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Planned Care for Better Health (PCBH) is one of 7 key NSW Health Integrated Care Initiatives. PCBH focuses on improving health outcomes for vulnerable people in our communities.
PCBH identifies patients at risk of hospitalisation early, using the Risk of Hospitalisation (ROH) algorithm in the Patient Flow Portal (PFP) and strengthening care and services to support these patients to improve their experience of receiving care and to keep them healthier over the long term.
The ROH algorithm went live in the PFP in May 2021. Chronic Disease Management Service (CDM) staff are utilising the ROH daily to identify patients
who have a ROH score above 0.18, which indicates they are at risk of hospitalisation within the next 12 months.
The ROH algorithm will replace the Chronic Conditions Patient Identification Algorithm (CCPIA). The new algorithm will better identify patients who would benefit from integrated care interventions under PCBH.
Benefits of ROH:
- ROH was tested against CCPIA in a representative sample of 150,000 patients in NSW.
- ROH has 50% better accuracy in identifying patients who will be hospitalised compared to CCIPA.
- The additional variables highlight people at risk and vulnerable with chronic disease and social concerns that increases their complexity and the number of potential patients that require pathways to care.
Once they are identified, CDM staff consult with the patient, and families/carers if appropriate, to provide chronic disease management and/or other person-centered services to better support them in the community.
Cate Mowbray, PCBH Project Officer, NNSWLHD with the support of Daniel Barry, Temporary Trainee Biostatistician, MOH, have conducted a deep dive into ROH algorithm data which identified specific cohorts at risk of hospitalisation across our LHD. This has helped to inform the project and create awareness for key stakeholders.
The team have also engaged and consulted with CDM staff who have given vital feedback about current service provision helping to refine processes and workflows into the future
PCBH Goals for 2022:
The goals for NNSWLHD PCBH project are to:
- Implement the RoH algorithm in the PFP across services, and to
- Scope the patient journey to determine needs and / or gaps to streamline referrals and strengthen relationships between inpatient and community services.
In 2022 work will involve collaboration with consumers, clinicians and other key stakeholders across NNSWLHD to drive the co-design process in planning and providing the best care for patients and to support better health outcomes.
For any enquiries please contact Debbie Banovic, Manager, Integrated Care Debbie.Banovic@health.nsw.gov.au