Table 1 Clinical criteria for eligibility

Age

Inclusion

50 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