Eastern Health Pathways++ a stepped model of care using risk stratification for people with chronic and complex health conditions

Short introduction/summary: The Eastern Health Pathways++ model is a stepped model of integrated care for people with chronic and complex health conditions using patient activation as a risk stratification tool. Who is it for? New and innovative models of care are required to address current and future demand to manage an ageing population and the ongoing burden of disease associated with chronic diseases. We worked in a partnership and integrated stepped model of care to deliver care in the community based on acuity and individual need. The Eastern Health pathways++ model uses risk stratification to stream and deliver care. This model of care provides an example of care delivered from existing workforce and funding models to establish a sustainable design to meet the community need. Who did you involve and engage with? This trial is an integrated model of care in collaboration with Eastern Health Hospital at Risk program (HARP) and EACH. The program was delivered by Eastern Health Community Health. Services were delivered by registered nurses, allied health and nurses within usual services. What did you do? We tested a model of care that streamed clients between usual care services and a care coordination model of care Pathways ++. Patient activation measures (PAM) was used as a risk stratification tool to determine the stream of care. PAM is a patient reported outcome measure utilised to determine activation levels or clients level of self-advocacy, health literacy and motivation. Clients with high levels of activation were streamed into usual clinical services and clients with low ‘activation’ (suggesting potential challenges with healthcare knowledge and confidence) were provided with Pathways ++. The Pathways ++ Program provided care coordination and clinical interventions that were determined by individual goals and risk based assessments of the clients. This included connecting patients to clinical and social services addressing the needs identified in individual assessments. Usual care was provided for clients with high activation (suggesting higher levels of self-advocacy, health literacy and motivation) based on an initial risk based assessment of their needs. What results did you get? The Program has shown a significant reduction in the length of stay and increase in admissions thus supporting access and flow both within HARP and the acute sector. Ongoing informal evaluation of emergency department presentations, service utilisation, patient reported outcomes and coordination of care is in progress. What is the learning for the international audience? This model is a program has potential to be adopted by other health services in addressing the global health care crisis. Next steps? A detailed evaluation of this program and a comprehensive health economic analysis will be finalised by July 2024. This will form the basis for ongoing program review, development and expansion.