Better Outcomes for People with Chronic and Complex Health Conditions through Primary Health Care

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1 Better Outcomes for People with Chronic and Complex Health Conditions through Primary Health Care 7 September 2015 What aspects of the current primary health care system work well for people with chronic or complex health conditions? Primary health care in Australia is provided in a range of settings, by a range of professions. Broadly, healthcare in Australia is underpinned by the principle of universal access with public hospital services offered free-of-charge, and the option of accessing a range of primary care services at either a partly or fully subsidised rate. The principle of universal access, particularly as it relates to general practitioner (GP) services is a core element of the primary care system. It ensures that anyone, regardless of social status or income level, can access healthcare in a timely manner and when necessary, receive a referral to other more specialised parts of the health system. The Victorian community health service (CHS) model is delivered in both hospital and community settings and offers a multidisciplinary approach to primary and community health care. Many CHS employ GPs as an element of an integrated care team, and when combined with the other core services such as allied health, mental health, social services and dental, supports a comprehensive and person-centred approach to primary health care. While the MBS funding model does not readily enable chronic disease management, the CHS platform provides an example of how single organisations can utilise multiple program and funding streams to support individual clients. While there are examples of GP clinics with co-located allied health, mental health or imaging services across Australia, the Victorian CHS model provides the Primary Health Care Advisory Group (PHCAG) with an established case study for how the primary care sector can respond to chronic disease. What is the most serious gap in the primary health care system currently provided to people with chronic or complex health conditions? In your area? A serious gap in the primary healthcare system is the difficulty communicating between health sectors. For example, discharge summaries, medication management, advance care plans rely on a range of methods to communicate between GPs, CHS, residential aged care and the hospital sectors. This problem is exacerbated when a client attends a health service geographically distant from their home, as a single client record that is accessible by all clinicians is still not widely adopted and used. As with any funding model, various barriers and incentives exist and the fee-for-service approach that characterises much of the MBS does not incentivise prevention, assertive outreach or management of chronic disease to the extent required. The MBS funding model is well-suited to supporting individual consultations that don t require any long-term ongoing care relationship between a GP and client. VHA Submission Managing Chronic and Complex Conditions through Primary Health Care - Page 1

2 Continuity of program funding from the Commonwealth Government has been undermined in recent years as a result of the cessation or modification of National Partnership Agreements, which have impacted on well-functioning programs such as Healthy Together Victoria, and measures taken to address public dental waiting lists and treatments. Lack of certainty in these areas has restricted the ability of health services to plan for ongoing service delivery, which limits the effectiveness of such programs. Nationally The MBS as it is currently structured is not ideal for managing complexity. While incentives can be included to promote delivery of care for specific population cohorts, the MBS is limited in its ability to respond to biopsychosocial complexity in a coordinated manner. To recognise the complex needs of clients with chronic disease, client complexity must be taken into account. There are few clients with chronic disease who would not be considered to have complex needs, and even fewer who would have a single chronic disease in isolation of others. Chronic disease is often a combination of risk factors, family history, and the impacts of the social determinants of health. Complexity may exist through co-morbidities such as mental illness, or through social factors such as homelessness or domestic violence. Such complexity could be addressed through mechanisms such as a complexity index or weighting associated with MBS rebates. For example, the hospital system in Victoria acknowledges complexity of care and therefore increased costs associated with healthcare for people of Aboriginal or Torres Strait Islander descent through a loading to hospital funding for these clients. Early interventions, introduced before a client develops a chronic disease, would reduce the burden of disease on the healthcare system, and promote keeping people well and out of hospital. More effective utilisation of the primary health care workforce could also lead to service efficiencies, and improve the support clients receive by broadening their exposure to health promoting messages and interventions. MBS funding for the allied health workforce is restricted to specific professions and specific interventions. This limits the ability of clinicians to refer people to services such as exercise and lifestyle management programs which may be clinically indicated. The existing fee-for-service model of funding primary health care, in particular the Medicare Benefits Schedule (MBS), is not well-suited to caring for people with complex and chronic conditions. While incentives can be built into the system, the ability of many GPs to operate in a manner that promotes planning and assertive multi-disciplinary care is limited. What can be done to improve the primary health care system for people with chronic or complex health conditions? In your area? States and territories function as system operators for health care within their jurisdictions, with the exception of primary health. Funding arrangements, policy frameworks, and government identified priorities can all influence the manner in which chronic disease is addressed. Data collected by states should be available to the health sector to facilitate benchmarking, performance evaluation and population health planning. An efficient and effective health system requires continuous quality improvement, and data to inform this process. VHA Submission Managing Chronic and Complex Conditions through Primary Health Care - Page 2

3 The structure of federal and state government departments must recognise the cross-sector nature of chronic disease management and prevention. This emphasises the importance of states developing jurisdiction-wide approaches that address key issues such as chronic disease and facilitate crosssector planning. An example of a framework to support the role of governments in promoting health is the Helsinki Statement on Health in all Policies, (HiAP), developed at the World Health Organisation s 8th Global Conference on Health Promotion in The HiAP approach calls on governments to consider all public policies across all sectors through a health framework, and to recognise the implications of decisions, seek synergies, and avoid harmful health impacts to improve population health and health equity. It emphasises the impacts of public policies on health systems, determinants of health and wellbeing. Such an approach has been undertaken by South Australia. Projects include the promotion of active transport, encouraging active ageing through employment, and promoting uptake of digital technology. Through centralised decision making, health can be promoted outside of health services, creating more effective channels to address issues such as risk factors for chronic disease, through avenues such as safe active transport, food security, and health literacy. CHS deliver a range of services to clients within their local catchments. They are funded by the Victorian Government to deliver the Community Health Integrated Program and a range of other health and social services on behalf of other Government departments, including programs related to housing, employment, justice, early years, social engagement and a full range of health, mental health and community services, including providing GP services. This platform is ideal for helping clients with chronic disease to manage their condition, as an intervention can be tailored to meet an individual s needs and coordinated across medical, allied health and other care modalities. Further embedding the community health model and supporting clients to access care in community settings is a clear way of improving the health system from the perspective of chronic disease management. Theme 1: Do you support client enrolment with a health care home for people with chronic or complex health conditions? The concept of client enrolment in a health care home is one that may be worthy of further investigation. Coordinated and integrated primary healthcare is of significant benefit to people with chronic or complex health conditions; however a formal enrolment with a health service should not be seen as a precursor to accessing this form of care. CHS offer many of the benefits of client enrolment and a health care home without clients having to undergo the formal requirement of either registration or enrolment, and the potential limitations both of these can entail. Do you support team based care for people with chronic or complex health conditions? Integrated, coordinated team-based care enables the best use of the skills and knowledge of clinicians involved in healthcare delivery. This facilitates service efficiency and promotes best use of clinical training, skills and knowledge. For clients with chronic or complex health conditions, access to clinicians with a range of relevant skillsets is crucial to keeping these clients well and out of hospital. Team based care also emphasises the importance of holistic care for clients using a biopsychosocial approach to healthcare as opposed to a narrowly focused biomedical model. Furthermore, team based care arrangements provide multiple, appropriate points of contact for clients with chronic disease. For example, a client with well controlled osteoarthritis may benefit from care VHA Submission Managing Chronic and Complex Conditions through Primary Health Care - Page 3

4 coordinated by a skilled physiotherapist who is able to provide conservative management, but also able to identify when to escalate treatment and refer on to other health professions. Additionally team care arrangements can reinforce health education and health promotion messages through repetition of key messages. What are the key aspects of effective coordinated client care? 1. Client participation 2. Care coordinators 3. Client pathways. How can client pathways be used to improve client outcomes? Client pathways provide best practice clinical guidelines and local information about available services. These are helpful for clinicians, health services and clients. Clinicians are able to clearly identify the referral pathways and best practice approaches to managing clients with easily accessible and locally appropriate information. Adhering to best practice and basing clinical decisions on evidence based practice is important to ensure best possible client outcomes. Client pathways can assist health services to identify opportunities for service partnerships with local providers as well as identify gaps in service delivery. Identified gaps can then assist organisations to plan services, apply for funding and initiate projects and programs that can address such gaps in the system. Lastly, clients can benefit from client pathways through education about processes, expectations, and beginning a dialogue with their healthcare providers about their health. This has the potential to impact on health literacy and empower individuals to advocate for the most appropriate healthcare for their individual circumstances. Are there other evidence-based approaches that could be used to improve the outcomes and care experiences of people with chronic or complex health conditions? Funding of prevention and health promotion activities, and early intervention to address risk factors such as overweight and obesity, and tobacco smoking, through funded programs must continue to be a core element of any approach to reducing chronic disease prevalence. There are currently limitations that exist within the MBS system in regards to funding such approaches, and through better-suited funding models these approaches could reduce the burden of disease. The Healthy Together Victoria (HTV) program is an example of an approach that incorporated blended funding models, cross-government and cross sector partnerships to deliver a multi-faceted intervention aimed at reducing risk factors associated with chronic disease, and particularly those associated with obesity. The HTV case-study, while not strictly a primary and community health approach, underscores how collaborative and innovative partnerships can be established and driven by a range of stakeholders to the benefit of clients. Theme 2: How might technology improve the way clients engage in and manage their own health care? What enablers are needed to support an increased use of the technology to improve team-based care for people with chronic or complex health conditions? A key enabler that will support the uptake and improvement of team-based care is the My Health Record (the Record). It is essential that the Record continues to be actively driven by the Commonwealth Government and where appropriate, supported by State and Territory Governments. There are significant gains to be made in terms of system intelligence through a single e-health VHA Submission Managing Chronic and Complex Conditions through Primary Health Care - Page 4

5 record, in addition to improved interoperability of IT systems between health sectors, and across health and non-health sectors which allow for secure messaging and document transmission. How could technology better support connections between primary and hospital care? Technology has the potential to optimise communication between health sectors. Improved technology and interoperability between sectors can facilitate transmission of client notes, correspondence, test results and planning documents between providers, health services, and streamline medical procedures such as diagnostic and pathology testing. This would include avoiding repetition of low cost, high frequency procedures such as blood tests and x-rays, and allow more accurate monitoring and management of clients prescriptions, particularly for individuals managing chronic illness and using multiple and potentially interacting medications. As an example of improved utilisation of technology, case conferences and service planning could utilise telehealth and video-conferencing facilities to better embed client centred care across healthcare sectors. Utilising technology such as this would require appropriate funding so that clinicians were adequately funded for their input. Telehealth consultations between specialists in metropolitan hospitals and generalists and GPs in rural areas are an important example of improved connections between the acute and primary care sectors. The benefits of telehealth consultations include enhanced professional support between clinicians, and importantly, the option of significantly reduced travel time and improved access for clients and their families. To facilitate an increased uptake of telehealth consultations, the Commonwealth Government should look to including an MBS item that specifically funds telehealth consultations. How could technology be used to improve client outcomes? Technology use in healthcare is an ongoing feature of the Australian health system. It is essential that areas in which the Commonwealth and State and Territory Governments maintain a direct interest for example My Health Record, telehealth consultations and the ongoing investment in IT infrastructure are supported on an ongoing basis, through financial and policy levers. A fully-functioning and widely adopted My Health Record will result in more accessible medical histories, visible discharge summaries and the ability for health services and an improved ability for clinicians across different sectors to access standardised information, all of which should contribute to improved clinical outcomes. Theme 3: Is it important to measure and report client health outcomes? Yes. The ability to measure catchment and population-level health data is an essential element of any advanced health system. Planning for the allocation of health resources must be informed, where possible, by up-to-date and accurate data outlining trends in health status, health service utilisation and other key population health indicators. At an individual level, client health outcomes should be routinely measured to indicate to health providers the effectiveness of their treatment plans, and to identify the need for changes and modifications to care plans. The MBS and its tendency to reward high volumes of care without recognising client outcomes is a risk that should be considered. It is important that client outcomes are measured where possible, with a view to using this data to inform funding models that support accountability for improving clients health outcomes. VHA Submission Managing Chronic and Complex Conditions through Primary Health Care - Page 5

6 It is crucial that any moves to measure and report population level client health outcomes are deidentified. Clients must have confidence in a health system that does not risk their personal liberties, and that does not provide information to organisations who may seek to benefit from accessing such information. However, it is essential that individual health outcomes and relevant data be available to healthcare professionals directly involved in a client s healthcare. With this in mind, measuring and reporting de-identified health outcomes could assist in providing research data to inform effectiveness of health interventions at local level, and broadly at a population health level. Data for such purposes would need to adhere to relevant legislation regarding privacy, and be collected with complete transparency. How could measurement and reporting of client health outcomes be achieved? Measurement and reporting of client health outcomes could occur through linking with electronic health records. This would allow a streamlined approach to such a task. It is important that duplication of tasks does not occur in measuring and reporting such outcomes, and that the work associated with measuring and reporting health outcomes is adequately funded. To what extent should health care providers be accountable for their clients health outcomes? Responsibility for health outcomes must be shared by health services, governments and individuals. With health literacy measured as adequate for only 41 per cent of Australians, individuals cannot be fully responsible for their decisions in relation to health if they are not able to make fully informed decisions. The principle of informed consent is difficult to abide by if individuals are not well supported to make autonomous decisions regards their health care, activities and therefore health outcomes. How could client responsibility for their own health outcomes be achieved? Health literacy is a critical factor in facilitating responsibility for health outcomes. Australian research demonstrates that only 41 per cent of Australians have adequate health literacy, with people living outside of major cities or with poorer self-reported health status with even lower levels of health literacy. Health literacy is necessary for individuals to understand and appraise information related to health, and therefore inadequate health literacy can limit a client s ability to actively participate in healthcare, make informed decisions and take responsibility for their health outcomes. Clients must be able to make informed decisions to be responsible for their own health outcomes, consistent with the principle of client autonomy in healthcare. To support clients to take responsibility for their own health outcomes, it is necessary to also support clients to increase their health literacy. This requires broad population education strategies which are accessible by all people regardless of cultural and linguistic diversity or socioeconomic status. Improvements in health literacy would allow individuals to properly appraise health information and make informed decisions. Additionally, access to feedback such as individual health information and health outcomes can further empower individuals to take responsibility for their own health. This must be done with relevant education to ensure clients understand information provided. These approaches could be further supported in a team-care approach, with ongoing reinforcement of health education messages, and supported goal setting for health outcomes centred on the client s objectives. VHA Submission Managing Chronic and Complex Conditions through Primary Health Care - Page 6

7 Theme 4: How should primary health care payment models support a connected care system? If you prefer a blended model, as described in Theme 4, select all the components that should apply: Pay for performance Capitated payments Fee for service Salaried professionals. Should primary health care payments be linked to achievement of specific goals associated with the provision of care? Yes. Linking payments to specific goals has the potential to incentivise best practice approaches to healthcare. This has been demonstrated in the hospital sector, particularly in international examples where specific aspects of care are known to facilitate better health outcomes. This has also been utilised in primary care to some degree through the MBS system which supports specific interventions for high risk groups, such as age-specific health checks. Given the long term nature of chronic disease management, the measurement of health outcomes will not always be appropriate to determine the eligibility to receive goal-related payments. A better method of incentivising positive health outcomes would be to support best practice management. For example, referrals to occupational therapists and physiotherapists for clients who are experiencing falls at home, which could ensure thorough home assessment for environment risk factors, and gait assessment with subsequent exercise prescription to identify physical weakness or balance issues. Health outcomes are multi factorial, and incentive payments linked only to physical health measures must be coupled with an ability for the health sector to better influence biopsychosocial aspects of health and wellbeing, such as active transport, food security and social supports. What role could Private Health Insurance have in managing or assisting in managing people with chronic or complex health conditions in primary health care? Private Health Insurers (PHIs) are increasingly becoming involved in the management of clients with chronic and complex health conditions outside of the acute settings. This in itself is an indication of the priority the private sector places on preventing avoidable hospital admissions, particularly in regards to clients with chronic and complex health conditions. It is important to note that not all Australians have Private Health Insurance, and any reliance on PHIs for population wide measures or services must be carefully considered with regards to accessibility and equity. Examples exist where effective, widely accessible services have been provided by PHIs, such as Nurse-on-Call, and these programs provide potential frameworks for future commissioning of services. PHIs have a vested interest in keeping their members well and to avoid costly hospital admissions. Recent trials in Victoria and interstate have investigated the effectiveness of PHI involvement in primary healthcare. There is an opportunity for trials between governments and PHIs to provide recommendations and guidance regarding prevention and management of chronic disease. Opportunities should be created and facilitated to explore potential relationships between the public and private sectors that support shared goals. VHA Submission Managing Chronic and Complex Conditions through Primary Health Care - Page 7

8 Any recommendations for policy change to increase access to the primary care sector for PHIs, for example allowing the funding of GPs, must be carefully balanced against the public interest and the potential for such a change to introduce barriers to access for those without insurance. The strength of Australia s public health system is its foundational tenet of universal access, and any changes that potentially undermine this foundation must be scrutinised carefully. Further information For further information, please contact: Tom Symondson Chief Executive Officer Victorian Healthcare Association Chris Templin Policy Advisor Victorian Healthcare Association chris.templin@ The Victorian Healthcare Association The Victorian Healthcare Association is the peak body representing the public healthcare sector in Victoria. Our members include public hospitals, rural and regional health services, community health services and aged care facilities. Established in 1938, the VHA promotes the improvement of health outcomes for all Victorians, from the perspective of its members. The VHA welcomes the opportunity to contribute to the Primary Health Care Advisory Group s consultation on managing chronic and complex conditions through primary care. The VHA agrees to this submission being treated as a public document and being cited in any reports that may result from this consultation process. VHA Submission Managing Chronic and Complex Conditions through Primary Health Care - Page 8