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.