Improving care by identifying patient complexity and hospitalisation risk

By 2026, nearly one in four Australians will be aged over 65, highlighting the need to shift how we approach healthy ageing across the country.¹ This demographic evolution brings both challenges and opportunities, with increasing complexity in patient care, the prevalence of multiple health conditions, and rising healthcare costs.

The CCQ region has significantly higher self-reported prevalence of long-term health conditions compared with Australia for all persons including children and young people.²

Amid these changes, primary care plays a pivotal role in identifying those who would benefit from more comprehensive support, helping to prevent avoidable hospitalisations and improve quality of life. By ensuring the right person receives the right care in the right place at the right time, we can enhance outcomes for individuals while reducing pressure on the broader health system.

This toolkit is designed to support general practices in navigating the growing complexity of patient care. By focusing on better identification and proactive management of complexity and hospitalisation risk, we can build a healthcare system that not only meets evolving needs but also prioritises compassion, person-centred care and equity.

This activity focuses on improving optimal care for patients with complex health needs and/or increased risk of hospitalisation.

Setting a goal

Improve the care of patients who are at an increased risk of poor health outcomes and who may benefit from additional care and support.

Resources to support your QI

To achieve this goal, you can access a range of resources:

Primary Sense ACG Tool video provides a high-level overview of what the tool is and how patients are stratified.
Review current best practices:
- RACGP – Shared Care Model for complex chronic conditions
- RACGP – Guiding patients through complexity
HealthPathways: Explore locally tailored approaches for managing patients with complexity. Search for: “Care Coordination” and “Chronic Disease Management Items” to get started.
NICE has developed a guideline for the assessment and management of multimorbidity.

Bringing the team together

Kickstart your quality improvement activity by bringing together a quality improvement team. Together, you’ll identify the key challenges and come up with innovative solutions, ensuring you all share a clear understanding of the improvement objectives and strategies.

Engage with your Primary Health Coordinator from CCQ; they can offer tailored support, resources and guidance to enhance your QI efforts wherever you are in your QI journey. Your Primary Health Coordinator can support your practice to:
- Bring a QI team together to decide on an improvement idea
- Plan, start and finish a QI activity
- Facilitate QI meetings
- Create practice-wide systems improvement

Gather data and information. Review current practice data and processes for identifying and supporting complex patients. .
Identify and discuss any common barriers to optimal patient care. Consider using process maps, flow charts or driver diagrams to generate change ideas and improve processes.

Maximising your data

What data might you need? You’ll need data to understand the problem and measure your outcomes. We suggest you start with:

Primary Sense can provide insight, detailed reports and targeted guidance on improving data quality. Primary Sense assigns people to one of six complexity levels ranging from 0-5 using the John Hopkins ACG System. The ACG system has over 30 years of evidence and is designed to measure the ‘medical need’ of a population, recognising that people using the most healthcare resources are not those with a single chronic illness but rather those with multiple conditions. Level 0 indicates a very low level of complexity with no known risks for poor health outcomes. Level 5 is the highest complexity, identifying people typically with high complexity, characterised by instability, multimorbidity, polypharmacy or patients requiring end-of-life care.The following report is available within Primary Sense:
- Patients with High Complexity (4 and 5): provides a list of patients that are eligible or due care planning items.

Tip: Primary Sense also provides a hospital risk score via the prompt function.

Improvement ideas for inspiration

To achieve your goal, you can consider several possible improvement ideas such as:

Utilise the Primary Sense report ‘Patients with High Complexity’ to recall patients due for a Chronic Conditions Management Plan, a medication review, or a home medication review if more suitable. Consider focusing on one type of appointment to develop a process. Tip: Remember to cross reference Medicare for eligibility.
Utilise the Primary Sense prompt ‘Due Care Plan’ to opportunistically schedule future care plan appointments for eligible patients.
Utilise the Primary Sense report ‘Voluntary Patient Registration,’ identifying patients with a complexity level of 4 or 5 and prioritise engaging these patients with enrolling in MyMedicare.
Utilise the Primary Sense prompt ‘Due Medication Review’ to opportunistically schedule a future appointment for a medication review before the patient leaves the practice.
Ahead of the flu season, run a targeted campaign to prioritise influenza immunisation uptake in patients with a complexity level of 4 or 5. This could include posters for awareness, implementing nurse-led clinics or using social media to encourage patients to schedule immunisation appointments.

Remember to self-report your QI project as a CPD activity. QI is a great tool for measuring tangible outcomes and demonstrating improvement in patient care!

Share your results with your CCQ practice support team and with your patients. Ensure you document your quality improvement activity to meet PIP QI guidelines and for CPD purposes.

References

Confronting ageing the talk Australia has to have [Internet]. The University of Sydney. Available from: www.sydney.edu.au/news-opinion/news/2023/10/09/confronting-ageing-the-talk-australia-has-to-have.html#:~:text=Australia%20is%20getting%20older%2C%20faster, accessed 19 December 2024.
Central Queensland, Wide Bay, Sunshine Coast Primary Health Network (CQWBSCPHN). General health: health needs and service analysis 2021. [Internet]. 2021. Available from: c2coast.org.au/wp-content/uploads/General-Health_HNA_10032022_Final-1.pdf

Ready to begin this QI activity?

CCQ acknowledges the Traditional Custodians of the land on which we work and live, and recognises their continuing connection to land, waters and community. We pay our respect to them and their cultures; and to Elders past, present and emerging.