Abstract
Introduction/summary: The Pathways++ 12-month trial program integrates care and addresses the longer-term management for chronic and complex conditions through a patient centered, interdisciplinary model.
Who is it for? Individuals with chronic and complex conditions often have fragmented care and many lack the information to access services available within their community leading to unnecessary complications, reduced quality of life and avoidable hospital admissions. As chronic conditions place a significant strain on the health care system in Australia, innovative care models are crucial. The Pathways++ program aims to bridge the gap between acute services, community services and primary care, addressing health system efficiencies and improving population health outcomes. The program empowers consumers to self-manage by educating them on the trajectory of their chronic disease and connecting them to the right resources and support services.
Who did you involve/engage with? The Eastern Melbourne Health Alliance; a collaborative partnership between community health services in the East of Melbourne, endorsed this proposal. The alliance aims to improve the lives of those living with chronic conditions by an integrated network of healthcare providers across the tertiary, community and primary care settings. EACH (Community Health Service) worked alongside the Eastern Health Better at Home Committee gaining approval from the Northeast Health Service Partnership with final endorsement for the 12-month pilot program from the Victorian Government Department of Health. EACH, in collaboration with the HARP team, co designed referral and escalation pathways and established a Community of Practice between teams. The programs model of care inclusive of in-home or clinic visits, remote monitoring, and telehealth, was developed with a skilled staffing profile. External providers were engaged to embed an evaluation framework for future analysis of the program.
What did you do? Pathways++ Program aims to:
• Identify patients at risk of avoidable hospital admissions
• Deliver person-centered nurse provided care planning and service coordination post medical stabilisation and discharge from HARP
• Engage patients and their health-care team in goal setting through education and health promotion
• Improve patient activation and self-management leading to an enhanced quality of life
• Connect patients with appropriate services
• Foster improved collaboration across general practice, community and acute sectors
• Reduce overall health service costs.
Results: The evaluation framework includes service utilisation measures, patient reported outcome measures and consumer/clinician satisfaction surveys. Initial results show a reduction in tertiary health service utilisation and shorter hospital length of stay. Moreover, with increased health education and heightened awareness of symptom self-management, favourable health outcomes were observed. Notably, the program has led to a decrease in HARP program length of stay, enabling more admissions in the acute phase, thus helping to alleviate flow and access issues. Anecdotal evidence indicates strengthened relationships among acute, primary, and community services.
Learnings: This integrated model is a program that can be adopted by other health services in addressing critical healthcare challenges we face globally.
Next steps: A detailed evaluation and comprehensive health economic analysis due by July 2024 will guide future program development, expansion, and funding.