Hospital emergency departments (ED) and adult medical services all over the world struggle to manage a workload that seems to increase inexorably. One group of ED presenters who have received particular attention are those who return repeatedly. It is assumed that, if they were somehow managed better, or differently, they might attend less frequently thus reducing the load on the ED and adult medical wards, while perhaps receiving better medical care. Useful models of alternative services have been trialled,1-3 but no-one would claim to have solved this problem.In a parallel trend, there is an ever-growing number of people with long-term conditions, mainly due to an aging population with a heavy burden of lifestyle-related illness, and longer survival with certain chronic conditionsespecially cardiovascular diseases4and comorbidities are the norm.5 Inevitably, a growing number of the ED presenters have long-term conditions as their primary or underlying problem. Meanwhile, our health care systems, both in primary care and secondary care, appear better designed to care for single, acute medical conditions.6,7 Attempts to adapt to the distinctly different and more complex demands of long-term conditions continue to challenge health systems internationally.8 9We will describe attempts at Middlemore Hospital to systematically study the issue of frequent presenters at the ED, and our plans to formally trial a targeted intervention. Our main thesis is that designing systems that integrate secondary and primary care, that are designed to support people with complex long-term conditions (often further complicated by psycho-social needs), may address at the same time both the short term challenges facing the ED and the long-term challenges of improving care for people with long-term conditions.Definition of frequent presenterThere is no universally accepted definition of frequent presenter. For example, the number of visits used as a criterion includes: four or more (in studies from Sweden,10 the UK11 and Ireland12); five or more (US,13 Australia14) and 10 or more (Christchurch, New Zealand15 and Spain16). Not surprisingly, a UK study noted that the profile of frequent presenters was a continuum; from about the fourth visit, the more frequently people attended the more likely they were to be male, older, attend after-hours and be more seriously ill.11The current definition of frequent presenter used at Middlemore Hospital includes any adult (age 15 or over) presenting to the ED on five or more occasions in the preceding twelve months. Those under the active care of the renal or haematology service are automatically excluded; surgical, orthopaedic, obstetric and gynaecological patients may be excluded after triage. The ED computer system flags those attending for the 5th or subsequent time in a year. The software behind this flag provides a first and partial filter to match our intended definition of frequent presenter.Numbers at Middlemore HospitalIn the year ending 28 February 2010, 64,409 patients presented to the ED 88,565 times. Of these, 1711 patients age 15 or over, in 8756 presentations, were flagged. Of these presentations, (5312, 61%) resulted in an overnight stay; total bed days for the year were 25,768, with a median per patient 10, interquartile range 4 to 23. According to the patient cost system, the total cost of flagged patients was approximately $31.5 million.The median age of these 1711 patients was 56 years; 653 (38%) were age 65 or older (so eligible for Aged Care Services); 900 (53%) were women; 659 (39%) were European, 558 (33%) were Pacific, 323 (19%) were M ori, 102 (6%) were Indian, 35 (2%) were Asian, 22 (1%) were Other and 12 (1%) were or unknown ethnicity.Fewest patients presented on Saturday (13%) and Sunday (12%), and most on Monday (16%). A total of 74% presented between 8am and 10pm (when most doctors are rostered at the hospital); and 56% presented between 8am and 6pm (when most doctors might be available in primary care). In all, 56% of presentations were on Monday to Friday between 8am and 10pm. A total of 69% of all presentations were self-referrals, suggesting a disconnection from primary care which has been noted in other studies of frequent presenters, although the literature also suggests that a subgroup are also high users of primary care.10 12 One hundred and sixty six patients (10%) were, or had been, on the Counties Manukau DHB Chronic Care Management Programme.Principal diagnoses on discharge ICD10 codes included diseases classified as: respiratory (18%), circulatory (14%), digestive system (10%), injury (8%), genitourinary (5%), endocrine (4%) and musculoskeletal (4%). These numbers do not account for co-morbidities. A record audit of 30 frequently presenting patients in 2009 found them to have an average of three chronic medical conditions, most commonly respiratory, cardiovascular disease or diabetes, and taking nine regular medications. Many had psycho-social problems.Pattern of same people over timeTable 1 shows that 77% of adults who frequent presented in a 9 month period from September 2008 to May 2009 also presented frequently in the following 9 monthsno attempt has been made to adjust for seasonal variation. (The count does not include the small number who returned in the second 9 month period without meeting the frequent presenter flag criteria.) Overall, the return rate seems higher than others have found; 38% of high users in San Francisco were similarly high users the following year (using a criterion of 5 or more ED visits over the years 1993-8)13; and 40% of high users at Christchurch Hospital in1997 were also high users the following year (using a criterion of 10 or more ED visits).15It is not clear why the numbers decrease the following year. Some die; 15% in the 18 months of our data shown in Table 1; 13% over the following 3-4 years in Christchurch;15 19% in Spain (10 or more ED visits), although the follow up period is unclear;16 and frequent presenters in Sweden (4 or more visits) had a standardised mortality rate of 1.55 compared to non-frequent presenters.10 Other plausible reasons for a decrease in attending the following year include getting better due to help from secondary care, primary care or social care. However, it is also possible that patients recovered spontaneously, moved out of the area, came to tolerate a condition or gave up their hope of help from the helping professions. Table 1. Adults flagged at Middlemore Hospital Emergency Department on their 5th or subsequent attendance in one year; comparing those who attended in one 9-month period with the subset who also attended in the following 9 months. Variables Presented to ED Sep 08 to May 09 Subset of first group who also presented Jun 09 to Feb 10 Visits, patients (% of baseline group) 6860, 1749 5387 (79%), 1348 (77%) Age (median, inter-quartile range) 56 (34 to 73) 57 (35 to 73) Female 914 (52%) 704 (52%) European M ori Pacific Asian Indian Other Unknown 686 (39%) 332 (19%) 560 (32%) 36 (2%) 104 (6%) 17 (1%) 14 (1%) 519 (39%) 263 (20%) 440 (33%) 23 (2%) 80 (6%) 13 (1%) 10 (1%) Note: The software behind the flag is intended to exclude those recurrently attending renal, haematology and gastroenterology day stay services. No attempt is made to adjust for seasonal variation. Solutions proposed in the literature Pope et al in Canada found that case management of 24 patientschosen for their complex or chronic medical conditions, drug use, or their violent or abusive behaviourreduced their number of admissions from a median of 27 to 7 visits per year.2 On the other hand, when Phillips et al implemented case management for 60 patients who had averaged over 20 ED visits in the previous year to a tertiary hospital in Australia1 they found that in the subsequent year these patients increased their use of both the ED and primary care. Perhaps this serves as a warning that some of the decrease in attendance in subsequent years seen at Middlemore and elsewhere may indeed be due to patients deciding we cannot meet their needs. Both these studies used a before and after study design without a contemporaneous control, which is problematic given the apparent natural history of decreased attendance over time (Table 1). Shumway et al used a randomised control design to study 165 patients under case management and 85 under usual care. Their patients had 5 or more visits in the previous year, and psychosocial problems that could be addressed by case management.3 Case management reduced ED use at a cost similar to usual care over 2 years. Very high intensive users programme at Middlemore In Counties Manukau a service has evolved over several years to coordinate care between ED, secondary care and primary care. Elements of this approach has already been tested with promising results.17 A pilot programme called the Very High Intensity Users (VHIU) project has been allocated $800,000 for 1 year by the DHB. Ongoing funding will depend on the results of an evaluation. The business case states that the VHIU project aims to improve patient care co-ordination, and to establish, or re-establish, effective care in the community and general practice. The multidisciplinary programme team includes part time input from general medicine Senior Medical Officers, Clinical Nurse Specialists, a Clinical Pharmacist, Primary Care Nurse Specialists and Locality Coordinators (who are employed by Primary Health Organisations (PHOs)). The role of the Clinical Nurse Specialists and pharmacist ensures early input for patients with the social worker, psychiatry liaison, Needs Assessment Coordination and associated allied health professionals as required. The role of the Primary Care Nurse Specialists and Locality Coordinators is to ensure safe integration and early collaboration with general practitioners, practice nurses and other community services. For each patient who is flagged when they attend ED, one of the VHIU staff uses a short checklist to review the electronic patient records for current and previously identified problems. See Figure 1 for a flow diagram of the filtering process. Patients who are still included have an interview structured around a risk assessment guide (RAG, see Box 4), a tool modified from Degelings observations in the United Kingdom.8 The RAG tool is primarily used before the patient has left hospital but is otherwise done in the patients home. The current RAG tool is a paper form that consists of 31 prompt items, space for free text comment, and a checklist for actions or referrals. The prompt items are grouped into six domains: demographic, social (including cultural and linguistic), health service related, mental health, pharmacy and clinical. The interview typical lasts about 20 minutes. Figure 1. Initial screening tool for flagged patients at Middlemore Emergency Department Experience suggests that the RAG supports a structured approach to identifying important patient issues that may have been missed, on repeated occasions, by a focussed clinical approach. Specialist Nurses and\/or the Pharmacist will visit the patient either in the ward or at home and hear the patient's concerns, understandings and expectations about their health issues. Navigation of the health system, literacy, cultural beliefs, coping mechanisms at home and various other barriers will become better understood as a consequence. After the RAG assessment, each patient is considered by a wider multi-disciplinary group and one team member is delegated as the navigator who then arranges any or all of: a more extensive review of secondary care or primary care medical records, a home visit to assess needs and living circumstances in more detail, a multi-disciplinary meeting with primary care or referral to secondary or primary service or social service agencies. The navigator then follows the patientfrequently and assertively if neededand will advocate for them with other health or social agencies, either in person or by phone or other communication. Patients remain enrolled in the VHIU programme until a decision is made collaboratively that they are receiving effective care and support from community services and have been integrated back into community care. In practice this process lasts from a few days to a few weeks. The programme has a small fund to reimburse short term costs of primary care, such as costs of waiving patient charges, or costs to have a GP attend a family conference. Examples of the range of services and outcomes credited to the VHIU team include: effective advocacy for better housing; acceleration of outpatient review or medical investigations; medical case note review revealing clinically important disconnections of knowledge between medical services; better coordination of health care; shifting a Pacific man from a rest home where no Pacific languages were spoken into one were staff spoke his language; and sorting medication confusion and arranging for medications to be blister packed. Any time a patient is flagged the same process is repeated, so that a patient not enrolled in the VHIU programme on the first occasion may be on another, or a patient who has been discharged from the programme may be re-enrolled. Anecdotes within the VHIU programme to date and from the evaluation of the earlier pilot which tested the underlying concepts,17 suggest that this programme may reduce the return visits to ED by as much as half. It is important to note that the VHIU focus is on preventing the next admission rather than early discharge at the index admission. The proposed evaluation includes a randomised controlled trial to assess the effect of the programme on acute hospital demand; a process evaluation to evaluate programme delivery; measures of patient outcomes; and measures of costs. Beyond VHIU The VHIU programme was not developed in isolationit is one of several programmes within Counties Manukau DHB addressing the problems of ED workloads and management of long-term conditions. It is in line with continuing experience at Counties Manukau which confirms the need for primary-secondary care integration and integration with social support for long-term care management.17-19 Other ongoing initiatives include Chronic Care Management,20 Care Plus, improvement programmes in Aged Related Residential Care,21 Year of Care, a Clinical Networks project (integrated Continuous Quality Improvement groups in primary care) and nurse-led clinics. A consortium of the three Auckland regional DHBs and eleven PHOs is currently developing a detailed project in response to the Better, Sooner, More Convenient Request For Proposal. We look forward to the day when long-term condition management will be centred on family and patient self monitoring and will be organised from community-owned, locality-based organisations that will hold budgets for long-term condition managements; when Continuous Quality Improvement will be the hallmark of care provision; and when information technology will provide the backbone for an integrated care system that supports a single shared patient record. This vision can be achieved, but requires local pilots which are carefully evaluated and infrastructure developed around successful pilots, both requiring funding at a level that does not doom the pilots to failure. The VHIU project may be the first such pilot. Box 1. People who have been involved in this work in Counties Manukau, and who have endorsed the concerns and the proposals outlined here (Alphabetically) Jacqui Adair, Alex Boersma, Tom Bracken, Linda Bryant, Fay Burke, Ria Byron, Sam Cliffe, Janine Cochrane, Alan Cumming, Helen Duyvesten, Debbie Eastwood, Priya Francis, Jeff Garrett, Meg Goodman, Brad Healey, Denise Kivell, Chris Lash, Christine Lynch, Mangere Community Health Centre, Mangere Family Doctors, Tina McCafferty, Shirley Miller, Allan Moffitt, Helen Morrish, Primary Health Organisation Group (GPHO), Karyn Sangster, Vanessa Thornton, Sarah Tibby, Vanessa Whiu, Anne Williamson Box 2. The archetypical VHIU patient in CMDHB is: A woman of 50-55 years old, obese with type 2 diabetes, cellulitis, gout and COPD or CHF. She will be as disabled as an 85 year old but will not be getting the services available to aged care such as case conferencing, care plans and home support. In fact, she will have dependent children and possibly parents, one reason she seeks her own medical care in EC after 10pm is that for a few hours the family do not need her. She will have appointments at 5 sub specialty outpatients clinics, and she will be labelled non compliant \/ DNA and will have no continuity of care with her GP. She will not be helped by being told that she must look after herself or she will not see her children grow upshe knows this. Health literacy will be zero as will self efficacy, and she will be unable to navigate the health \/ social welfare systems. She will be in a state of medication confusion and will be seeing 6 health care workers none of whom knows what the others are doing Box 3. Elements of the proposed intervention in Counties Manukau Risk Assessment Guide (RAG) - global assessment of needs to include patient and family\/whanau perspective Multidisciplinary input Home visits Relationship building Clinical review Case conference of health professional and family meeting, preferably in primary care One co-ordinator \/ navigator \/ key worker Rigorous follow up Care plan Self \/ family management Crisis management Advocacy for social services Evaluation Continuous improvement Box 4. Data collected in the Risk Assessment Guide (RAG). Modified with permission from Degeling et al8 Patient sticker Date Ethnicity First Language Age 65+ Y N Uses multiple pharmacies Y N Housing issues Y N Poly-pharmacy (>8 items) Y N Risk at home Y N Compliance (meds) Y N Living alone Y N Progression of disease Y N Living alone Y N Multiple co-morbidities Y N Living with dependent Y N CNS involved* Y

Hospital emergency departments (ED) and adult medical services all over the world struggle to manage a workload that seems to increase inexorably. One group of ED presenters who have received particular attention are those who return repeatedly. It is assumed that, if they were somehow managed better, or differently, they might attend less frequently thus reducing the load on the ED and adult medical wards, while perhaps receiving better medical care. Useful models of alternative services have been trialled,1-3 but no-one would claim to have solved this problem.In a parallel trend, there is an ever-growing number of people with long-term conditions, mainly due to an aging population with a heavy burden of lifestyle-related illness, and longer survival with certain chronic conditionsespecially cardiovascular diseases4and comorbidities are the norm.5 Inevitably, a growing number of the ED presenters have long-term conditions as their primary or underlying problem. Meanwhile, our health care systems, both in primary care and secondary care, appear better designed to care for single, acute medical conditions.6,7 Attempts to adapt to the distinctly different and more complex demands of long-term conditions continue to challenge health systems internationally.8 9We will describe attempts at Middlemore Hospital to systematically study the issue of frequent presenters at the ED, and our plans to formally trial a targeted intervention. Our main thesis is that designing systems that integrate secondary and primary care, that are designed to support people with complex long-term conditions (often further complicated by psycho-social needs), may address at the same time both the short term challenges facing the ED and the long-term challenges of improving care for people with long-term conditions.Definition of frequent presenterThere is no universally accepted definition of frequent presenter. For example, the number of visits used as a criterion includes: four or more (in studies from Sweden,10 the UK11 and Ireland12); five or more (US,13 Australia14) and 10 or more (Christchurch, New Zealand15 and Spain16). Not surprisingly, a UK study noted that the profile of frequent presenters was a continuum; from about the fourth visit, the more frequently people attended the more likely they were to be male, older, attend after-hours and be more seriously ill.11The current definition of frequent presenter used at Middlemore Hospital includes any adult (age 15 or over) presenting to the ED on five or more occasions in the preceding twelve months. Those under the active care of the renal or haematology service are automatically excluded; surgical, orthopaedic, obstetric and gynaecological patients may be excluded after triage. The ED computer system flags those attending for the 5th or subsequent time in a year. The software behind this flag provides a first and partial filter to match our intended definition of frequent presenter.Numbers at Middlemore HospitalIn the year ending 28 February 2010, 64,409 patients presented to the ED 88,565 times. Of these, 1711 patients age 15 or over, in 8756 presentations, were flagged. Of these presentations, (5312, 61%) resulted in an overnight stay; total bed days for the year were 25,768, with a median per patient 10, interquartile range 4 to 23. According to the patient cost system, the total cost of flagged patients was approximately $31.5 million.The median age of these 1711 patients was 56 years; 653 (38%) were age 65 or older (so eligible for Aged Care Services); 900 (53%) were women; 659 (39%) were European, 558 (33%) were Pacific, 323 (19%) were M ori, 102 (6%) were Indian, 35 (2%) were Asian, 22 (1%) were Other and 12 (1%) were or unknown ethnicity.Fewest patients presented on Saturday (13%) and Sunday (12%), and most on Monday (16%). A total of 74% presented between 8am and 10pm (when most doctors are rostered at the hospital); and 56% presented between 8am and 6pm (when most doctors might be available in primary care). In all, 56% of presentations were on Monday to Friday between 8am and 10pm. A total of 69% of all presentations were self-referrals, suggesting a disconnection from primary care which has been noted in other studies of frequent presenters, although the literature also suggests that a subgroup are also high users of primary care.10 12 One hundred and sixty six patients (10%) were, or had been, on the Counties Manukau DHB Chronic Care Management Programme.Principal diagnoses on discharge ICD10 codes included diseases classified as: respiratory (18%), circulatory (14%), digestive system (10%), injury (8%), genitourinary (5%), endocrine (4%) and musculoskeletal (4%). These numbers do not account for co-morbidities. A record audit of 30 frequently presenting patients in 2009 found them to have an average of three chronic medical conditions, most commonly respiratory, cardiovascular disease or diabetes, and taking nine regular medications. Many had psycho-social problems.Pattern of same people over timeTable 1 shows that 77% of adults who frequent presented in a 9 month period from September 2008 to May 2009 also presented frequently in the following 9 monthsno attempt has been made to adjust for seasonal variation. (The count does not include the small number who returned in the second 9 month period without meeting the frequent presenter flag criteria.) Overall, the return rate seems higher than others have found; 38% of high users in San Francisco were similarly high users the following year (using a criterion of 5 or more ED visits over the years 1993-8)13; and 40% of high users at Christchurch Hospital in1997 were also high users the following year (using a criterion of 10 or more ED visits).15It is not clear why the numbers decrease the following year. Some die; 15% in the 18 months of our data shown in Table 1; 13% over the following 3-4 years in Christchurch;15 19% in Spain (10 or more ED visits), although the follow up period is unclear;16 and frequent presenters in Sweden (4 or more visits) had a standardised mortality rate of 1.55 compared to non-frequent presenters.10 Other plausible reasons for a decrease in attending the following year include getting better due to help from secondary care, primary care or social care. However, it is also possible that patients recovered spontaneously, moved out of the area, came to tolerate a condition or gave up their hope of help from the helping professions. Table 1. Adults flagged at Middlemore Hospital Emergency Department on their 5th or subsequent attendance in one year; comparing those who attended in one 9-month period with the subset who also attended in the following 9 months. Variables Presented to ED Sep 08 to May 09 Subset of first group who also presented Jun 09 to Feb 10 Visits, patients (% of baseline group) 6860, 1749 5387 (79%), 1348 (77%) Age (median, inter-quartile range) 56 (34 to 73) 57 (35 to 73) Female 914 (52%) 704 (52%) European M ori Pacific Asian Indian Other Unknown 686 (39%) 332 (19%) 560 (32%) 36 (2%) 104 (6%) 17 (1%) 14 (1%) 519 (39%) 263 (20%) 440 (33%) 23 (2%) 80 (6%) 13 (1%) 10 (1%) Note: The software behind the flag is intended to exclude those recurrently attending renal, haematology and gastroenterology day stay services. No attempt is made to adjust for seasonal variation. Solutions proposed in the literature Pope et al in Canada found that case management of 24 patientschosen for their complex or chronic medical conditions, drug use, or their violent or abusive behaviourreduced their number of admissions from a median of 27 to 7 visits per year.2 On the other hand, when Phillips et al implemented case management for 60 patients who had averaged over 20 ED visits in the previous year to a tertiary hospital in Australia1 they found that in the subsequent year these patients increased their use of both the ED and primary care. Perhaps this serves as a warning that some of the decrease in attendance in subsequent years seen at Middlemore and elsewhere may indeed be due to patients deciding we cannot meet their needs. Both these studies used a before and after study design without a contemporaneous control, which is problematic given the apparent natural history of decreased attendance over time (Table 1). Shumway et al used a randomised control design to study 165 patients under case management and 85 under usual care. Their patients had 5 or more visits in the previous year, and psychosocial problems that could be addressed by case management.3 Case management reduced ED use at a cost similar to usual care over 2 years. Very high intensive users programme at Middlemore In Counties Manukau a service has evolved over several years to coordinate care between ED, secondary care and primary care. Elements of this approach has already been tested with promising results.17 A pilot programme called the Very High Intensity Users (VHIU) project has been allocated $800,000 for 1 year by the DHB. Ongoing funding will depend on the results of an evaluation. The business case states that the VHIU project aims to improve patient care co-ordination, and to establish, or re-establish, effective care in the community and general practice. The multidisciplinary programme team includes part time input from general medicine Senior Medical Officers, Clinical Nurse Specialists, a Clinical Pharmacist, Primary Care Nurse Specialists and Locality Coordinators (who are employed by Primary Health Organisations (PHOs)). The role of the Clinical Nurse Specialists and pharmacist ensures early input for patients with the social worker, psychiatry liaison, Needs Assessment Coordination and associated allied health professionals as required. The role of the Primary Care Nurse Specialists and Locality Coordinators is to ensure safe integration and early collaboration with general practitioners, practice nurses and other community services. For each patient who is flagged when they attend ED, one of the VHIU staff uses a short checklist to review the electronic patient records for current and previously identified problems. See Figure 1 for a flow diagram of the filtering process. Patients who are still included have an interview structured around a risk assessment guide (RAG, see Box 4), a tool modified from Degelings observations in the United Kingdom.8 The RAG tool is primarily used before the patient has left hospital but is otherwise done in the patients home. The current RAG tool is a paper form that consists of 31 prompt items, space for free text comment, and a checklist for actions or referrals. The prompt items are grouped into six domains: demographic, social (including cultural and linguistic), health service related, mental health, pharmacy and clinical. The interview typical lasts about 20 minutes. Figure 1. Initial screening tool for flagged patients at Middlemore Emergency Department Experience suggests that the RAG supports a structured approach to identifying important patient issues that may have been missed, on repeated occasions, by a focussed clinical approach. Specialist Nurses and\/or the Pharmacist will visit the patient either in the ward or at home and hear the patient's concerns, understandings and expectations about their health issues. Navigation of the health system, literacy, cultural beliefs, coping mechanisms at home and various other barriers will become better understood as a consequence. After the RAG assessment, each patient is considered by a wider multi-disciplinary group and one team member is delegated as the navigator who then arranges any or all of: a more extensive review of secondary care or primary care medical records, a home visit to assess needs and living circumstances in more detail, a multi-disciplinary meeting with primary care or referral to secondary or primary service or social service agencies. The navigator then follows the patientfrequently and assertively if neededand will advocate for them with other health or social agencies, either in person or by phone or other communication. Patients remain enrolled in the VHIU programme until a decision is made collaboratively that they are receiving effective care and support from community services and have been integrated back into community care. In practice this process lasts from a few days to a few weeks. The programme has a small fund to reimburse short term costs of primary care, such as costs of waiving patient charges, or costs to have a GP attend a family conference. Examples of the range of services and outcomes credited to the VHIU team include: effective advocacy for better housing; acceleration of outpatient review or medical investigations; medical case note review revealing clinically important disconnections of knowledge between medical services; better coordination of health care; shifting a Pacific man from a rest home where no Pacific languages were spoken into one were staff spoke his language; and sorting medication confusion and arranging for medications to be blister packed. Any time a patient is flagged the same process is repeated, so that a patient not enrolled in the VHIU programme on the first occasion may be on another, or a patient who has been discharged from the programme may be re-enrolled. Anecdotes within the VHIU programme to date and from the evaluation of the earlier pilot which tested the underlying concepts,17 suggest that this programme may reduce the return visits to ED by as much as half. It is important to note that the VHIU focus is on preventing the next admission rather than early discharge at the index admission. The proposed evaluation includes a randomised controlled trial to assess the effect of the programme on acute hospital demand; a process evaluation to evaluate programme delivery; measures of patient outcomes; and measures of costs. Beyond VHIU The VHIU programme was not developed in isolationit is one of several programmes within Counties Manukau DHB addressing the problems of ED workloads and management of long-term conditions. It is in line with continuing experience at Counties Manukau which confirms the need for primary-secondary care integration and integration with social support for long-term care management.17-19 Other ongoing initiatives include Chronic Care Management,20 Care Plus, improvement programmes in Aged Related Residential Care,21 Year of Care, a Clinical Networks project (integrated Continuous Quality Improvement groups in primary care) and nurse-led clinics. A consortium of the three Auckland regional DHBs and eleven PHOs is currently developing a detailed project in response to the Better, Sooner, More Convenient Request For Proposal. We look forward to the day when long-term condition management will be centred on family and patient self monitoring and will be organised from community-owned, locality-based organisations that will hold budgets for long-term condition managements; when Continuous Quality Improvement will be the hallmark of care provision; and when information technology will provide the backbone for an integrated care system that supports a single shared patient record. This vision can be achieved, but requires local pilots which are carefully evaluated and infrastructure developed around successful pilots, both requiring funding at a level that does not doom the pilots to failure. The VHIU project may be the first such pilot. Box 1. People who have been involved in this work in Counties Manukau, and who have endorsed the concerns and the proposals outlined here (Alphabetically) Jacqui Adair, Alex Boersma, Tom Bracken, Linda Bryant, Fay Burke, Ria Byron, Sam Cliffe, Janine Cochrane, Alan Cumming, Helen Duyvesten, Debbie Eastwood, Priya Francis, Jeff Garrett, Meg Goodman, Brad Healey, Denise Kivell, Chris Lash, Christine Lynch, Mangere Community Health Centre, Mangere Family Doctors, Tina McCafferty, Shirley Miller, Allan Moffitt, Helen Morrish, Primary Health Organisation Group (GPHO), Karyn Sangster, Vanessa Thornton, Sarah Tibby, Vanessa Whiu, Anne Williamson Box 2. The archetypical VHIU patient in CMDHB is: A woman of 50-55 years old, obese with type 2 diabetes, cellulitis, gout and COPD or CHF. She will be as disabled as an 85 year old but will not be getting the services available to aged care such as case conferencing, care plans and home support. In fact, she will have dependent children and possibly parents, one reason she seeks her own medical care in EC after 10pm is that for a few hours the family do not need her. She will have appointments at 5 sub specialty outpatients clinics, and she will be labelled non compliant \/ DNA and will have no continuity of care with her GP. She will not be helped by being told that she must look after herself or she will not see her children grow upshe knows this. Health literacy will be zero as will self efficacy, and she will be unable to navigate the health \/ social welfare systems. She will be in a state of medication confusion and will be seeing 6 health care workers none of whom knows what the others are doing Box 3. Elements of the proposed intervention in Counties Manukau Risk Assessment Guide (RAG) - global assessment of needs to include patient and family\/whanau perspective Multidisciplinary input Home visits Relationship building Clinical review Case conference of health professional and family meeting, preferably in primary care One co-ordinator \/ navigator \/ key worker Rigorous follow up Care plan Self \/ family management Crisis management Advocacy for social services Evaluation Continuous improvement Box 4. Data collected in the Risk Assessment Guide (RAG). Modified with permission from Degeling et al8 Patient sticker Date Ethnicity First Language Age 65+ Y N Uses multiple pharmacies Y N Housing issues Y N Poly-pharmacy (>8 items) Y N Risk at home Y N Compliance (meds) Y N Living alone Y N Progression of disease Y N Living alone Y N Multiple co-morbidities Y N Living with dependent Y N CNS involved* Y