The Universal Health (UHC) movement in its latest iteration, has adopted key objectives of Primary Health Care (PHC). This is a notable shift in the right direction but achieving what appears to be simple targets is a highly complex endeavour across both wealthy and less wealthy countries and jurisdictions. Improving health for all targets requires political-economic, bureaucratic and alignment with bottom-up grass-roots agencies. Despite present successes, there is a need to adapt to constant challenges including pandemics, adverse climate phenomena and political-economic shifts.
Rationale aims and objectives Potentially preventable hospitalizations (PPH) are a challenge. What happens before hospital admission? Are there crucial tipping points before admissions in at-risk cohorts’ trajectories? HealthLinksChronicCare (HLCC) hospital risk-prediction algorithms using admission, diagnosis, and lifestyle data identifies at-patients. MW monitors HLCC patients with outbound phone calls using telehealth – the Patient Journey Record System with alerts representing a real-time anticipated risk of PPH. Health Coaches triage and intervene to optimize GP, hospital and community service utilization to reduce the risk of PPH. Aims To describe a time series of telehealth phone calls related to an acute admission ( 10 days) to investigate tipping points in self-reported biopsychosocial environmental concerns (total alerts) and or condition symptoms of concern (red alerts). Methods MW participants had an acute (non-surgical) admission and >44 calls between 23/12/16 - 11/10/17. The Patient Journey Record System (PaJR) and Victorian Admitted Episode Data/ Emergency Minimum Dataset provided longitudinal data. Descriptive time series analysis employed Pettitt’s homogeneity test to detect ‘tipping points’ using XLSTAT package. Findings One hundred three patients aged 74 ± 15.4 years, with 59% male and 61% female, provided 764 call records around admission(s) and 22,715 records over 10 months. Total alerts and red alerts were higher in the 10 days before and after admission. Total alerts significantly increased (tipped) at day 3 before hospitalisation persisting until 10 days. Red alerts increased (tipped) 1 day before admission and remained high following discharge. Discussion and Conclusion Self-report in phone calls describe a pre-hospital phase of ‘post-hospital syndrome’ (PHS), which began at least 10 days before admission and persisted after discharge. Wide-ranging health, psychosocial, and environmental concerns preceded a tipping point into acute symptoms. Telehealth monitoring of biopsychosocial, as well as disease, concerns require further investigation.
Rationale, aims and objectives. Applying traditional industrial Quality Improvement (QI) methodologies to primary care is often inappropriate because primary care is best thought of as a network of highly interconnected agents in a complex adaptive system (CAS) that is particularly responsive to bottom-up rather than top-down management approaches. We report on a demonstration case study of improvements made in the Family Health Center (FHC) of the JPS Health Network in a refugee patient population that illustrate features of QI in a CAS framework as opposed to a traditional QI approach. Methods. We report on changes in health system utilization by new refugee patients of the FHC from 2016-2017 and summarize relevant theoretical understandings of quality management in complex adaptive systems. Results. Applying CAS principles in the FHC, utilization of the Emergency Department and Urgent Care by newly arrived refugee patients before their first clinic visit was reduced by more than half (total visits decreased from 31% to 14% of the refugee patients). Our review of the literature demonstrates that traditional top-down QI processes are most often unsuccessful in improving even a few single-disease metrics, and increases clinician burnout and penalizes clinicians who care for vulnerable patients. Improvement in a CAS occurs when front-line clinicians identify care gaps and are given the flexibility to learn and self-organize to enable new care processes to emerge, which are created from bottom-up leadership that utilize existing interdependencies made more sustainable as front-line clinicians use sensemaking to improve care processes. Conclusions and future directions. Recent reforms announced in primary care in Scotland, a few examples in the medical literature, and statements from some healthcare system leaders are examples of early adapters who are applying the principles of CAS to their QI efforts. Such initiatives and our example provide models for others to follow.