Using data to prevent unnecessary hospitalisations  

How one general practice is using data to review and improve its communication and follow-up processes.  

In a world where health care is constantly evolving, Don Medical Clinic in Devonport is making waves by using data to drive better patient outcomes.  

Led by practice manager and data enthusiast Ian Abraham, this practice has taken a proactive approach to managing chronic conditions, reducing hospital admissions, and improving follow-up care, all through a strategic use of data. 

For Ian and his team, the foundation of good health care starts with good data. 

“If you want to use your software well and look at your patient community, then you’ve got to know what your community is about—who they are, what conditions they have, age groups, demographics,” Ian says.  

By ensuring simple yet vital details—such as height, weight, smoking status, and alcohol consumption—are accurately recorded, the practice can identify risk factors for conditions like cardiovascular disease and diabetes.  

Using Primary Sense, the practice identifies patients at high or moderate cardiovascular risk and ensures they are reviewed and followed up with appropriate appointments. While the tools have evolved, the team continues to adapt its approach to make the most of the available data and deliver proactive care.  

A key focus for the practice has been preventing unnecessary hospital admissions. By auditing emergency department presentations, the team has been able to identify high-risk patients, pinpoint gaps in care, and affirm that their current practices are having an impact.  

“Our goal is to follow up on every emergency presentation,” Ian says.  

“The hospitals up here are very good at getting discharge summaries out—usually within 24 to 48 hours. That allows us to act quickly, rather than waiting until a patient deteriorates.”  

By conducting regular audits—often in collaboration with medical students— the team has found that very few of its chronic disease patients end up in hospital emergency departments due to poorly managed conditions.  

Instead, the majority of presentations are injuries or unrelated acute illnesses. 

One area where the practice has been particularly effective is in reducing frequent emergency presentations among high-needs patients, including those with intellectual disabilities and complex mental health issues. 

“For some of these patients, the emergency department was almost a default option,” Ian says.  

“We worked with them and the hospitals to put management plans in place to ensure they were getting the right care without unnecessary duplication of treatment.”  

The practice also took a closer look at patients who frequently presented with airway diseases like chronic obstructive pulmonary disease (COPD) and asthma.  

Seeing a need for better management, it has recently introduced a dedicated asthma clinic—run by a registrar one afternoon a month—to provide structured assessments, action plans, and spirometry testing.  

The goal? To educate patients, improve asthma control and prevent avoidable hospital visits.  

One of the standout aspects of the practice’s approach is its proactive patient follow-up system. Rather than waiting for patients to call, the practice takes the initiative, says GP Dr Jane Cooper. 

“We don’t just look at the discharge summary and move on,” Jane says. 

“We call the patient and say ‘We saw that you were in emergency. How are you? Do you need to come in and see us? Because we think you probably should’.  

“Patients are often told to follow up with their GP, but many wait to see if things improve, and often by the time they call, it’s late on a Friday afternoon. 

“That’s why we take a proactive approach. It might be a quick call from the GP or practice nurse to check in early, understand their immediate needs, and make sure they’re happy with the care they received. 

“And the patients are really grateful for that, because often they have gone in in a really distressed state. 

“We are quite assertive in our follow up. I think as practices, we can be more assertive about this.” 

The practice also uses this process for follow up when discharge summaries are received from Medicare Urgent Care Clinic presentations.  

This simple step has made a huge difference, especially for parents of young children and elderly patients who may be hesitant to book an appointment, or who forget and need a little nudge.  

In 2019, Primary Health Tasmania supported Don Medical and other general practices taking part in the Health Care Homes trial, which served as the impetus to look at their data.  

“We were a part of the Health Care Homes pilot project – that was the beginning for us to start looking at our data and our systems and processes and management of chronic disease,” Jane says.  

“The purpose of that program was to manage chronic disease better in primary care and be proactive rather than reactive.  

“I know from doing this for 15 years, that it’s worthwhile getting people back when they are in that less distressed state to talk about their conditions and educate them and look at their techniques, particularly in the context of asthma, and keep them out of hospital.” 

Another key strategy has been using data to identify at-risk patients before they experience a crisis. 

“We have some patients who are flagged as high risk for hospitalisation. By scheduling regular follow ups—sometimes just a quick phone call from a nurse—we’ve been able to keep them well and out of emergency,” Jane says.  

One of the practice’s most high-risk patients, who had previously been in and out of hospital frequently, has not had a single emergency hospitalisation in over five years due to the team’s structured follow up and support. 

The practice has also fostered a culture of continuous learning. 

“Every morning, we have a quick team huddle where reception staff, nurses, and doctors, whoever is in on the day, check on their wellbeing and then review what happened the day before—no-shows, emergency presentations, GP Assist calls, cancelled appointments,” Jane says.  

“That way, we can pick up on any follow ups, assign them to people, and remind people about the importance of data. The reception team are integral to contacting patients to arrange review as needed.  

“Something that the Health Care Homes project taught us is the importance of having a team and that reception need to be a part of that team.  

“With the urgent care clinics and the hospital, it’s all about collegial communication, with the patients’ needs at the forefront.”  

Ian says medical students and registrars play a key role in this learning process, conducting audits on areas such as osteoporosis management, antenatal care, and prostate cancer screening. 

“We’re always asking, ‘How do we prove what we’re doing is actually good?’ That means measuring outcomes, looking at best practice guidelines, and making changes where necessary,” he says.  

By embedding data-driven decision making into everyday practice, this Tasmanian general practice is proving that small changes can lead to significant improvements in health care.  

Its approach is a testament to the power of communication and proactive, patient-centred care—one data point at a time. 

“We started this work because we wanted to ensure our patients were getting the best care possible,” Jane says. 

“Now, we’re seeing real results—fewer hospital visits, better chronic disease management, and a healthier community.” 

The Primary Health Information Network 

Primary Health Tasmania supports Tasmanian general practices to use de-identified data to improve patient care and health service planning. 

Through the Primary Health Information Network (PHIN), participating practices receive regular summary reports that help identify quality improvement opportunities and inform care planning. 

Practices can use the data to explore trends within their patient population, supported by Primary Health Tasmania to answer specific questions and improve data quality. 

The program also supports reporting against national Practice Incentive Program Quality Improvement (PIP QI) measures. 

All data is de-identified, securely stored in Australia, and never used for commercial gain. 

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This story features in Issue 20 of our Primary Health Matters magazine. Click here to read the rest of the issue

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