Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program
Sharon Lawn A E , Sara Zabeen A , David Smith A , Ellen Wilson B , Cathie Miller C , Malcolm Battersby A and Kevin Masman DA Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, School of Medicine, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia. Email: sara.zabeen@flinders.edu.au; david.smith@flinders.edu.au; Malcolm.battersby@flinders.edu.au
B Hospital Admission Risk Program, Post-Acute Care, Community Health Programs and Diabetes Service, Bendigo Health, 100 Barnard St., Bendigo, 3550, Vic., Australia. Email: ewilson@bendigohealth.org.au
C Hospital Admission Risk Program, Healthy Communities and Continuing Care, Bendigo Health, 100 Barnard St., Bendigo, 3550, Vic., Australia. Email: cmiller@bendigohealth.org.au
D Collaborative Health Education and Research Centre, Organisational Development and Improvement, Bendigo Health, 100 Barnard St., Bendigo, 3550, Vic., Australia. Email: kmasman@bendigohealth.org.au
E Corresponding author. Email: sharon.lawn@flinders.edu.au
Australian Health Review 42(5) 542-549 https://doi.org/10.1071/AH17099
Submitted: 29 January 2017 Accepted: 10 July 2017 Published: 24 August 2017
Journal compilation © AHHA 2018 Open Access CC BY-NC-ND
Abstract
Objective The study aimed to determine the impact of the Flinders Chronic Condition Management Program for chronic condition self-management care planning and how to improve its use with Bendigo Health’s Hospital Admission Risk Program (HARP).
Methods A retrospective analysis of hospital admission data collected by Bendigo Health from July 2012 to September 2013 was undertaken. Length of stay during admission and total contacts post-discharge by hospital staff for 253 patients with 644 admissions were considered as outcome variables. For statistical modelling we used the generalised linear model.
Results The combination of the HARP and Flinders Program was able to achieve significant reductions in hospital admissions and non-significant reduction in emergency department presentations and length of stay. The generalised linear model predicted that vulnerable patient groups such as those with heart disease (P = 0.037) and complex needs (P < 0.001) received more post-discharge contacts by HARP staff than those suffering from diabetes, renal conditions and psychosocial needs when they lived alone. Similarly, respiratory (P < 0.001), heart disease (P = 0.015) and complex needs (P = 0.050) patients had more contacts, with an increased number of episodes than those suffering from diabetes, renal conditions and psychosocial needs.
Conclusion The Flinders Program appeared to have significant positive impacts on HARP patients that could be more effective if high-risk groups, such as respiratory patients with no carers and respiratory and heart disease patients aged 0–65, had received more targeted care.
What is known about the topic? Chronic conditions are common causes of premature death and disability in Australia. Besides mental and physical impacts at the individual level, chronic conditions are strongly linked to high costs and health service utilisation. Hospital avoidance programs such as HARP can better manage chronic conditions through a greater focus on coordination and integration of care across primary care and hospital systems. In support of HARP, self-management interventions such as the Flinders Program aim to help individuals better manage their medical treatment and cope with the impact of the condition on their physical and mental wellbeing and thus reduce health services utilisation.
What does this paper add? This paper sheds light on which patients might be more or less likely to benefit from the combination of the HARP and Flinders Program, with regard to their impact on reductions in hospital admissions, emergency department presentations and length of stay. This study also sheds light on how the Flinders Program could be better targeted towards and implemented among high-need and high-cost patients to lessen chronic disease burden on Australia’s health system.
What are the implications for practitioners? Programs targeting vulnerable populations and applying evidence-based chronic condition management and self-management support achieve significant reductions in potentially avoidable hospitalisation and emergency department presentation rates, though sex, type of chronic condition and living situation appear to matter. Benefits might also accrue from the combination of contextual factors (such as the Flinders Program, supportive service management, clinical champions in the team) that work synergistically.
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