A coordinated
approach
to chronic care

CarePoint

CarePoint is an integrated care program that provides coordination and support for patients with the highest level of chronic and complex needs.

Focus on complex health needs

CarePoint is for patients with chronic or complex conditions who have a history of hospitalisations, particularly visits to an
emergency department for problems related to their diabetes, asthma, heart failure or chronic obstructive pulmonary disease.

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Partnering with general practice

A Care Coordinator works with doctors and practice staff to help patients navigate the complexities of the healthcare system and access the support and resources they need.

Support services

CarePoint offers evidence-based support services to encourage behaviour change, including:

  • a home assessment and tailored care plan
  • a centralised Care Coordinator to integrate and connect support
  • additional telephone support by a dedicated Care Navigator.

Program duration

The CarePoint program runs for two years, to develop and implement a comprehensive health plan to support lasting change.

GP Practice registration

CareComplete helps build practice capacity to offer evidence-based chronic condition management services.

The programs are designed to enhance existing chronic disease management practices without requiring significant time or investment from clinic staff.


For further information please call the CareComplete team on 1300 650 742








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Case study: Belle

Age: 81 Health details: Osteoarthritis, osteoporosis,
bilateral knee joint replacements and recurrent urinary tract infections (UTI).

“I want to feel more comfortable and safe at home, and be aware of what services I can call on.”

Belle’s doctor was not aware that she had recently fallen several times. Belle had previously fractured her wrist and also suffered frequent urinary tract infections. However she rarely discussed the UTIs with her GP, instead waiting until her symptoms progressed to the point where she needed to go to hospital. All of these risks were identified during Belle’s home visit with the Occupational therapy (OT), and were reported to her doctor by the Care Coordinator.

Action

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Fast-tracked home assessment with an OT home assessment

Support to reduce falls including:

  • a referral for council-funded personal care support to help conserve energy and minimise falls risk due to fatigue
  • a walking frame to support mobility
  • equipment to improve safety while getting in and out of bed

Belle’s care was led by her GP with her Care Coordinator ensuring continuity through the process.

Results

A collaborative partnership to support Belle to stay out of hospital

  • Belle rang her Care Coordinator to say she had a temperature and no appetite, and thought she should go to hospital as she had no way to get to her GP
  • Belle’s Care Coordinator consulted with her GP who arranged for a practice registrar to visit Belle at home that day
  • Belle commenced antibiotic therapy for a UTI and further investigations were scheduled as an outpatient
  • She recovered at home, and is now aware of the support available, including urgent GP appointments and after hours visits
  • Belle’s GP is now aware of her falls history, and has reinforced the recommendations made by her OT and physiotherapist, but also referred her for a neurological review

Patient’s name and photo have been changed for privacy purposes.

A participant’s view…

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They look into the vital parts, the things that mean the most – your health and how to manage yourself.”

 

A GP’s view…

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“If a patient is enrolled in this program we know for sure that they’re looked after holistically.”

Evidence

CarePoint is based on international best practice evidence which demonstrates substantial reductions in hospital admissions and average length of stay when a coordinated multidisciplinary approach is used.

A systematic review of 29 randomised trials including more than 5,000 patients with heart failure found that interventions which used a coordinated multidisciplinary approach could reduce hospitalisations by 25 per cent.1,2 Another study found 50 per cent fewer hospital days and 45 per cent fewer admissions per 1,000 patients when a coordinated approach was used.3

Moreover, a robust analysis of programs to reduce hospitalisation rates in high risk patients found that successful interventions have several common features, including:

  • a mix of face-to-face visits and follow-up calls
  • open and frequent communication between care coordinators and providers
  • using behaviour change techniques and motivational interviewing to improve medicine adherence and self-management.4

In Australia, a large scale intervention using a coordinated multidisciplinary approach, along with tailored telephone support, reduced hospitalisations in veterans by approximately 20 per cent.5 Likewise, an intervention in Victoria showed 35 per cent fewer emergency department attendances and 53 per cent fewer emergency admissions.6

CarePoint is built on this framework.

References: 1. Scott IA. Public hospital bed crisis: too few or too misused?, 2010, Aust. Health Review 34, 317–324. 2. McAlister FA, et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: A systematic review of randomised trials, 2004, Journal of the American College of Cardiology, Vol 44 (4): 810–819. 3. Claffey TF, et al. Quality In Maine Medicare Advantage Plan Health Affairs, 31, no.9 (2012): 2074–2083. 4. Brown, R.S., et al. Six Features Of Medicare Coordinated Care Demonstration Programs That Cut Hospital Admissions Of High-Risk Patients. Health Affairs, 2012. 31(6):p. 1156–66. 5. Darkins A, et al. Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions Telemedicine and e-Health. December 2008, 14(10): 1118–1126. 6. Victorian Government Department of Human Services: Improving care Hospital Admission Risk Program. Public report, 2006.