At Risk Individuals (ARI) programme reaches 22,000 patients

Two years ago I wrote a blog about the launch of the At Risk Individuals (ARI) programme. At the time I was excited to announce that we’d be supporting up to 30,000 people with long-term conditions and other risk factors – such as inadequate housing – to keep well and out of the hospital, as much as possible. People in this group are at a greater risk of poor health outcomes, including unplanned hospitalisation, and they use a disproportionate amount of healthcare services. The goal of the ARI programme was to provide earlier intervention and planned, proactive, patient-centred care by helping primary care identify our ‘at risk’ patients and better coordinate their services. So, two years on, how have we fared?

I’m pleased to report that, thanks to the incredible work of our clinicians and community, the approach has proven to be an outstanding success. More than 22,000 patients have now been reached through the programme. Every one of those patients has developed an individualised care action plan, based on their own goals and needs. Under ARI, patients also have a named Care Coordinator (usually their practice nurse or another member of the care team), and they are connected to the right support services so they can cope better and stay at home for longer. The plan and a summary of the medical information are shared electronically between the patient and their care team in both hospital and community. The power of this approach is best captured by the following quote from Gill Aspin, one of our Diabetes Nurse Specialists:

“As we scrolled through her shared care plan, we came to the box where her goals and aspirations had been carefully noted. They were simple, humbling, and yet so powerful. The room fell silent. It brought the patient into the room with us and we kept those goals in mind as we discussed her care.”

While it’s early days to be talking about outcomes, it looks like we’re already seeing reduced Emergency Department visits and fewer hospital stays for patients that have received this type of care. Perhaps more importantly, we’re hearing that ARI patients are experiencing a better quality of life. It seems that the extra time that the programme allows patients to have with health practitioners is increasing their confidence and ability to manage their own health.

ARI is one part of the new way that we’re tackling the rise of chronic diseases and complex health and social needs in the community with more pro-active and coordinated care. Together, General Practices, Primary Health Organisations and Counties Manukau Health staff have been developing innovative approaches including clinical pathways, community central and reablement, locality hubs, GP clusters, and multi-disciplinary teams. Our integrated care approach is starting to be widely recognised internationally, and I’ll be talking more about this over the coming months.



Author: Geraint Martin

Geraint Martin was appointed Chief Executive Officer of Counties Manukau DHB in December 2006. It is one of the largest District Health Boards in New Zealand and services a population of half a million. He has significant experience over 30 years in national policy & in managing both primary and secondary care . Previously, he was Director of Health and Social Care Strategy at the Welsh Government .He authored a radical 10 year strategy of reform, including the successful “Saving 1000 lives” Campaign.Until 2004, he was CEO at Kettering General Hospital & had held senior positions in London & Birmingham.He has worked closely with clinicians in improving clinical standards,patient safety,chronic disease management & managing acute care to reduce hospital demand.In NZ, He has promoted clinical quality and leadership as central to improving patientcare. This has led to a significant increases in productivity and access, whilst maintaining financial balance. CMH has completed in 2014 a $500 m capital redevelopment programme, the largest in New Zealand. A central part of this is the establishment of Ko Awatea,the Centre for Innovation and Research which will underpin CMH as one of the the leading health systems in Australasia.In 2008, he chaired the Ministerial Review of Emergency Care in New Zealand, and in 2013 was an member of the Expert Advisory Panel on Health Sector Performance. Geraint has an MSc in Health Policy from Birmingham University .His post-graduate work has focused on health economics and Corporate Strategy . He is adjunct Professor of Healthcare Management at AUT and Victoria University, Wellington Elected in 2006 as a Companion of the Institute of Healthcare Management, previously he was an Associate Fellow at Birmingham University.He is is Chair of the Auckland Philharmonia Orchestra, a member of the Institute of Directors, on the Board of the NZ Institute of Health Management & previously the Board of The NZ Health Quality and Safety Commission.

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