None listed
Conditions
Brief summary
This project aims to further improve care for patients who frequently attend Middlemore Hospital Emergency Department (ED). About 850 adults attend ED five or more times each year for ‘medical‘ (rather than surgical and other) services. We call these people Very High Intensity Users (VHIU). These people might have unmet needs. Counties Manukau DHB has established a new pathway for VHIU clients whereby, upon discharge from ED or a medical ward, health and social care is coodinated by a community-bsed case manager. The DHB wishes to ascertain whether the programme reduces re-admissions to hospital.
Interventions
A systematic assessment of health and social service needs followed by multidisciplinary case review followed by coordinated care and advocacy. The intervention involves undertaking an enhanced risk assessment on admission into the emergency department followed by a case conference with dedicated clinicians. A care plan is then determined in conjunction with a dedicated clinical team, pharmacists, cultural support, and social workers and at discharge, a locality coordinator will be assigned to
A systematic assessment of health and social service needs followed by multidisciplinary case review followed by coordinated care and advocacy. The intervention involves undertaking an enhanced risk assessment on admission into the emergency department followed by a case conference with dedicated clinicians. A care plan is then determined in conjunction with a dedicated clinical team, pharmacists, cultural support, and social workers and at discharge, a locality coordinator will be assigned to visit the patient in their home until their health stabilises and their access to social support services is realised. The service will not exceed 6 months.
Sponsors
Associate Professor Timothy Kenealy
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Treatment
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
15 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Presented to Emergency Department 5 or more times in the last year; able to give written consent
Exclusion criteria
Under regular care from renal, haematology services; assigned to surgical, orthopaedic, obstetric, gynaecology services; principal problem mental health
Outcome results
None listed