A Multidisciplinary, Community-Based Program to Reduce Unplanned Hospital Admissions.

To evaluate the effect of Hospital Admission Risk Program (HARP) on unplanned hospitalization, bed days, and mortality of enrolled individuals and to evaluate the cost-effectiveness of HARP. A retrospective longitudinal analysis of hospital administrative data. Individuals at risk of hospitalization were provided with multidisciplinary, community-based care support managed by care coordinators including integrated care planning, education, monitoring, service linkages, and general practitioner liaison over 6-9 months. Individuals who were enrolled into 1 of 8 HARP chronic disease management programs between July 1, 2017, and June 30, 2018, at the Royal Melbourne Hospital, Australia. Hospital admissions between 18 months before and 18 months after HARP enrollment were analyzed. Total hospital costs were compared between 18 months before and 12 months after HARP enrollment. A total of 1553 individuals with a median age of 71 years (interquartile range 60-81), 63.4% males, were admitted to HARP. Both unplanned hospitalizations and bed days were reduced during the HARP intervention compared to within 3 months before enrollment in each of the HARP management programs. After the HARP intervention, cardiac coach, cardiac heart failure, chronic respiratory, diabetes comanagement, and medication management programs had higher hospitalizations and bed days than individuals' baseline of at least 3 months before HARP enrollment. Individuals in cardiac heart failure and chronic respiratory management programs had a higher mortality rate than other HARP chronic disease management programs. Individuals in cardiac coach, diabetes comanagement, and medication management programs had lower hospital costs during the HARP intervention compared to within 3 months before HARP enrollment. HARP reduced unplanned hospitalization and bed days but did not return individuals' hospital use to baseline before the intervention. The variations in mortality between HARP chronic disease management programs implies that condition-specific goals between programs is preferable.

Wan CS ，Mitchell J ，Maier AB 《-》

Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program.

Lawn S ，Zabeen S ，Smith D ，Wilson E ，Miller C ，Battersby M ，Masman K ... -  《-》

A Remote Medication Monitoring System for Chronic Heart Failure Patients to Reduce Readmissions: A Two-Arm Randomized Pilot Study.

Hale TM ，Jethwani K ，Kandola MS ，Saldana F ，Kvedar JC ... -  《JOURNAL OF MEDICAL INTERNET RESEARCH》

A Telephone Support Program to Reduce Costs and Hospital Admissions for Patients at Risk of Readmissions: Lessons from an Evaluation of a Complex Health Intervention.

Morello RT ，Barker AL ，Watts JJ ，Bohensky MA ，Forbes AB ，Stoelwinder J ... -  《-》

Utility of the Hospital Admission Risk Programme diabetes risk calculator in identifying patients with type 2 diabetes at risk of unplanned hospital presentations.

Prevention of hospitalisation is an important aspect of type 2 diabetes (T2D) management. We retrospectively determined the utility of the Hospital Admission Risk Programme (HARP) diabetes risk calculator (HARP tool) in identifying patients with T2D more likely to have unplanned hospital presentations. The HARP tool includes a clinical assessment score (Part A) and a psychosocial and self-management impact score (Part B), and categorises patients into low, medium, high or urgent risk of acute hospitalisation. It was completed for T2D patients attending Royal North Shore Hospital, Sydney, in 2013. Within the cohort of 278 patients (age 65.3 ± 10.5 years; 62.9% male; diabetes duration 10.7 ± 6.6 years), 67.3% were classified as low risk, 32.7% as medium risk and none as high or urgent risk. Following adjustment for confounders, a medium HARP score was associated with a 3.1-fold increased risk of unplanned hospital presentations in the subsequent 12 months (95% confidence interval: 1.35-7.31; P = 0.008). Part A scores were significantly higher for patients that presented to hospital compared to those that did not (14.2 ± 6.8 vs 11.4 ± 5.5; P = 0.034), whereas there was no difference in Part B scores (P = 0.860). In patients with low and medium HARP scores, clinical features were more predictive of hospital presentations than certain psychosocial or self-management factors in the present cohort. Further studies are required to characterise unplanned hospitalisation in patients with higher HARP scores, or whether additional psychosocial assessments could improve the tool's predictability.

McGrath RT ，Dryden JC ，Newlyn N ，Pamplona E ，O'Dea J ，Hocking SL ，Glastras SJ ，Fulcher GR ... -  《-》