Care Navigation and Coordination Program on Reducing Hospital Use for Adults with Complex Health and Psychosocial Needs in South West Sydney, Australia

Anita Hartati; Madison Jarrett; Brendon McDougall; Megan Kent; Maja Ljubojevic; Kylie Stolzenhein

doi:10.5334/ijic.7739

Figures & Tables

Planned Care for Better Health care navigation and coordination program structure.

Table 1

Eligibility criteria for PCBH enrolment and exclusion criteria.

Eligibility:

adults age 16 years old or over residing in SWSLHD
recent discharge from any NSW public hospital facility
at least one chronic condition
unmet health and/or psychosocial needs requiring navigation or coordination of care
RoH score of 0.2 to 0.5 (excluding direct referral pathway)
These criteria reflect the emphasis of PCBH in early identification of adults at risk of hospitalisation [28].

Exclusion criteria:

Aboriginal and Torres Strait Islander background
current inpatient
Residential Aged Care Facility resident
group home resident (criteria removed in 2023)
correctional facility inmate
DVA Gold Card holder who utilise its care coordination services

The rationale of the exclusion criteria is that there are current care navigation and coordination services available for these population, for example the SWSLHD Aboriginal Chronic Care Program, and inpatient services from hospital, residential aged care, group home or correctional facility.

Table 2

Items included in patient assessments in week 1 and week 12 of intervention.

Comprehensive health and psychological assessments are completed using the NSW CCoPS tool, which assess the patient’s risk profile in the following domains.
1.Diagnosis or clinical symptoms of chronic conditions
2.Service access profile
    a.Hospital use in the past 12 months
    b.GP checks at least twice in the past 12 months
    c.Reduced ability to self-care impacting on disease management
3.Risk factors:
    a.Smoking
    b.Overweight/underweight
    c.Hypercholesterolaemia
    d.Hypertension
    e.Physical inactivity
    f.Polypharmacy
4.Potentially extenuating factors:
    a.Use of community-based services previously
    b.Carer stress issue
    c.No carer
    d.Cognitive impairment
    e.Recent change to drug regimen
    f.Chronic pain
    g.Compromised skin integrity
    h.Exposure to triggers for asthma
5.Patient self-reported health status
6.Psycho-social and demographic factors
    a.Mental health issues
    b.Disability
    c.Difficulty accessing transport to services
    d.Financial issues
    e.Aboriginal or Torres Strait Islander status
    f.Culturally and linguistically diverse
    g.Illiteracy and/or limited English
    h.Unstable living environment
    i.Social isolation
    j.Drug and/or alcohol problems
    k.Impact rating on self-management ability
7.Patient’s readiness to change.

Reasons for not enrolling into PCBH program.

Table 4

Participants demographic, health and psychosocial characteristics.

Characteristics	Intervention cohort (n = 60)	Comparison cohort (n = 60)
Age – Mean ± SD	69 ± 15	61 ± 18
Sex (%)
Male	55.0%	51.7%
Female	45.0%	48.3%
Country of origin (%)
Australia	46.7%	50.0%
Overseas	53.3%	50.0%
Primary language spoken (%)
English	65.0%	85.0%
Non-English	35.0%	15.0%
Chronic Disease (n)
Chronic Cardiac Condition	38	38
Chronic Pain	36	39
Diabetes, Renal Failure and/or Liver Disease	33	20
Chronic respiratory issues	27	20
Compromised skin integrity, e.g. wounds	12	12
Vulnerability (n)
Mental health and/or drug & alcohol issues	35	33
CALD background and/or limited English	35	32
Mental and/or physical disability	30	35
Financial issues	8	2
Social isolation	4	4
Risk factors and lifestyle concerns (n)
Lives in socio-economic disadvantaged area	49	50
Overweight, obesity or underweight	31	25
Dementia, falls, or incontinence	30	21
Hypercholesterolaemia	27	31
Reduced ability to self-care	26	20
Recent change to drug regimen	22	26
Physical inactivity	20	12
Smoking	10	9
Carer stress and/or no carer availability	13	23

Table 5

Hospital utilisation before and after PCBH program.

	UNPLANNED HOSPITALISATIONS		TOTAL BED DAYS		AVERAGE LENGTH OF STAY (DAYS)		ED PRESENTATIONS
	INTERVENTION	COMPARISON	INTERVENTION	COMPARISON	INTERVENTION	COMPARISON	INTERVENTION	COMPARISON
0–3 months pre-PCBH program enrolment	77	61	444	253	5.218	4.48	79	67
4–6 months pre-PCBH program enrolment	33	20	104	113	3.486	5.889	56	49
Total pre (0–6 months)	110	81	548	366	8.704	10.369	135	116
0–3 months post-PCBH program completion	52	40	126	151	3.754	4.009	30	30
4–6 months post-PCBH program completion	33	35	174	159	5.492	5.063	42	18
Total post (0–6 months)	85	75	300	310	9.246	9.072	72	48
Reduction pre-post (n) at 0–3 months	25	21	318	102	1.464	0.471	49	37
Reduction pre-post (%) at 0–3 months	32.5%	34.4%	71.6%	40.3%	28.1%	10.5%	62.0%	55.2%
Reduction pre/post (n) at 0–6 months	25	6	248	56	–0.542*	1.297	63	68
Reduction pre-post (%) at 0–6 months	22.7%	7.4%	45.3%	15.3%	–6.2% *	12.5%	46.7%	58.6%

[i] note that *indicates an increase in hospital use rather than a decrease.

Care Navigation and Coordination Program on Reducing Hospital Use for Adults with Complex Health and Psychosocial Needs in South West Sydney, Australia

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