AUTHOR=Martin Carmel M. , Sturmberg Joachim P. , Stockman Keith , Hinkley Narelle , Campbell Donald 

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

JOURNAL=Frontiers in Public Health

VOLUME=Volume 6 - 2018

YEAR=2019

URL=https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2018.00376

DOI=10.3389/fpubh.2018.00376

ISSN=2296-2565

ABSTRACT=Purpose: 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 approach to PPH, the Patient Journey Record System (PaJR) is proposed.  
Application: PaJR is a web-based service supporting weekly telephone calls by trained Care Guides (CG) to individuals at risk of PPH. The Victorian HealthLinks Chronic Care algorithm provides case finding from hospital big data. Prediction algorithms on call data helps optimize emergency hospital use through adaptive and anticipatory care. Monash Watch deployment incorporating PaJR is conducted by Monash Health in its Dandenong urban catchment area, Victoria, Australia. 
Theory: A Complex Adaptive Systems (CAS) framework underpins PaJR, and recognizes unique individual journeys, their historical and current influences, and difficult-to-predict tipping points. Rosen’s modelling relationship and anticipation theory additionally informed the CAS framework. PaJR uses current and future health perceptions (interoception) through conversations to anticipate potential tipping points and intervene in PPH trajectories. 
Evaluation: Monash Watch is actively monitoring 272 of 376 intervention patients, with 195 controls over 22 months (ongoing). Trajectories of poor health (SRH) and anticipation of worse/uncertain health(AH), and CG concerns statistically shifted at a tipping point, 3 days before admission in the subset who experienced 1 acute admission. The -3 day point was generally consistent across age and gender. 3 randomly selected case studies demonstrate the processes of anticipatory and reactive care in relation to tipping points. PaJR-supported services achieved higher than pre-set targets – consistent reduction in acute bed days (20-25%) versus target 10% and high levels of patient satisfaction. 
Discussion: Anticipatory care in an emerging trajectory data analytic approach that uses human sense-making as its core metric demonstrates improvements in processes and outcomes. Multiple sources can provide big data to inform trajectory care, however simple tailored data collections may prove effective if they embrace human interoception and anticipation. Admission risk may be addressed with a simple data collections including SRH, AH and CG perceptions, where practical.
Conclusion: Anticipatory care, as operationalized through PaJR approaches applied in Monash Watch demonstrates processes and outcomes that successfully ameliorate PPH.