Criteria | Type | Description |
---|---|---|
Age | Inclusion | 50Â years old and over at consent. |
Cognitive capacity | Inclusion | Abbreviated Mental Test (AMT) [23] score >7. |
Unplanned acute admissions | Inclusion | A rate of unplanned acute admission with the required principal diagnosis code(s) indicated below: |
a) ≥2 in the last 12 months, or | ||
b) ≥4 in the previous 5 years. | ||
ICD-10-AM principal diagnosis code(s) for each unplanned acute admission | Inclusion | Code(s) for each unplanned acute admission indicate a diagnosis for one or more of the following chronic conditions: |
a) Chronic Obstructive Pulmonary Disease (J41 – J44, J47 and J20, with secondary diagnosis of J41-J44, J47), | ||
b) Coronary Artery Disease (I20 – I25), | ||
c) Hypertensive Diseases (I10 – I15, I11.9. Note: Hypertensive Heart Failure (I11.0) is included in Congestive Heart Failure), | ||
d) Congestive Heart Failure (I11.0, I50, J81), | ||
e) Diabetes (E10 - E14), | ||
f) Asthma (J45). | ||
Unsuitable conditions | Exclusion | The study team considers the presence of the following conditions to be unsuitable for participation in the study: |
a) Any form of cancer, | ||
b) Any neuromuscular disease | ||
c) Any psychiatric conditions. | ||
Care team | Inclusion | The eligible patients must be under the care of any of the following: |
a) General Practitioner | ||
b) Community Nurse | ||
Care programs | Inclusion | Participation in one of the following government care programs: |
a) Commonwealth Chronic Disease Management | ||
b) Commonwealth Coordinated Veterans’ Care Program | ||
c) NSW Connected Care Program | ||
Unsuitable care programs | Exclusion | Participation in one of the following government care programs: |
a) Commonwealth Extended Aged Care in the Home |