ISIA Team Monique Davies - PM 20,000 Days Campaign Tim Hou - GP

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ISIA TeamMonique Davies - PM 20,000 Days
Campaign Tim Hou - GP Clinical Lead for
Mangere LocalityAlison Howitt - PM 20,000 Days
Campaign and Pauline Sanders-Telfer - PM High
Risk Individuals Localities Project (SPMO)
Improvement Science Professional Development
Program Caring For Our Complex Patients in the
Community
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Caring for our Complex Patients in the
Community (As identified on PARR Risk Reports)
By 01 Dec 2014 We aim to provide coordinated
planned community management for our PARR
identified high risk patients reducing unplanned
hospital admissions from 50 (813 bed days)
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High Risk Individuals Monitoring Evaluation
Framework

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Measures
Name of Measure Is this an Outcome, Process or Balancing Measure? Operational Definition (e.g., numerator denominator)
Number of Patients identified on the Risk Score Tool. (PARR 30) Process measure Number of patients for triage Number of high risk patients
Number of HR patients appropriate for intervention (Triaged including amenable to intervention by GP) Process measure Number of HR patients for interventions Number of patients for triage
Number of patients start interventions Process measure Number high risk patients start interventions Number of HR patients for interventions
Number of patients who complete their prescribed interventions Process measure Number of patients who have completed year of care Number enrolled into intervention programme
Positive patient experience questionnaires Outcome measure Number of positive questionnaires Total number of questionnaires completed
Reduction in risk score and predicted day usage compared with actual usual (after 12months) Outcome measure (Long Term) Ratio Actual measure of readmission for 12 months Predicted chance of hospital admission
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Change Concepts PDSAs
Idea for Testing in a PDSA Theory and prediction about what will happen when ideas are tested
List of interventions drafted and tested with GPs Interventions list drafted by one of our GPs and approved by the Counties Manukau Clinical Reference Group, to be tested further with eight GP Practices in four localities (test to be completed by December 2013). Testing continues
GP Practice Readiness That GP practices have the processes and systems in place to allow them to take part in providing community based care for this complex patient group. Testing continues
That 50 of patients on the monthly High Risk list would be suitable for intervention Nursing staff in Otara GP practice gauged patient amenability for intervention during a consultation using the December Risk report and the result was 50 were amenable to taking part in the suite of interventions. Testing continues
Triage time for GP to assess monthly high risk list Completed with one GP, most patients took less than a minute to evaluate (for GPs own patients) and 2-3 minutes to assess colleagues patients using the monthly risk report. Testing continues
Home Visit Assessment Transfer and adaptation of skills and tools from VHIU home visit assessment to Primary Healthcare Team. Testing continues
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Profound Knowledge Worksheet
Appreciation for a System Optimizing the care of the patient in their medical home (the community), by understanding the interactions between primary and secondary care providers Incorporating primary and secondary data into the risk tool to ensure we appropriately identify our high risk group, by increasing the tools predictive power Psychology Understanding primary and secondary care perspectives and standardising the approachs to high risk patients Understanding beliefs and assumptions and the will to change i.e. the patients home is with the GP and the care should be driven from there Do whats best for the patient!
Theory of Knowledge Our subject matter experts are GPs, Primary Healthcare Centre Predictive Risk Model (PRM) collaborative Very High Intensity User (VHIU) collaborative Learning from our experiences we are incorporating the PRM tool and the VHIU model and further developing a primary care intervention model to deliver care differently for our patients with complex needs Understanding Variation Every patients needs are different and the system needs to cater for the majority of those needs The interventions allow flexibility for treating the patients but standardizing each process to reduce variation in the standard of care delivered
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Shared Learnings

• Very valuable having Tim Hou, a GP and the
  Clinical Lead for Mangere Locality, attend the
  ISIA course with us and having both Tim and
  Harley Aish (GP Clinical Lead PRM collaborative)
  work on this project
• Working as an Inter-collaborative (PRM and VHIU),
  we have shared learnings to inform this project
• Having team members with knowledge and expertise
  in both Improvement Methodology and Prince2-lite,
  has benefited our understanding and approach to
  the project
• Recognition of the overlaps between the
  collaboratives and the High Risk Individual
  Localities Project, brought this team together,
  enabling us to work together for enhanced
  outcomes