Practices undertake care planning in a range of ways. Chronic disease is a leading cause of illness and death and a most significant burden on the Australian health system SEMPHN has commissioned general practices for between $125,000 and $250,000 to provide Care Coordination within their practices.
Three-quarters of Australians over the age of 65 have at least one chronic condition that puts them at risk of serious complications and premature death. People on low incomes have more chronic conditions and nearly twice the rate of avoidable hospital admissions as those with high incomes.
POLAR worked with SEMPHN to develop a series of Care Coordination dashboards. The focus is on priority patient cohorts, in particular refugees and people with chronic disease. Drawing on the data entered by the care coordinator, the POLAR dashboard tracks activities via the allocation of both MBS and non-billable codes specific to the project (including at PHN level), and HARP hospital risk scores are included to further define and measure a cohort.
There is much more granularity that can be gained from the POLAR Care Co-ordination dashboards. They provide data on an ongoing and systematic basis, to allow SEMPHN to fund practices and ensure the right patient cohorts are being cared for.
POLAR worked extensively with SEMPHN to create a set of reports specific to their requirements, but there is relevance to all PHNs.