Western HealthLinks: An Integrated Care Model using Community-Based Care to Reduce Hospital Admissions

Background: People with chronic illness often spend substantial time in hospital, taking them away from their homes and communities. At hospital discharge, patients are at risk of receiving fragmented care, potentially leading to hospital readmission. Western HealthLinks uses an integrated care-based intervention offering community-based care for people at high risk of hospital admission, seeking to reduce hospital utilisation and expenditure.

 

Approach: Western HealthLinks, an integrated care-based intervention delivered in Western Melbourne, Australia, aimed to support patients at high risk of hospital readmission as they transitioned from hospital to the community with home-based care delivered by our community partner, SilverChain. This program was developed following engagement with over 1000 community members including patients and carers in order to identify shared values and vision. Eligible adult patients at high risk of readmission were identified with a digital algorithm using electronic medical records and were enrolled in Western HealthLinks if they consented.

 

The aim of this study was to assess if the intervention would reduce the amount of time participants spent in hospital and reduce healthcare expenditure. It was expected that without intervention, patients would spend more time in hospital with greater hospital expenditure as they got older with increasing health problems, and it was hoped that this intervention could help to keep participants well at home and keep hospital usage and expenditure stable.

 

For each participant, hospital utilisation and expenditure were assessed during the intervention period (from intervention commencement until study end (or date of death if a participant died before study end)) and compared to a pre-intervention period of the same duration, finishing at the time of intervention commencement. This quasi-experimental pre-post intervention per-protocol analysis was conducted using R version 4.4.3.

 

Results: 4714 patients consented to participate in Western HealthLinks and community partner, SilverChain, attempted to contact each of them. 26 patients died prior to attempted contact. After excluding these and patients with missing admissions data, there were 4366 participants who received the intervention for a median of 507 days. Preliminary per-protocol results are presented as followed with further analysis to be conducted and presented when available. Median intervention number of days in hospital was 5 with interquartile range (IQR) 0.8-14.5, compared to pre-intervention 6 (IQR 2.3-12.6). Median intervention number of hospital episodes was 2 (IQR 1-4), compared to pre-intervention 3 (IQR 2-4). Median intervention hospital expenditure (measured as Weighted Inlier Equivalent Separation) was 2 (IQR 0.7-4.9), compared to pre-intervention 2.5 (IQR 1.3-4.6).

 

Implications: Western HealthLinks is an integrated care-based intervention developed following engagement with patients and carers, seeking to support patients at high risk of hospital readmission with community-based care. Per-protocol analysis showed that patients on the Western HealthLinks program had fewer hospitalisations, fewer days in hospital and lower hospital expenditure in the intervention period compared to the preceding period of equal duration. This study demonstrates the benefits of an integrated care intervention providing community delivered care, targeting people at high risk of hospital admission identified using a digital solution.