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Inclusion characteristics
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Usual residential address within North Coast Area Health Service, and
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Aged over 65 at admission, and
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One or more diagnoses of:
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· Chronic Obstructive Pulmonary Disease (COPD) (ICD10: J41 to J44)
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· Diabetes (ICD10: E10 to E15)
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· Hypertension (ICD10: I10, I11.9)
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· Congestive heart failure (CHF) (ICD10: I50, I11.0, J81)
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· Coronary artery disease (ICD10: I20 to I25)
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At least one unplanned acute admission in any 12 month period between July 2008 and Dec 2009 with one of the above five diseases as the principal diagnosis and a total of 3 or more unplanned acute hospital admissions in the same 12 month period with one of the five diseases as either the principal diagnosis or an additional diagnosis
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Exclusion characteristics
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In receipt of palliative care
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In a residential aged care facility
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