Evaluation of Gold Coast Integrated Care for patients with chronic disease through a non-randomised controlled clinical trial

An intervention group of patients with complex and chronic conditions at high risk of hospitalisation will be recruited to have their care managed within the integrated care program. The program was developed in collaboration with general practitioners to reduce presentations to the health service emergency department, improve the capacity of specialist outpatients, and decrease planned and unplanned admission rates. The program is delivered by a multidisciplinary team facilitated by sharing information between primary and secondary health services through a highly advanced information and communication systems platform. Patients who are identified as high risk with complex co-morbid conditions will undertake a Holistic Assessment process. The Holistic Assessment is a comprehensive review of existing client information, their relevant clinical results, and identification of their current service providers in order to generate a detailed summary of the patient’s medical and social needs to build a jointly agreed individualised and flexible Shared Care Plan. The patient-centred shared care plan considers all physical, mental, emotional, social and environmental factors that may be influencing a client’s health status and their service utilisation. The assessment and development of the care plan is conducted over a two week period from the time the patient is consented. Service Navigators contact patients by phone to begin the process of Holistic Assessment. Once consent is obtained, the Service Navigators have patients complete an evaluation questionnaire (including quality of life, social support, satisfaction with care, and capabilities) by phone which includes a health profile of approximately one hour. Appointments are then made for the patient to have a one hour personal core risk assessment conducted by a Nurse Navigator/GCIC clinician, and a medical and pharmacy review all of which are conducted either at the Coordination Centre, the general practice or the patient’s home. The risk assessment includes validated tools to gather patient data on cognition, medication misadventure, falls, pressure injury/care, malnutrition, function, emotional health and wellbeing, continence, pain, wound, dysphagia, lower limb care, advanced care planning and frailty. The risk of hospitalisation is then estimated through purposely designed instruments. Information from the core risk assessment is then shared between the GP and the GCIC medical staff as the basis for a collaborative care plan which is then signed off by the patient, the GP and the GCIC medical team. The Shared Care Plan is generated by the Nurse Navigator/GCIC Clinician who performs the risk assessment, which is then shared with the patient’s general practitioner. Once the patient, the GP and the GCIC medical team agrees on the plan, the Nurse Navigator/GCIC Clinician delegates tasks to the Service Navigators and other clinicians who will organise services. The Shared Care Plan includes an Exacerbation Plan. The GCIC Coordination Centre monitors all hospital admissions/discharges for patients of network practices through the state-wide electronic Management Information System. Irrespective of whether a patient has had a hospital admission they are advised during the initial enrolment with GCIC that if they experience exacerbation of symptoms they should contact Gold Coast Integrated care on a 1300 number. Alternatively they have the choice of contacting their General Practice. General practice staff (GP/practice nurse/GCIC Nurse Navigator) in turn are requested to contact GCIC for any patient exacerbations so that their shared care record can be updated. The Coordination Centre can also be notified of a patients exacerbation event by other care providers i.e. other hospital and health services or non-government organisations. The patients shared care record will provide notifications of all exacerbation events that have occurred. In case of an emergency Queensland Ambulance Service will attend calls as usual. Where patients are identified as not requiring the Emergency Department, but are on the GCIC program the need for hospitalisation will be determined by the paramedics (who may seek support from GCIC or the GP to confirm actions required) based on the Exacerbation Plan included in the patient's copy of the Management Plan. The Shared Care Plan, event history and monitoring information is kept in the Shared Care Record, which is a custom-built computer database with internet access, designed to assist with creating, gathering, storing and presenting of longitudinal healthcare history and patient information, as contributed by the patient’s care team. This information will be used to manage the patient's ongoing care. The Shared Care Record will be linked with other information systems including GP Practice Management systems to ensure that a patient’s healthcare information is available from one location, and will be central to facilitating timely communication of care needs between multiple health care providers. The service will be accessible to all members of a patient’s care team, including the patient. Participants of the intervention group will be exposed to the intervention for at least 24 months. If the program is not funded to continue at the end of the trial than patients and practices will be notified and a transition process (lasting approximately 6 months) will be initiated in which patients' care coordination will revert to their general practice. As the GCIC model is founded on the general practice remaining at the centre of patient care this transition is expected to be a relatively straightforward process for all stakeholders involved.