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Predictive risk model being developed for Australian Government’s Health Care Homes initiative

The Australian government recently launched a new healthcare initiative, called Health Care Homes, based on a proposal from the Primary Health Care Advisory Group’s Report into “Better Outcomes for People with Chronic and Complex Health Conditions”, released in March 2016.

The programme aims to keep the millions of Australians with chronic and complex conditions out of hospital and living happier and healthier lives at home. Health Care Homes will develop a shared care plan with the patient, which will be implemented by a team of health care providers. This plan will identify the local providers best able to meet each patient’s needs, coordinate care with these providers and include strategies to help each patient better manage their conditions and improve their quality of life. Care will be integrated across primary and acute care as required.

Twenty practices will begin Health Care Home services on 1 October 2017. Another 180 practices will begin on 1 December 2017. An intuitive and secure risk stratification tool is being developed by Precedence Health Care1, in partnership with The Commonwealth Scientific and Industrial Research Organisation (CSIRO) for use by all 200 Homes. CSIRO will help Precedence to validate and re-calibrate the PRM algorithm for Australian conditions.

The solution will use a cloud-based coordinated care platform from Precedence, cdmNet, to determine an individual patient’s eligibility for the Health Care Home. It will identify and stratify patients based on their disease complexity and other factors so that health care services can be targeted accordingly.  

The first stage of the stratification process uses a Predictive Risk Model (PRM) running on cdmNet to identify and automatically target populations based on practice data. The solution enables the PRM to be run on the entire practice population or whenever an individual patient visits their GP.

Once a patient is identified by the PRM algorithm as potentially eligible for the Health Care Home, an alert will pop up to the GP or practice nurse who can proceed to the second stage of the enrolment process with a single click.

In the second stage a questionnaire is automatically created using smart form technology. The form is prefilled with clinical and other data obtained from the practice and other sources. Non-clinical information, such as data on psycho-social factors, is added to the questionnaire during conversations with patients, family members, carers and providers.

The smart forms automatically check for consistency and then calculate a risk score based on an eligibility algorithm. This enables patients to be positively identified for enrolment, while determining a risk stratum for optimising treatment.

The media release from Precedence stated that the solution is highly secure. Smart encryption techniques are used to ensure no personal health information is stored in the cdmNet cloud. The use of the cdmNet platform enables a Health Care Home to include the risk stratification and eligibility checking into their existing practice workflows while simultaneously  off-loading all the management overheads to the cloud.

The PRM will be developed under an open source licence. In time, other software providers will be able to implement Health Care Home eligibility testing for patients without needing to pay royalties or licensing charges, subject to other conditions of use and any refinements that may arise during the stage one trial.

There is no obligation on participating Health Care Homes to use the full suite of cdmNet services. 

1Precedence Health Care Pty Ltd is an Australian software company providing advanced digital healthcare technologies for connecting healthcare professionals and patients and facilitating the coordination of care. It was established in Australia in 2007 and acquired by Sonic Clinical Services, the primary care division of Sonic Health Care, in late 2015.

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