title: Integrated systems to improve care for very high intensity users of hospital emergency department and for long-term conditions in the community.
abstract: Adult patients who are very high intensity users of hospital emergency departments (VHIU) have complex medical and psychosocial needs. Their care is often poorly coordinated and expensive. Substantial health and social resources may be available to these patients but it is ineffective for a variety of reasons. In 2009 Counties Manukau District Health Board approved a business case for a programme designed to improve the care of VHIU patients identified at Middlemore Hospital. The model of care includes medical and social review, a multidisciplinary planning approach with a designated 'navigator' and assertive follow-up, self and family management, and involvement of community based organisations, primary care and secondary care. The model has been organised around geographic localities and alongside other initiatives. An intermediate care team has been established to attend to the current presenting problems, however the main emphasis is on optimising ongoing care and reducing subsequent admissions especially by connecting patients with primary health care. This whole process could be driven by the primacy care sector in due course. The background and initial experience with implementation are described.
authors: South Auckland Clinical School, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand.
authors: Harry
authors: H
authors: Rea
authors: Tim
authors: T
authors: Kenealy
authors: Fiona
authors: F
authors: Horwood
authors: Nicolette
authors: N
authors: Sheridan
authors: Matthew
authors: M
authors: Parsons
authors: Beverly
authors: B
authors: Wemekamp
authors: Fionna
authors: F
authors: Winter
authors: Gray
authors: G
authors: Maingay
authors: Pieter
authors: P
authors: Degeling
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D000553:Ambulatory Care / Q000706:statistics & numerical data; D019090:Case Management / Q000706:statistics & numerical data; D002908:Chronic Disease / Q000628:therapy*; D003153:Community Health Services / Q000458:organization & administration*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000706:statistics & numerical data*; D005006:Ethnicity / Q000145:classification / Q000706:statistics & numerical data; D005260:Female; D006301:Health Services Needs and Demand / Q000458:organization & administration; D006801:Humans; D008297:Male; D008875:Middle Aged; D009520:New Zealand; D011320:Primary Health Care / Q000458:organization & administration; D011787:Quality of Health Care / Q000458:organization & administration*; D017678:Sex Distribution