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| Journal of the New Zealand Medical Association,
21-February-2003, Vol 116 No 1169
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Primary Options for Acute Care: general practitioners using
their skills to manage “avoidable admission” patients in the
community
Harley Aish, Peter Didsbury, Paul Cressey, Janice Grigor and
Barry Gribben
Primary Options for Acute Care (POAC) is a service to GPs,
allowing them to access investigations, levels of care, or treatment not usually
available or affordable to the patient. By utilising primary care resources,
these “avoidable admission” patients could be safely and
appropriately managed in the community, under the responsibility of their
GP.
South Auckland Health (SAH, also historically known as
Middlemore Hospital), the hospital servicing the Counties Manukau area, is
experiencing a steady growth in acute demand. Counties Manukau is a large
catchment area, with a population of approximately 380 000, made up of many
cultures, and socioeconomic classes.
At the beginning of 2000, the Primary Care Organisations of
South Auckland were invited to respond to an Operation Plan prepared by South
Auckland Health Integrated Care to address acute demand at Middlemore Hospital.
The resulting response, ‘A service plan for Counties Manukau –
August 2000,’1 recommended, amongst other
options, funding a POAC trial. SAH chose to adopt the POAC trial only.
POAC was launched following a dialogue between SAH, and the
three largest independent practitioner associations (IPAs) in the area. The
three IPAs, ie. SouthMed, EastHealth, and ProCare South, agreed to fund 50% of
the costs of the programme from their own savings, and SAH the other 50%. A
joint venture company, Clinical Assessments Limited (CAL) was used for
administration and funding purposes. Agreement to proceed was reached in
November 2000, and the full service was launched, with infrastructure and
service providers in place, in February 2001.
The concept of allowing primary care providers to spend up
to a nominated figure, to obtain investigations or care not normally available
in a primary care setting, had already been tried and proven by Pegasus Health
(Christchurch, NZ). The sharing of their ideas and experience was invaluable in
setting up this programme. An aim at the beginning of the programme was to
manage 75% of patients in the community without requiring subsequent admission
to SAH. This figure was chosen for several reasons. First, so that primary care
providers could manage patients with serious illnesses, knowing that if the
patient did deteriorate, they could be admitted to hospital. Second, if a
patient was eventually admitted, it was important the GP would not feel that
they had “failed” and therefore reject the POAC system in the
management of future cases. Finally, aiming for an eventual admission rate of
25% meant that critics couldn’t say that the primary care sector was
simply taking more money, or doing more investigations, to manage patients who
wouldn’t have been referred anyway.
The three IPAs represented 167 out of approximately 300 GPs
in the area.
MethodsPrimary care provdiers were
informed of the programme using the established networks of the three IPAs, ie,
peer or cell groups, continuing medical education lectures, opinion leaders,
video and regular newsletters. A Service Coordinator was employed to organise
whatever the GP requested. No limit was placed on this service, other than a
loose budget of $266 per patient. The Coordinator had already contacted various
providers (for example, rest homes, radiology services, home help services,
after hours clinics) to enlist their involvement in the programme.
To enrol a patient, the GP had to fill in a form with relevant details, including the service required and a unique identification number. If the GP wanted the Service Coordinator to organise something, this form was faxed to her, or she was phoned. At the end of the care episode, the GP then invoiced POAC for the services provided. Patients whose care was related to an accident or pregnancy were not eligible for enrolment. The Coordinator had no gatekeeping role other than to keep the predicted expenses to budget. A GP was employed one tenth as a Clinical Director, to evaluate the appropriateness of the referrals. He had the responsibility of giving feedback to any GPs using the service inappropriately. Providers of other services (for example radiology, or laboratory) invoiced POAC using the unique identification number the GP had used on the referral form. The programme aimed to enrol 600 patients by 31 December 2001, with 75% of the patients being successfully and appropriately managed in the community. One in every three patients, for the first 387 enrolled, was phoned after the episode of care, and surveyed by an independent interviewer regarding satisfaction with their care. Results1) A 31-year-old patient came to
see the GP complaining of a tender swollen calf. Usually, this patient would
have to be referred acutely to the Hospital for an urgent Doppler ultrasound
scan of the leg, to confirm or exclude a deep vein thrombosis (DVT). Using POAC,
the GP obtained a Doppler scan at the local radiology clinic. Within a few
hours, the patient had her scan, a DVT was excluded, and appropriate treatment
within the community was continued.
Sixty four patients had this investigation in the community
during the programme.
2) A 27-year-old Cook Island
patient had redness spreading up his arm for a few days. He came to see his GP,
who diagnosed cellulitis of a large enough area to require antibiotics
intravenously. Usually this patient would have to go to hospital and be admitted
for several days. Using POAC, the GP gave IV antibiotics, arranged for an after
hours clinic to administer the second dose, and then reviewed the patient the
next day. Because POAC paid for the extra costs, the patient was able to receive
the appropriate treatment without going to hospital.
Eighty nine patients with cellulitis were enrolled in POAC
during the programme.
3) A 91-year-old patient, who
lives alone, developed a urinary tract infection. Because of her age, and lack
of support, she would usually be admitted to hospital. The GP phoned the POAC
Coordinator, who arranged with a local rest home for the patient to have respite
care for 2–3 nights. The GP visited the patient the next day. The
rest-home staff and the patient knew that if she got worse overnight, they could
request a home visit at any time, at no cost.
Forty patients used this “dinner, bed and
breakfast” service during the programme.
Table 1. Main diagnosis on referral to POAC
programme
NB Percentages add to less
than 100 due to rounding
Statistics
In total, 707 patients were referred to POAC by the end of
December, 2001. Table 1 shows the diagnostic categories and the number of
patients in each category for the period.
Table 2. Services provided in the community and
associated costs (all patients, n = 707)
A&M=Accident and Medical; AHS=After Hours
Service
Services provided in the community are shown in Table 2. The
average cost per patient care episode was
$200.73. Administration costs were not
included, as these were mostly fixed.
Table 3. Eventual outcomes of referrals to POAC
programme
*These cases were reviewed independently. The deaths
were not unexpected, nor due to failure to refer the patient to
hospital.
Table 3 shows the eventual outcomes of treatment. The
cut-off time for “Eventually admitted” was one week after the
patient was referred to POAC. Table 4 shows the ethnicity of the patients
enrolled.
Table 4. Ethnicity of patients enrolled in POAC
programme
NB Percentages add to greater
than 100 due to rounding
Evaluation of
satisfaction
A qualitative evaluation of the programme, conducted as part
of an independent evaluation commissioned by Counties Manukau District Health
Board (CMDHB) from Auckland Uniservices,2
reported a very high level of patient and GP satisfaction with the programme,
including clinical management.
Comments from patients included the following:
“I feel that we saved the
Hospital for others and that’s good. I had no wish to go to hospital. We
depend on each other [referring to his wife].”
“The care was excellent at
the surgery. I felt safe with all the nurses around and I was happy to come back
home. Who likes hospital?”
“I think that the care was
far better – you end up sat around a corridor somewhere – I had the
test results that day and an outpatient appointment.”
“We could have called the
surgery or an ambulance at any time. You are quite secure, they know what they
are doing.”
A focus group comprising Maori POAC patients was summarised
in the following way:
“The features of the
alternative [POAC] service that appealed to the participants were the
accessibility and the likelihood of having their health problems addressed in a
timely manner, contrary to their past experience of hospitals. Each person who
took part in the alternative primary care option, rather than hospital
treatment, substantially benefited from the peace of mind (Te Whare Tapa Wha)
that their health problem was going to be attended to.”
Interviews with Samoan POAC patients also confirmed their
satisfaction with the programme:
“The consumers were more
than satisfied with the programme. The advantages of being treated outside the
hospitals prevented their fear of being in the hospital arena. This programme
not only satisfied their health needs but also provided them with full control
over their social life and wellbeing.”
“The consumers also talked
about the difference in the time frame for treatment at the hospital compared to
being under the Primary Care Options Programme. One consumer provided the
following comment: ‘It was great to sit there only a few minutes and the
nurse came and took me to the doctor’s clinic room. I was only there for
20 minutes and left.’ ”
Primary care providers that used the POAC programme enjoyed
the continuity of care that it reinforced. They had many positive comments to
make, two of which are included below:
“Put that sticker on and
the results are back in a few hours. It is superb – you do feel confident
in keeping the patient rather than sending them to wait at the
hospital.”
“This service can encourage
empowerment of its patients in care and involve families in
support.”
Evaluation of referrals to
POAC
As part of the evaluation, a group of four doctors (3 GPs
and one emergency department physician) evaluated all of the referrals to that
point in the programme.2 They found that over
90% of all referrals were truly “avoided admissions” (Table 5). None
of reviewers were part of the IPAs involved; therefore none had used POAC. Due
to time constraints, no reviewer evaluated all referrals, but all referrals were
evaluated by more than one reviewer.
Table 5. Independent review of first 387 referrals to
the POAC programme
While the programme was not designed to evaluate a
difference in referral rates between the GPs, Figure 1 shows a difference
between the admission rates of GPs utilising/participating in POAC and those of
non-participating GPs. When more data is available, we will be able to establish
if this clear trend of fewer admissions from POAC participants is statistically
significant.
Figure 1. Pattern of admissions for participating
versus non-participating doctors (CAL = Clinical Assessments Ltd)
 DiscussionFirst, it is clear that the primary
care sector is willing and able to extend the level of care it provides to its
patients. Also, patients on the whole are grateful that they don’t have to
be admitted to hospital. There was, in addition, a high degree of patient
satisfaction with the programme itself. Even though the management of their care
was often quite different from what they had expected, the continued
relationship with their familiar primary care team appears to have reassured
patients through this change.
Another phenomenon that emerged in the evaluation focus
groups, was the shift in expectations of both GPs and patients; serious illness
no longer implied admission to hospital, and other solutions could be
found.
Several services mentioned in Table 2 perhaps need further
explanation. Practice observation room costs are those associated with keeping
the patient observed in a room of the clinic. They include the cost of materials
(eg, intravenous fluids, intravenous cannulae). A lot of treatments require time
to evaluate the patient’s response, or even observation of the
patient’s improvement or deterioration with time. Patient observation was
a valuable tool used by all doctors. GP surgery visit costs are those of a
patient returning to see the doctor. By removing financial barriers, patients
are more willing to see the GP a second or third time. Although GPs can make
home visits, the real cost (incorporating lost income during absence from the
clinic) is quite a barrier to patients, particularly in the Counties Manukau
region.
Also of note is the availability of resources within the
community. The Coordinator reported that she was always able to find a rest-home
bed, albeit occasionally the patient had to travel a significant distance.
Likewise, investigations were almost always available on the same day as
requested. For management of acute demand, this level of service availability is
imperative. It would be interesting to compare the Hospital’s ability to
offer these investigations in such a timely fashion.
Of interest is that, on average, GPs under-spent the budget.
This programme has been unique, in that primary care providers were trusted to
charge for their services appropriately. It is heartening to confirm that the
primary care sector is responsible with spending health money. Freedom from
bureaucratic resource constraints has allowed it to deliver better care, cost
effectively.
Both the number of GPs using POAC, and the number of
patients enrolled, has increased steadily. It is likely that the initial slow
uptake has been due to several reasons: 1) the time it takes to change
GPs’ behaviour; 2) the fear of litigation or scorn from colleagues if
something new is tried and fails; 3) the time it takes to investigate and manage
in more depth complicated problems, when there may be a lot of other patients
waiting to be seen; 4) a lack of GP confidence to manage more complicated
problems; 5) a lack of GP knowledge of the full spectrum of community resources
available; 6) in some areas most patients have private health insurance, which
allows access to expensive or resource-limited investigations.
South Auckland Health is resource-constrained and operating
at full capacity. While the absolute numbers of patients who have utilised POAC
is not large, if a department or system is at capacity, even a small increase in
admissions or investigations required can result in a paralysis or loss of
efficiency in the affected area. For example, the Radiology Department in South
Auckland Health now refuses community referrals for ultrasound investigations
(of which Doppler scans are a subset). Approximately 64 Doppler scans were
carried out in the community, during the POAC programme. This equates to 64
fewer referrals to the Radiology Department, which in turn allows other
inpatients quicker access to this limited service. The flow-on effects are thus
very significant.
There is a marked difference in the number of GPs using this
programme across the different IPAs. No analysis into the reasons behind this
phenomenon has been undertaken. Possible reasons include how well paid the GPs
are in the different areas, the number of patients they usually refer to
hospital, the culture of the IPAs, and the different use of peer/cell groups and
continuing medical education.
In summary, primary care providers as represented by the
three IPAs acknowledged the problem of “avoidable admissions”, and
were able to provide a solution. Eight two per cent of patients in the POAC
programme, who would have otherwise been admitted, were safely managed in the
community. Most of them preferred and appreciated this care. If the pilot
programme is expanded, more rigorous statistical analysis of the observed trends
in avoiding admissions will be possible.
Author information:
Harley Aish, General Practitioner, and Clinical Director, Primary Options for
Acute Care (POAC); Peter Didsbury, General Practitioner, Auckland; Paul Cressey,
Manager, POAC and Director, EastHealth; Janice Grigor, Service Coordinator,
POAC, Auckland; Barry Gribben, Senior Research Fellow, Department of General
Practice and Primary Health Care, University of Auckland, Auckland
Acknowledgements:
The doctors, nurses and office staff working in the Primary Care Teams in
SouthMed, ProCare South, and EastHealth IPAs, who have used this service to
provide more care for their patients; South Auckland Health for their funding
and support; the IPAs for facilitating the provision of more services for their
patients; the approximately 700 patients who have participated in the POAC
programme so far; Pegasus Health, for piloting and sharing the POAC
concept.
Correspondence: Dr
Barry Gribben, Department of General Practice and Primary Health Care,
University of Auckland, Private Bag 92019, Auckland. Fax: (09) 373 7006; email:
barry.gribben@cbg.co.nz
References:
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