What is Ochre's "Health Outcomes Program" All About?

Published on 01/09/2016

​In Australia, chronic diseases are the leading cause of illness, disability and death. According to the Australian Institute of Health and Welfare (AIHW), 1 in 5 Australians are affected by multiple chronic diseases. Chronic conditions such as cancer, diabetes, cardiovascular disease, chronic obstructive pulmonary disease, chronic kidney disease, as well as asthma, arthritis, osteoporosis, and depression are known to inhibit the everyday abilities of sufferers and significantly lower quality of life. Our doctors and nurses at Ochre Health are committed to combating the issue of chronic disease in Australia, and we have therefore implemented an industry leading health outcomes program as part of our approach to chronic disease management (CDM).

Ochre Health has devised its own CDM strategy which involves carrying out a thorough annual assessment of each of our patients, led by a doctor and/or a dedicated practice nurse. Nurses play a very important role in Ochre’s health outcomes program, as the nursing cohort’s focus on CDM has been shown to coincide with better health outcomes for our patients. To monitor our patients’ progress efficiently we use a patient-centred management plan, which is created by collaborating health professionals, who work with the patient to organise and plan SMART goals for the upcoming year. As soon as the annual assessment has been completed, it is followed up with GP or nurse-led reviews every 13 weeks.

what is ochres health outcomes program all about

Through the analysis of clinical data collected from all of our 31 rural and urban health centres since 2012, we can see that, through its methods of CDM, Ochre Health has made a significant impact upon the health of its patients suffering with chronic disease. We measure clinical indicators such as Blood Pressure, HbA1c, pneumococcal immunisation rates in patients with COPD, smoking rates, and BMI. The data from our clinics is then collected together, and each practice’s progress is compared against the Ochre average, our targets, and the APCC national average. Ochre Health’s targets are more ambitious than those of the Australian Primary Care Collaborative (APCC), meaning that our practices are working harder to achieve our targets and get results. Each year the practice with the best health outcomes is awarded the “Golden Ochie”, so our doctors, nurses, and other medical staff are always doing their best to achieve the most ambitious and outstanding results for our ‘Overall Quality Index’.

The Overall Quality Index measures the number of patients achieving the following 5 clinical targets:

  • CHD: BP <130/80 mmHg

  • CHD: Lipids LDL <2 mmol/l

  • Diabetes: BP 130/80 mmHg

  • Diabetes: Lipids LDL <2 mmol/l

  • Diabetes HbA1c <8%

Ochre aims to have 40% of its patients reaching these targets. The graph below demonstrates the progress that Ochre has made in its patients’ health since Ochre assumed management of each practice.

what is ochres health outcomes program all about

For the average Australian medical practice which has undergone 18 months of quality improvement, 3 out of 10 people are meeting their targets for Chronic Disease (Diabetes and Coronary Heart Disease), and in established Ochre practices 4 out of 10 people are meeting their targets. These results highlight the excellent health improvements facilitated by Ochre practices.

Ochre Health also gathers a second set of results relating to the health of Australia’s indigenous population. These figures are then compared with the rest of the population, and any gaps between indigenous and non-indigenous patients are noted and assessed. The results are used to help us improve the quality of the health of indigenous people as part of the Close the Gap campaign.

The results we have observed show that Ochre Health’s efficient and thorough CDM strategy is helping patients and medical staff hit targets, monitor patient progress, and achieve positive health outcomes.

We are continually looking for ways to improve our outcome program, and build on the positive results we are already achieving. To find out more about what we do, please don’t hesitate to get in touch with our expert team today.

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