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Reducing Potentially Preventable Hospitalisations (GEN 8, 9
Potentially preventable hospitalisations (PPH) can result from chronic health conditions (e.g. asthma, diabetes), acute conditions such as throat infections and from vaccine preventable conditions such as influenza or whooping cough. Hospitalisation incurs a high financial cost to the health care system, especially when a proportion of these admissions could potentially be avoided by the timely use of primary health care services.
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Identified Need Key Issue Description of Evidence
Reducing Potentially Potentially preventable hospitalisation rates are above the ∙ NHPA analysis of the Admitted Patient Care National Minimum Data Set Preventable state average in all regions except the Lower North and Hospitalisations - outcome Adelaide Hills. Rates in the Outback - North and East are of health needs analysis almost double the state and national rates, while the Adelaide Hills is around three quarters of the state average.
Priority Reducing Potentially Preventable
Hospitalisations (GEN – 8, 9) opportunities, priorities and options
Possible Options
1. Partnership with RFDS to improve chronic disease care by employing a chronic disease and mental health nurse to support existing clinics. ∙ Better access to chronic disease and mental health support for remote patients. ∙ Reduction in hospitalisations due to chronic disease and mental health support for remote residents.
2. Investigate discharge planning processes across the acute sector and research best practice models to inform project design enabling improvements in the continuity of care including medication management.
3. Create strategies that facilitate and enable LHNs and private providers, including pharmacy, to develop the capacity of the region to engage care coordinators in routine activities to implement better discharge planning.
Expected Outcome
∙ Improvements achieved in discharge planning. Improved connection between the acute care and primary care sectors for discharge management.
∙ The efforts of the PHN to implement a patient-centred care model widely includes attention to discharge planning and coordination and practical examples. ∙ Care coordinators implemented in a variety of models as defined by local resource capacity and systems management.
Potential Lead
∙ RFDS
∙ CSAPHN
∙ CSAPHN partnering with the six regional Local Health
Networks
∙ CSAPHN ∙ CSAPHN facilitating and supporting LHN/GP led local initiatives
Priority Reducing Potentially Preventable
Hospitalisations (GEN – 8, 9) opportunities, priorities and options - continued
Possible Options
4. Implement projects that reduce the number of older
Australians’ residing in residential aged care facilities (RACFs) for low level health events including technology assisted GP After Hours services to RACFs.
5. Identify main causes of Emergency Department admissions and hospital re-admissions.
Design and implement projects that address identified risks leading to Emergency Department admissions and hospital re-admissions in conjunction with Local
Community Advisory Committees, Clinical Councils and key stakeholders.
6. Support appropriate peak bodies in capacity building and the sharing of information to pharmacy managers and practitioners, including retail managers, for upskilling with
GP practice managers.
7. Using Primary Health Care Service delineation model and health data in conjunction with LHNs, define and implement a multilevel predicative modelling framework and process to inform decision making.
8. Investigate implementation of intermediary care and home-based care in local setting. 9. Promote and facilitate alternative care arrangements especially for people in palliative stages of life.
10. Investigate healthcare needs in small communities where inpatient care best utilises available resources rather than trying to provide an alternative service.
Expected Outcome
∙ Projects and applications achieved, and evidence of reduced demand achieved in identified areas of need or application of the activity.
∙ Issues identified and partnership occurring with the LHN to manage potential outcomes.
Potential Lead
∙ CSAPHN
∙ CSAPHN facilitating and supporting GP led local initiatives
∙ Evidence demonstrated of a connection of pharmacy to the discharge planning activity including routine MMR of patients associated with the discharge activity.
∙ Improved capacity for effective discharge planning through appropriate resource allocation. ∙ Peak bodies in partnership with CSAPHN
∙ CSAPHN in partnership with the six regional LHNs
∙ General practice, allied health and pharmacy included in acute care sector planning of out of hospital services. ∙ Reduced evidence of the prevailing disconnection between public and private sector in this regard.
∙ Provide an advocacy platform to achieve better coordination of local resources enabling better cost effect and coordination of care. ∙ CSAPHN facilitating with
LHNs and supporting GP led local initiatives.
∙ CSAPHN facilitating and supporting GP led local initiatives.
Priority Reducing Potentially Preventable
Hospitalisations (GEN – 8, 9) opportunities, priorities and options - continued
Possible Options
11. Multi-party conferencing to enable activities such as case conferencing with health professionals in different locations including those within SA Health.
12. Work with communities, ACCHOs, general practice, the six regional LHNs and metropolitan LHNs and the Rural
Doctors Workforce Agency to identify needs for provision of specialist services via telehealth.
Expected Outcome
∙ Links established ensuring effective communication between all health professionals engaged in passage of the patient back to community.
∙ Effective linking of specialist and niche providers to the issue of out of hospital opportunities for care.
Potential Lead
∙ CSAPHN facilitating and supporting GP led local initiatives.
∙ CSAPHN initiative in collaboration with ACCHO’s
AMS’s RFDS and RDWA and the six regional LHNs
