Evaluation of early intervention for healthy ageing in primary care

The intervention involves development and implementation of an evidence-based Healthy Ageing quality improvement (QI) toolkit. The intervention is targeted to general practice professionals, including general practitioners and practice nurses. The healthy ageing QI toolkit contains best practice processes to identify patients, recommended assessments, treatments and management plans with resources to support best use of Medicare MBS items for patients with chronic disease, dementia, and frailty in general practices. The intervention is targeted to 10 general practices within Adelaide Primary Health Network, and involves education, facilitated quality improvement, development and use of a tool kit for identification and management of chronic conditions for patients. This program involves three 3-4 month sprints involving a range of facilitated activities to support patients to be appropriately assessed, treated and supported in primary care to live well. Each sprint was targeted for education and facilitation to support care to a specific patient cohort: patients with 1) chronic disease; 2) frailty; and 3) early dementia. The activities within each of the 3 sprints include: • Participation in 2-3 hour education session (face to face group training) facilitated by practice consultants on development opportunities to support healthy ageing for each sprint relevant to the patient cohort. The timing of the education sessions will be within the first 1-2 months of each sprint, depending on availability of the practice consultants providing the education. • Weekly virtual huddles with general practices and practice consultants to facilitate and develop continuous improvement action plans targeted to implement early interventions (such as care plans and team care arrangements) for the patient cohort. • Use of QI processes over 10 weeks for each general practice to: - Understand the needs of the practice population - Identify patients at risk of or who have chronic diseases including frailty, early dementia - Identity patients who will benefit from chronic disease management, frailty prevention and management and early dementia management plans - Understand and implement treatment management plans, health assessments, team care arrangements for each patient cohort. • Development and application of a Healthy Ageing Toolkit into routine general practice to identify and support the patient cohort with chronic conditions. The toolkit includes resources for assessments, management plans, MBS items, patient identification and recall reminders, QI cycle templates, referral pathways. Assessments can include 40-49 year old health assessments, healthy heart assessments, cognitive assessments, FRAIL scales. Treatments plans can include GP management plans, indications for practice nurse consultations, primary care multi-disciplinary case conferencing, HealthPathways to guide referrals. Supported uptake of use of MBS items relevant to chronic disease management, such as chronic disease management plans, health assessments, medication reviews, team care arrangements, and case conferencing. Through facilitation and education of use of the implemented toolkit, general practice professionals will provide care to patients with chronic conditions utilising the toolkit resources for a proactive early intervention for healthy ageing for patients aged 40-70 years. The toolkit will be used by general practice professionals providing care to a range of patients with chronic conditions, including frailty and early dementia. Therefore, the frequency of the intervention will be continuous throughout the project duration and throughout the three sprints. It is anticipated that during the education, facilitation and implementation of the Healthy Ageing Toolkit, general practice professionals will provide care to patients with chronic conditions using the implemented toolkit and resources. No set frequency/duration of patient consultations will be measured. The uptake of the implemented Healthy Ageing Toolkit will be measured by pre- post- MBS item utilisation collected from the existing de-identified database at Adelaide Primary Health Network. Education, facilitation and support will be provided to general practice professionals through various modes. Weekly online virtual huddles with each general practice will occur to facilitate and support uptake of the toolkit resources. An education session will occur face to face in a group setting during each sprint. The general practices will also be supported with online communication (Teams pages, emails) and occasional visits to each practice on sporadic, needs basis. During the implementation phase, general practice professionals will provide care to patients with chronic diseases utilising the Healthy Ageing toolkit and resources during their patient consultations (online, in person and in case conferencing with multi-disciplinary team members). • Map local medical neighbourhood services for primary care referrals of services and team care arrangements.