Almost half (47%) of the potentially preventable hospitalisations in Australia in 2014–15 were due to the five conditions examined in this chapter: chronic obstructive pulmonary disease (COPD), heart failure, cellulitis, kidney infections and urinary tract infections (UTIs), and diabetes complications.1 Substantial variation was observed between Statistical Area Level 3 (SA3) areas in the rates of hospitalisation for each condition. Variation was greatest for COPD (16-fold difference), diabetes complications and cellulitis (approximately 12-fold difference for both). Rates of hospitalisation for heart failure and UTIs varied seven-fold and six-fold, respectively.
The high hospitalisation rates and substantial variation reported for the chronic diseases in this chapter show that recommended care is not always provided for people with these conditions. Even with the significant funding provided through Medicare to better coordinate primary care for people with complex chronic disease, fragmented health services contribute to suboptimal management.2 Likely contributors to variation include a higher proportion in some areas of patients with the most complex chronic disease, for whom hospitalisation may be inevitable. Poor access to health services in the community is also related to higher rates of potentially preventable hospitalisations.3 Ability to access health services is determined not only by clinician supply, but also by costs, transport, cultural factors and sufficient health literacy to know when to consult health providers.3 For all the conditions examined in this chapter, hospitalisation rates were higher among Aboriginal and Torres Strait Islander Australians, people living in areas of relative socioeconomic disadvantaged, and those living in remote areas.
A fundamental component of system changes to reduce potentially preventable hospitalisations must be a shift to a better integrated primary care system, with a stronger focus on coordinating care.2 Critically, health systems also need to become better at managing disease where it already exists, to reduce the progression of chronic disease, minimise negative impacts and improve patients’ quality of life.
Patients live with their chronic disease all day, every day. They have to be put at the centre of prevention and management, particularly in primary care.4 The implementation of a Health Care Home model will greatly improve appropriateness and coordination of care for patients with multiple chronic and complex conditions.2
1a. Local Hospital Networks, Primary Health Networks and the Aboriginal Community Controlled Health Service sector to follow the following principles in developing chronic disease management programs, as described in the report of the Primary Health Care Advisory Group Better Outcomes for People with Chronic and Complex Health Conditions and consistent with the National Strategic Framework for Chronic Conditions:
i. Voluntary patient enrolment with a practice or healthcare provider to provide a clinical ‘home base’ for coordination of, management of, and ongoing support for, the patient’s care
ii. Patients, families and carers as partners in care, where patients are activated to maximise their knowledge, skills and confidence to manage their health, aided by technology and with the support of a healthcare team
iii. A risk stratification approach that supports identification of patients with high coordination and multiple provider needs, to ensure personalisation of service provision
iv. Enhanced access by patients to care provided by their Health Care Home; this may include in-hours support by telephone, email or videoconferencing, and effective access to after-hours advice or care
v. Nomination by patients of a preferred clinician, who is aware of their problems, priorities and wishes, and is responsible for their care coordination
vi. Flexible service delivery and team-based care that supports integrated patient care across the continuum of the health system through shared information and care planning
vii. A commitment to care that is of high quality and safe, including care planning and clinical decisions that are guided by evidence-based patient healthcare pathways, appropriate to the patient’s needs
viii. Data collection and sharing by patients and their healthcare teams to measure patient health outcomes and improve performance. Many patients will recognise features of the Health Care Home in their existing general practices.
Chronic obstructive pulmonary disease
1b. Local Hospital Networks, Primary Health Networks and the Aboriginal Community Controlled Health Service sector to promote appropriate care for the management of people with chronic obstructive pulmonary disease (COPD) using:
i. The COPD-X Plan: Australian and New Zealand Guidelines for the Management of Chronic Obstructive Pulmonary Disease 2016 as the routine model of care
ii. Targeted anti-smoking programs in populations with high smoking rates, including areas with a high proportion of the population who are Aboriginal and Torres Strait Islander Australians, rural and remote areas, and areas of socioeconomic disadvantage.
1c. State and territory health departments to develop culturally appropriate pulmonary rehabilitation programs for Aboriginal and Torres Strait Islander Australians with COPD.
1d. Local Hospital Networks, Primary Health Networks and the Aboriginal Community Controlled Health Service sector to implement process improvement for the effective management of people with heart failure, including:
i. Multidisciplinary care across the acute and primary care sectors
ii. A combination of strategies, including non-pharmacological approaches such as physical activity programs and fluid or dietary management, and pharmacotherapy.
1e. Local Hospital Networks, Primary Health Networks and the Aboriginal Community Controlled Health Service sector to promote appropriate care for the management of people with diabetes using:
i. The guidelines General Practice Management of Type 2 Diabetes 2016–18 as the routine model of care
ii. The Australian National Diabetes Strategy 2016–2020 to ensure the provision of integrated models of care
iii. Performance management frameworks to assess compliance of care with relevant diabetes treatment guidelines.
All conditions associated with potentially preventable hospitalisations
1f. The Commission, in collaboration with Aboriginal and Torres Strait Islander Australians and relevant organisations, to produce resources for addressing health literacy.
1g. State and territory health departments, in collaboration with Aboriginal and Torres Strait Islander Australians, and Australian Government health agencies, to continue to invest in whole-of-government approaches for addressing the social determinants of health for Aboriginal and Torres Strait Islander Australians, people in areas of socioeconomic disadvantage, and people living in outer regional and remote areas.
1h. State and territory health departments to investigate funding and pricing strategies within the activity-based funding framework to promote appropriate care for people with conditions associated with potentially preventable hospitalisations, with a particular focus on potentially avoidable hospital readmissions.
1i. Australian, and state and territory health departments to develop appropriate service specifications, evidence-based education and training, and other tools to enable providers, patients, practice managers and the broader healthcare sector to engage with chronic disease management programs, such as Health Care Homes.
1j. Primary Health Networks to use HealthPathways, where practicable, to improve the coordination of care across providers for chronic conditions.
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