CarePoint Integrated Care Program

Abstract

Expenditure on healthcare in Australia is increasing at an unprecedented rate as the population ages, chronic disease becomes more prevalent, and technological development accelerates. A small proportion of patients with complex, chronic health conditions utilize a hugely disproportionate burden. The current Australian healthcare system, with its fragmented structure and fee for service model, is reactive not proactive and rewards quantity not quality. It does not incentivise cost and utilisation management, nor does it focus on the consumer experience and engagement. It is failing in secondary prevention and cost effective management of chronic disease. CarePoint is a program designed test the effectiveness and efficacy of a care planning and facilitation model in primary care for patients with chronic disease resulting in poor health, frequent hospitalisations and high healthcare costs. Multiple interventions will be used at the General Practice level for patients with complex, chronic health conditions, including enhanced care planning use of a specialized IT platform, case managers, home assessments, improved communication between care providers, and increased education and engagement of General Practitioners. It is postulated that these interventions would result in a reduction in hospital admissions and readmissions by 25%, reduced length of stay, and a reduction in emergency department attendances. Better care coordination of care will improve patient experience, improve health outcomes and significantly reduce cost to the health system. CarePoint is a longitudinal case-control cohort study including both public and privately insured patients. 2000 patients in Southern and Eastern Melbourne, who have had frequent recent hospitalizations as a result of chronic disease, will be recruited from General Practice. The Program is a jointly funded initiative between the Victorian Department of Health and Medibank Private. There has been active engagement with local hospital networks, local service providers and GP practices. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116673– http://www.ijic.org/ Patients will be recruited over a 6 month timeframe with the intervention being applied for a period of 2 years for every patient. The program commenced recruitment in July 2014. Data evaluation will be performed by an independent body at baseline and program end. CarePoint has been designed around successful integrated care programs in place for many years internationally. A model of integrative care directed at the general practice level is innovative and breaking new ground in Australian healthcare. It has the potential to reduce hospital and other healthcare costs dramatically, remove inefficiencies and duplication of service, along with improving population heath, and the experience and satisfaction of patients and healthcare providers alike. The program is sustainable, the cost being minimal compared with the savings gained from reduced preventable hospitalizations and other healthcare costs. It is easily transferable to all of Australia, given General Practice is structured and funded consistently across all states and territories. The program is a simple structure utilizing existing services and aligning with but enhancing current models of care. This program is in the initial stages of recruitment. Conclusions including key findings are not available at this point.