Capitated Telehealth Coaching Hospital Readmission Service in Australia: Pragmatic Controlled Evaluation.

Background: MonashWatch is a telehealth public hospital outreach pilot service as a component of the Government of Victoria's statewide redesign initiative called HealthLinks: Chronic Care. Rather than only paying for hospitalizations, projected funding is released earlier to hospitals to allow them to reduce hospitalization costs. MonashWatch introduced a web-based app, Patient Journey Record System, to assess the risk of the journeys of a cohort of patients identified as frequent admitters.

Potentially preventable hospitalizations-The 'pre-hospital syndrome': Retrospective observations from the MonashWatch self-reported health journey study in Victoria, Australia.

Rationale, Aims, And Objectives: HealthLinks: Chronic Care is a state-wide public hospital initiative designed to improve care for cohorts at-risk of potentially preventable hospitalizations at no extra cost. MonashWatch (MW) is an hospital outreach service designed to optimize admissions in an at-risk cohort. Telehealth operators make regular phone calls (≥weekly) using the Patient Journey Record System (PaJR).

Improving quality in a complex primary care system-An example of refugee care and literature review.

Rationale, Aims And Objectives: Applying traditional industrial quality improvement (QI) methodologies to primary care is often inappropriate because primary care and its relationship to the healthcare macrosystem has many features of 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 to 2017.

Universal health care - A matter of design and agency?

Universal health care (UHC) is primarily a financing concern, whereas primary health care (PHC) is primarily concerned with providing the right care at the right time to achieve the best possible health outcomes for individuals and communities. A recent call for contributions by the WHO emphasized that UHC can only be achieved through PHC, and that to achieve this goal will require the strengthening of the three pillars of PHC - (a) enabling primary care and public health to integrate health services, (b) empowering people and communities to create healthy living conditions, and (c) integrating multisectoral policy decisions to ensure UHC that achieves the goal of "health for all." "Pillars" - as a static metaphor - sends the wrong signal to the research and policy-making community.

Health and Disease-Emergent States Resulting From Adaptive Social and Biological Network Interactions.

Health is an adaptive state unique to each person. This subjective state must be distinguished from the objective state of disease. The experience of health and illness (or poor health) can occur both in the absence and presence of objective disease.

Anticipatory Care in Potentially Preventable Hospitalizations: Making Data Sense of Complex Health Journeys.

Potentially preventable hospitalizations (PPH) are minimized when adults (usually with multiple morbidities ± frailty) benefit from alternatives to emergency hospital use. A complex systems and anticipatory journey approach to PPH, the Patient Journey Record System (PaJR) is proposed. PaJR is a web-based service supporting ≥weekly telephone calls by trained lay Care Guides (CG) to individuals at risk of PPH.

Resilience and health (care): A dynamic adaptive perspective.

This special forum on resilience explores particular worldviews of resilience-clinical, psychosocial, sociological, complexity science, organizational, and political economy through eight papers. This forum aims to open up the wealth of understandings and implications in health care by taking a transdisciplinary overview.

Quantifying resilience of humans and other animals.

All life requires the capacity to recover from challenges that are as inevitable as they are unpredictable. Understanding this resilience is essential for managing the health of humans and their livestock. It has long been difficult to quantify resilience directly, forcing practitioners to rely on indirect static indicators of health.

Resilience, health perceptions, (QOL), stressors, and hospital admissions-Observations from the real world of clinical care of unstable health journeys in Monash Watch (MW), Victoria, Australia.

Rationale, Aims, And Objectives: Monash Watch (MW) aims to reduce potentially preventable hospitalisations in a cohort above a risk "threshold" identified by Health Links Chronic Care (HLCC) algorithms using personal, diagnostic, and service data. MW conducted regular patient monitoring through outbound phone calls using the Patient Journey Record System (PaJR). PaJR alerts are intended to act as a self-reported barometer of stressors, resilience, and health perceptions with more alerts per call indicating greater risk.

General practice work and workforce: Interdependencies between demand, supply and quality.

Background: General practice is regarded as central to the Australian health system. However, issues affecting the general practitioner (GP) workforce have been focused mainly on remuneration, numbers and distribution. The focus is shifting to how best to enable GPs to deliver effective, efficient and equitable care.

What matters in "multimorbidity"? Arguably resilience and personal health experience are central to quality of life and optimizing survival.

Rationale: Much is written about "multimorbidity" as it is a difficult problem for health systems, as it reflects a complex phenomenon unique to each individual health journey and health service context. This paper proposes the adoption of 2 constructs or knowledge streams into mainstream "multimorbidity" care which are arguably most important to person-centered care-personal health perceptions and resilience.

Analysis: "Multimorbidity" is the manifestation of multiple nonlinear physical, psychosocial, and environmental phenomena in an individual health journey.

'Multimorbidity' as the manifestation of network disturbances.

We argue that 'multimorbidity' is the manifestation of interconnected physiological network processes within an individual in his or her socio-cultural environment. Networks include genomic, metabolomic, proteomic, neuroendocrine, immune and mitochondrial bioenergetic elements, as well as social, environmental and health care networks. Stress systems and other physiological mechanisms create feedback loops that integrate and regulate internal networks within the individual.

It is complicated! - misunderstanding the complexities of 'complex'.

Terminology matters - as Lakoff emphasised, words and phrases evoke powerful images and frames of understanding. It is for that reason that we need to discern and use appropriately the term complex/complexity in the health science/professional/policy domain. Complex is the fashionable term used when in reality one means 'complicated', 'difficult to understand' or 'multiple simultaneous actions'.

Person-centred health care: a critical assessment of current and emerging research approaches.

Rationale, Aims And Objectives: Person-centred health care is prominent in international health care reforms. A shift to understanding and improving personal care at the point of delivery has generated debates about the nature of the person-centred research agenda. This paper purviews research paradigms that influence current person-centred research approaches and traditions that influence knowledge foundations in the field.

What weekday? How acute? An analysis of reported planned and unplanned GP visits by older multi-morbid patients in the Patient Journey Record System database.

Rationale, Aims And Objectives: Timely access to general practitioner (GP) care is a recognized strategy to address avoidable hospitalization. Little is known about patients seeking planned (decided ahead) and unplanned (decided on day) GP visits. The Patient Journey Record System (PaJR) provides a biopsychosocial real-time monitoring and support service to chronically ill and older people over 65 who may be at risk of an avoidable hospital admission.

Self-rated health: patterns in the journeys of patients with multi-morbidity and frailty.

Rationale, Aims And Objectives: Self-rated health (SRH) is a single measure predictor of hospital utilization and health outcomes in epidemiological studies. There have been few studies of SRH in patient journeys in clinical settings. Reduced resilience to stressors, reflected by SRH, exposes older people (complex systems) to the risk of hospitalization.