitations of the study relate to the small sample sizes that were involved in terms of participants in the different phases of research.
Suggestions for future research:
Future work should take a systems approach to integrate behavioural interventions with the provision of health services along the continuum of patient care. This could include examining the feasibility of developing new primary health services, or re-designing existing services, to better meet the needs of consumers with non-urgent conditions.

1. Introduction

Increasing global demand exists for innovative models of care that promote proactive management of chronic disease in the community, with the aim of enhancing patient experience, clinical outcomes and cost-effectiveness. Additionally, program logic suggests such approaches could reduce demand on hospital emergency department and bed-based services.
During 2018-19, Melbourne’s geographically largest public health service network (Eastern Health) participated as an intervention site in “Health-links Chronic Care” (HLCC), a multi health-network study led by the Victorian Department of Health (DHHS) in association with the Commonwealth Science and Industrial Research Organisation (CSIRO). The HLCC study applied predictive analytics to routinely-collected Victorian public hospital Patient Admission Systems data, to identify patients at risk of three or more admissions in the upcoming twelve months. Individual health services then further screened these patients, and offered additional proactive community intervention.
Eastern Health selected its existing “Hospital Admission Risk Program” (HARP) as its HLCC community-based intervention, due to it being an evidence-based model that staff were also describing as under-utilised.

2. Theory/Methods

The HLCC algorithm provided Eastern Health with an opportunity to systematically test the size and nature of the true gap in patients suitable for referral to HARP.

a) The size of the gap was obtained by measuring the percentage of overlap between HARP referrals and the Health-links enrolments list.

b) The nature of the gap was obtained by profiling enrolees, testing their HARP suitability, and further probing their issues and needs.

3. Results

228 patients at high risk of avoidable hospital admissions were identified using the HLCC algorithm were Clinician screened.

a) Size of the Gap:
Clinicians’ perceptions of under-utilisation of the HARP model were confirmed:
For every one patient presently being referred to HARP, ten more who were appropriate could be identified using the algorithm, and half of these (five) were consenting to HARP”.

b) Nature of the Gap:

The HLCC analytics derived cohort was found to include a wider range of diagnoses than those Clinician-referred. Observed patterns in the admitting unit and patient needs will also be identified in this presentation.

4. Discussions

The HLCC admission risk algorithm is a promising tool that can form part of a high admission risk management strategy.

5. Conclusions

1. Eastern Health’s was previously only using the HARP model at 16% of its potential, when dependent on Clinician referrals alone.
2. The HLCC admission risk algorithm presents an opportunity to greatly better identify and hence better manage chronic disease patients at risk of avoidable hospital presentations.

6. Lessons learned

HARP structure and staffing needs to be streamlined and adequate to provide effective care to the newly identified cohort of patients.

7. Limitations

Only patients who have presented at hospital can be detected by the HLCC admission risk algorithm.

8. Suggestions for future research

There is huge scope for further work optimising technical and clinical application of the algorithm, merging hospital and community datasets to optimise predictive value, and to streamline subsequent individual enrolee case triage and models of care to optimise cost effectiveness.

1. Introduction

The Hospital Admission Risk Program (HARP) has operated within many Victorian health services since 2005, and targets people with chronic and complex care needs at risk of avoidable hospitalisations. HARP has been proven effective in reducing hospitalisation through provision of an integrated response of specialist medical and multidisciplinary care. It is however underutilised at Eastern Health

During 2018-19, Melbourne’s geographically largest public health service network (Eastern Health) participated as an intervention site in “Health-links Chronic Care” (HLCC), a multi health-network study led by the Victorian Department of Health (DHHS) in association with the Commonwealth Science and Industrial Research Organisation (CSIRO).
HLCC applied predictive analytics to routinely-collected Victorian public hospital patient admission data to identify patients at continued high risk of avoidable hospital admissions. Individual health services were then able to further screen these patients, and offered additional proactive community intervention.

The HLCC Algorithm has previously been demonstrated as having a positive predictive value of 32% for identifying patients who will have three or more bed-based admissions in the upcoming 12 months. However further refinement of the cohort via secondary individual case review is generally accepted as also indicated. This review may focus on confirming the level of admission risk and / or suitability for specific risk prevention models of care.

2. Theory/Methods

228 patients at high risk of avoidable hospital admissions were identified using the HLCC algorithm. These cases were subsequently Clinician screened, to obtain Patient and Clinician perspectives on a variety of admission-risk related topics.

3. Results

The following were determined when the intervention cohort was examined in terms of levels of risk, perception of risk and suitability for HARP.

• A trigger admission via Short Stay Unit may indicate greater need for individual case review
• 90.4% correlation between patient and Clinician assessment of “high risk”
• Only 15% thought they were at “high risk” – only around half of the 32% who progress to three or more admissions
• Whilst diagnosis is widely regarded as not correlating with admission risk, there may be some correlations that can be drawn with regards HARP service suitability


4. Discussions

The Health-links Chronic Care Algorithm is a promising tool that can form part of a health community’s high admission risk management strategy.

5. Conclusions (comprising key findings)

Information has been identified that can guide a “resource intelligent” future Health-links HARP services, by targeting specific patient groups rather than attempting to intervene with all Health-links enrolees.

6. Lessons learned

Admissions related to Diabetes are often coded under an alternate primary diagnosis, and as such are more difficult to diagnostically profile until they reach individual case review.

7. Limitations

As a pilot project, limits of statistical power must be kept in mind when interpreting these findings.

8. Suggestions for future research

There is huge scope for further work optimising technical and clinical application of the algorithm, merging hospital and community datasets to optimise predictive value, and to streamline subsequent individual enrolee case triage and models of care to optimise cost effectiveness.

Introduction: A Potentially Preventable Hospitalisation(PPH) is an admission for a condition where hospitalisation could have potentially been prevented through provision of appropriate timely chronic disease and/or acute condition care. The HealthLinks Chronic Care algorithm predicts PPH (patients at risk of 3+ hospitalisations) from Victorian admitted episode public hospital data. This is so that local health systems find innovative approaches to improve outcomes for these patients.

Innovation: A complex systems and anticipatory journey approach to addressing the PPH, the Patient Journey Record System (PaJR) is described.TeleCare Guides (TCG) track the health of individuals at risk of PPH with a ≥weekly telephone calls using a web-based system. Prediction algorithms on details of the outbound TCG telephone calls anticipate individual trajectory trajectories in order to optimize emergency hospital use. The MonashWatch deployment incorporating PaJR is conducted by Monash Health in its Dandenong urban catchment area, Victoria, Australia.

Theory: A Complex Adaptive Systems (CAS) framework underpins PaJR, and recognizes unique individual journeys, their historical and biopsychosocial influences, and difficult to predict tipping points. Rosen's anticipation theory informs the framework. PaJR uses perceptions of current and future health (interoception) through analytics on ongoing conversations to anticipate possible tipping points. Timely intervention in the biopsychosocial domains of their unique trajectories is intended.

Evaluation: Monash Watch is actively monitoring a variable cohort of 259 active patients from a monitored cohort of 674 who have either died, moved on, been lost etc. with 270 controls over >36 months (ongoing). Trajectories of SRH (Self-rated Heath), AH anticipation of worse/uncertain health, and TCG concerns demonstrated a tipping point 3 days before acute non-surgical admissions. The −3 day point was consistent across age and gender. PaJR-supported services achieved consistent reduction in acute bed days (20–25%) vs. target 10% and high levels of patient satisfaction.

Conclusion: Anticipatory care is an emerging journey tracking data approach that uses human conversations as the core metric demonstrates improvements in processes and outcomes. Multiple sources can provide big data to inform trajectory care, however simple tailored data collections may prove effective if they embrace human interoception and anticipation.

Introduction: Following a trend of decentralization, the Japanese government has been promoting community-based integrated care since 2014, “taking into account each region’s conditions.” The government has given the initiative to local communities without, however, giving guidance on how to understand actual area conditions. Previous research has pointed out several obstacles to the provision of community-based integrated care, but it too has neglected the examination of regional conditions. As a result, gaps have widened between better and worse performers. This study proposes that regional history is one method of understanding how area conditions and assets can help with the implementation of community-based integrated care.
Methods: This study focuses on the Onomichi Method, used in Onomichi, a provincial city experiencing aging and depopulation. The special feature of this method is its care conference system, which brings together diverse stakeholders: local medical practitioners, hospital doctors, social workers, patients, families, residents, and government officials. The system has been recognized to be superior, and adopted as national policy. This study uses field research to determine how Onomichi was able to construct its unique version of community-based integrated care. Research mainly consists of investigations into local history, using historical documents and statistics, and semi-structured interviews with relevant parties.
Results and Discussions: Upon inquiry, this study reveals that Onomichi’s integrated care system is structured on a traditional network of local medical practitioners, going back to the 1890s. Area physicians have, historically, advanced various projects through this network, such as infectious disease control, the distribution of doctors to schools, revisions of local medical fees, and so on.
The inventor of the Onomichi Method first appealed to the network of area doctors to cooperate with various interested parties to support patients with chronic diseases or disabilities. Most doctors agreed, having already recognized the need to make changes in patient care. These physicians’ local authority easily attracted other shareholders. Credit for the success of the Onomichi Method is shared among its numerous participants.
Conclusions and Lessons learned: This study concludes that identifying and utilizing local organizations and networks is beneficial in the construction of broadly-supported community-based integrated care. Essential to this is the proper understanding of a given region’s history and traditions, i.e. its “conditions.”
Limitations and Suggestions for future research: Lessons taken from this study are meaningful for historic rural communities with little migration. Area history and local networks may produce different effects in urban environments with shorter histories and higher flows of migration. Accordingly, field studies in cities are needed in order to assess the importance of history and networks.

Keywords: local conditions; local history; local networks