Pathways++ a stepped model of integrated care

Short introduction: The Pathways++ is a stepped model of integrated care initiative for people with chronic and complex health conditions through person centred and collaborative care. Who is it for? Chronic conditions place a huge burden on the health care system. Almost half of all potentially preventable hospitalisations in Australia are due to chronic conditions (ACSQHC –Second Australian Atlas of Healthcare variation). New and innovative care models are required to address current and future demand. This partnership and integrated stepped model of care aims to deliver care in the community based on acuity and individual need. This in turn aims to improve the consumer and clinician experience, population health outcomes, and health system efficiencies by enabling consumers to self-manage their care, educating them on the trajectory of their conditions, and by connecting them to the right resources. Who did you involve? This 12-month trial is a step-down service from Eastern Health Hospital at Risk program (HARP). The program was delivered by EACH and Eastern Health Community Health with integration of care between Eastern Health HARP program. Services were delivered by registered nurses and Health Coaches. Two community health partners tested varied models of care to establish a comparative model evaluation. The evaluation framework developed includes measures of service utilisation and patient reported outcome measures as well as consumer and client satisfaction. What did you do? The primary aims were to decrease hospital demand by reducing unplanned Emergency Department presentations, preventing avoidable hospital admissions, and reducing hospital length of stay. It was also anticipated that the program would facilitate a reduction in HARP waiting lists and length of stay. The Program provided care planning and service coordination related to a patient’s individual goals and determinants of health. This included connecting patients to clinical and social services addressing social and well being needs that might contribute to the ongoing management of their chronic health conditions. Education and health promotion was provided to inform and engage patients in making decisions about their own health, self-manage and improve their quality of life. The programs supported clinical symptoms via timely escalation of clinical deterioration and put strategies and services in place to “safeguard” patients preventing unnecessary admissions to hospital. What results did you get? The Program has shown a significant reduction in the length of stay in the HARP program simultaneously resulting in increased admissions. This has enabled increased access into HARP and flow from the acute sector. The program has anecdotally strengthened the relationships between services and is helping to engage not only the patient in the management of their chronic conditions but provide linkage to services for ongoing support. Learnings? This integrated collaborative model is a program that can be adopted by other health services in addressing the global health care crisis. Next steps? A detailed evaluation and a comparison between the two models of care implemented as well as a comprehensive health economic analysis will be finalised by July 2024. This will form the basis for ongoing program development, expansion and funding.