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Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital
Sharon Lawn1, Sara Zabeen1, David Smith1
1Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, School of Medicine, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia. Email: ;
Summary
The Flinders Program significantly reduced hospital admissions for patients in the Hospital Admission Risk Program (HARP). Targeted care for high-risk groups like respiratory patients could further improve outcomes in chronic condition management.
Area of Science:
- Health Services Research
- Chronic Disease Management
- Public Health Interventions
Background:
- Chronic conditions are a leading cause of disability and high healthcare costs in Australia.
- Hospital Admission Risk Program (HARP) aims to improve care coordination for chronic conditions.
- Self-management interventions like the Flinders Program support patients in managing their health.
Purpose of the Study:
- To evaluate the impact of the Flinders Chronic Condition Management Program combined with HARP.
- To identify improvements for self-management care planning and program utilization.
- To determine which patient groups benefit most from this combined intervention.
Main Methods:
- Retrospective analysis of hospital admission data from July 2012 to September 2013.
- Examined length of stay and post-discharge contacts for 253 patients (644 admissions).
- Utilized generalized linear models for statistical analysis.
Main Results:
- Combined HARP and Flinders Program significantly reduced hospital admissions.
- Non-significant reductions observed in emergency department presentations and length of stay.
- Vulnerable groups (heart disease, complex needs, respiratory) received more post-discharge contacts.
Conclusions:
- The Flinders Program positively impacted HARP patients, reducing hospital admissions.
- Targeted care for high-risk groups (e.g., respiratory patients without carers) could enhance effectiveness.
- Evidence-based chronic condition management and self-management support reduce avoidable hospitalizations.
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