1. ISIA Team Monique Davies - PM 20,000 Days Campaign Tim Hou - GP & Clinical Lead for Mangere Locality Alison 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

2. 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)

5. High Risk Individuals Monitoring & Evaluation Framework

6. Name of MeasureIs 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 measureNumber of patients for triage Number of high risk patients Number of HR patients appropriate for intervention (Triaged including amenable to intervention by GP) Process measureNumber of HR patients for interventions Number of patients for triage Number of patients start interventions Process measureNumber high risk patients start interventions Number of HR patients for interventions Number of patients who complete their prescribed interventions Process measureNumber of patients who have completed ‘year of care’ Number enrolled into intervention programme Positive patient experience questionnaires Outcome measureNumber 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 Measures

7. 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 ReadinessThat 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 GP’s own patients) and 2-3 minutes to assess colleagues’ patients using the monthly risk report. Testing continues Home Visit AssessmentTransfer and adaptation of skills and tools from VHIU home visit assessment to Primary Healthcare Team. Testing continues

8. 8 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 patient’s home is with the GP and the care should be driven from there  Do what’s 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 patient’s 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 Profound Knowledge Worksheet

9. Shared Learning’s 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