Addressing the Issue of High Attenders in General Practice: Developing a Team Approach to Care

The study aims to address the issue of high attenders in General Practice by developing and putting in place systematic team practice strategies to improve the appropriateness of these patients’ care and reduce attendance rates. The Medical Corner Doctors practice research team will identify the demographics, health issues and consultation types of the top 20 attenders at Medical Corner Doctors Medical Practice, 237 High St, Rangiora. These top 20 attenders will be invited to be participants in the study via a letter containing information about the study. Those that agree to take part will be invited to a preliminary no fee consultation with one of our two study nurses from the research team at which they will be given any further information that they require and then asked for informed consent. At this interview the nurse will establish the patient’s health goals which will form the basis of their Personalised Care Plan (PCP). The form used will be a modified version of the care plan template available at healthnavigator.org.nz The patient’s General Practitoner (GP) will do a case review looking at their clinical record, classifications and medications. The GP and the study nurse will then meet to complete a Practice management plan (PMP) which could include the following strategic interventions depending on patient need: • A medication review by the pharmacist and provision of a yellow card listing medications and their actions • An Acute Plan (AP) if the patient has recurrent acute exacerbations of a condition eg COPD requiring emergency treatment or hospitalisation. • Provision of self-medication for exacerbations of conditions where clinically safe and appropriate eg recurrent uncomplicated UTI • Advanced Care Planning (ACP) if considered appropriate for end of life planning. • Care coordination by the practice nurse to provide better support in the community. • Referral for counselling if anxiety or depression is considered a co-factor in their high attendance rates. The study nurse will follow up with the patient to get informed consent to implement the strategies chosen and to complete the PCP and other plans as appropriate. The twenty patients enrolled in the study will be identified on the practice management software in the patient’s alerts as: High Attenders Study (HAS) When an HAS patient phones the practice he/she will be triaged by one of the study nurses. The patient will be assigned to the most clinically appropriate intervention: • Telephone advice by the nurse - may involve guiding use of their PCP or AP • Telephone advice by their own GP • A timely appointment with their own GP for non-urgent or semi-acute problems • For acute problems a same day appointment with preferably their own GP preceded by nurse triage on arrival. These interventions will be put in place for a period of one year and delivered by the Medical Corner Doctors practice team. The study will include an evaluation of the effectiveness of the strategies that have been put in place by collecting qualitative data in the form of conducting interviews with some high attenders to the practice after a six month period. The purpose of the interviews is to gauge patients' views about the new strategies and to further refine the new strategies as a result of these findings. Further evaluation in the form of telephone interviews with participants will take place after 12 months. The Lead Investigator will carry out three monthly audits of the interventions put in place for each patient by their GP/study nurse team to ensure consistency and appropriateness of clinical care in line with the aims of the study. Any clinical concerns raised by this audit will be addressed at the weekly meeting of the Management team at Medical Corner Doctors which consists of the Lead Investigator, GP director, Practice Manager and Nurse Team leader.