2005 Finalist

Frequent attenders care co-ordination programme

Better co-ordination of care for patients with multiple ailments is helping them understand their illnesses and reducing the time they spend in hospital and the number of visits they make to specialists.

Hutt Valley Health's Care Co-ordination programme was designed for a group of people who were frequently admitted to hospital. Patients were seeing different specialists, both doctors and nurses, and duplicate referrals were being made to other health professionals.

To provide a single point of contact and ensure that care is effectively co-ordinated, a care co-ordinator is now appointed to each patient.

People covered by the programme include those who have two or more chronic diseases, those who have had three or more admissions to medical services within six months, people at risk of getting their medications wrong or those with social or lifestyle risks that make it difficult for them to manage their own illness.

Care co-ordinators provide home visits, phone contacts and liaison between the hospital and GPs and outside agencies. Home visits are spent discussing health issues, and checking that patients understand and are following their medication regime.

Participants are encouraged to self-manage their health, and make regular visits to their GP. A brief patient summary is copied to each member of a person's care team to ensure all involved are updated to avoid any duplication and miscommunications.

In the first eighteen months the programme was running, the hospital admission rate was greatly reduced. A sample of five patients showed 159 bed days were saved, 22 admissions were avoided and the number of visits to consultants was reduced by 14.

Hutt Valley District Health Board
Anna Joynes 04 5666999
Email: Anna.joynes@huttvalleydhb.org.nz