Adult patients (18 years or over) who have chronic and complex health problems who are thought likely to benefit from a focus on proactive care and monitoring including: optimised self-management, improved access to necessary support services and/or improved collaboration with LHD community and hospital services
- Coordinated Veteran’s Care program patients
- Patients in Palliative care programs.
Approaches to Patient Selection
Not all patients with a GPMP will be particularly high risk of hospital admission or major sickness through winter. However, those who also require a TCA may be a more complex and high risk group. A practice could use this as a starting point for patient selection. This will depend on how consistently GPMP-TCA has been implemented across the practice and how well you feel it indicates high risk for winter deterioration or hospitalisation.
You may consider the following criteria:
- One or more diagnosed chronic illnesses
- Complex treatment regimes
- Frequent hospital/ED presentations in the previous 12 months
- Escalation/deterioration of condition/s
- Measurable physical limitations
- Measurable mental limitation
- Social connectedness poor
- Patient would benefit from integrated care intervention
- Would not be surprised if this patient were to go to hospital in the next 6 months
- Heart Failure
- Inflammatory bowel disease
- Multi-morbidity with multiple long term conditions is a risk marker for admission.
Similarly, not all people with these conditions are unstable or at particularly high risk of hospital admission. Admission within the past year for one of these conditions could be added as an extra marker of risk.
Not all these conditions are likely to be as responsive to the key elements of “Winter Care” as others. There is a clear case for sick day action plans for asthma, COAD and Heart Failure. For simplicity a practice may choose to focus on these conditions.
You will then want to refine the list to those patients most likely to benefit, and apply the exclusion rules.
Some medications are mostly used in people with more advanced chronic disease, for example:
- Spironolactone (or equivalent) for CCF, Liver cirrhosis. (note can be used for hirsutism)
- Nikorel for difficult IHD/ angina
- Calcitriol as a marker of advanced renal disease
Poly-pharmacy, more than five medications is a risk marker.
- HbA1c > 9%
- eGFR < 45 or proteinuria
- Anaemia in the elderly
- LFTs > 3 x upper limit of normal
- Life style factors
- BMI > 35 or < 19
- CALD or Indigenous
- Health literacy, ability to gain benefit from health services and advice
- Drug and Alcohol problemsSocial-economic factors
The HARP Risk Calculator is an optional tool for Practices interested in a structured approach to grading risk of admission in the next 12 months. Download the “HARP Risk Calculator”.
The HARP Assessment Tool is used in conjunction with the HARP Risk Calculator to assess risk. Download the “HARP Assessment Tool”. There are benefits and limitations to this approach as follows:
Benefits of the HARP: It leads the patient/carer and assessor through consideration of a broad and inclusive range of factors that are associated with risk of hospital admission. This will probably prompt a more holistic assessment and highlight important areas for intervention that may otherwise have been missed. It may help clinicians “think outside the box”. LHD Chronic Disease Management teams use this tool, so using it in general practice may help to promote shared insight and a shared approach to patient care.
Limitations of Harp: It does not quantify an absolute risk of admission. It is somewhat subjective and has not been formally validated. Unless you know the patient very well, it will require discussion with patient/ carer.
Dr David Guest from Goonellabah Medical Centre has kindly shared his experience of selecting patients. In a brief article for GP Speak Dr Guest details how to use Best Practice to search your database for patients who may benefit from the Winter Strategy. The search instructions are easy to follow and it takes less than a minute to run.