SESLHD Integrated Care Strategy. Evaluation and Monitoring Framework

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Mark Shepherd
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1 SESLHD Integrated Care Strategy Evaluation and Monitoring Framework

2 Integrated Care Strategy Goal: To create an agile joined up system based on patient centred care and a health intelligence structure to enable targeted action through innovative models that deliver care proactively. The achievement of this goal is supported by change management and robust evaluation that will allow transfer and spread of successful ways of working. Priority populations People with diabetes Older people with complex needs.

current processes & delivery systems into a systemic & systematic approach

3 Evaluation SESLHD House of Care Planning Implementation Aspiration: By localising the elements of the HoC model, SESLHD & partners will transform current processes & delivery systems into a systemic & systematic approach to integrated care & develop a compelling local narrative about integrated care.

4 IC Strategy priorities 1. Engage with people and communities through person centred planning and evaluation 2. Use innovative models to target areas of need 3. Develop a health intelligence system 4. Utilise central support structures to evaluate, transfer and spread successful models

5 Priority areas & actions (revised) Priority area 1. Engage with people & communities through person centred planning & evaluation 2. Use innovative models to target areas of need Priority actions Develop better models for care coordination & collaborative, personalised care planning. Test implementation of community-based multidisciplinary teams in selected practice networks. 3. Develop a health intelligence system Develop localised LHD-wide mechanisms for risk stratification, taking into account social factors such as isolation & community support. 4. Utilise central support structures to evaluate, transfer & spread successful models All 4 priority areas Rapidly develop more sophisticated analytics capacity & decision support mechanisms. Rapidly develop mechanisms for enhanced clinical leadership in primary care & in relevant specialist services. Work with CESPHN to develop GP Clusters/Networks - to be the localised implementation mechanism.

6 IC Evaluation & Monitoring Framework Purpose To provide a blueprint for the ongoing monitoring and evaluation of the Integrated Care Strategy. As a stand alone resource for those intending to evaluate all or some components of the Integrated Care Strategy or other integrated care projects.

7 IC Evaluation & Monitoring Framework Aims Was the SESLHD IC Strategy: Appropriate for the SESLHD context Effective within and across the SESLHD and partner agencies Efficient in the reduction of avoidable costs and re-allocation of resources Sustainable (including scalable and replicable)

8 Rainbow model of integrated care

9 Program Logic Priority 1: Engage with people & communities Priority 1: Engage with people and communities Strategy 1: Spread motivational and health coaching techniques to support collaborative care planning Strategy 2: Test use of Patient Activation, Outcome and Experience Measures Overarching Inputs Activities (Actions 1 2) Outputs Outcomes Integrated Care Unit Improvement & Innovation Hub (IiHub) Program Management Office (PMO) Planning Population Health and Equity Unit (PPHEU) LHD central supporting activities: IC Governance IC Leadership development IC awareness activities Workforce development Financial & Contracting mechanisms Incentives for IC ICT support Service and Care Models Consumer engagement Quality improvement External partnerships PHN, GPs Specific Inputs Existing care planning processes 350 staff trained in techniques PAMS instrument State wide PRMs & PETs ACI work on state wide patient satisfaction and PETs Develop model to support collaborative care planning process Identify teams requiring training for health coaching and motivational interviewing Develop training plan to educate providers & promote HC & MI Train health providers in HC/MI Review PAM to assess feasibility of use & comparison with other tools Select PAM, PROMs & PREMs for trial Develop system for administering and using tools Work with ACI State Enabler and Innovation Project to learn from experience with state wide Patient Satisfaction and PETs Model for collaborative planning process in place Number/proportion people with current care plan Education strategy for new and existing services in place Number/proportion staff & care teams trained in HC/MI Number/proportion people receiving health coaching Improved staff skills & confidence in using MI PRMs tools endorsed and shared Systematic process for administering and following up on PRMs in place Number/proportion of GPs using PRMs during treatment as a clinical indicator Number/proportion of practices using PRMs as program quality indicator Shared data informs planning and care Staff are confident in using motivational interviewing within a strengths based approach to providing care Care planning identifies an individual s full range of needs Individuals are more involved in decisions about their care PRMs tools are used to support personalised collaborative care planning and delivery for patients PRMs are used routinely at practice level as a clinical indicator PRMs are used routinely at program level as a quality indicator Person centred care Organisational & supporting processes Engaged, informed individuals and carers Health & care professions committed to partnership working Commissioning = existing activity Context: Outer organisational: Policy environment promoting measurement of PHC impacts, processes and outcomes, Inner organisational: Stakeholder buy-in, Leadership,

10 Mapping of current IC project evaluations against the IC strategy evaluation questions IC evaluation PRISM PAM Health Failure Appropriate Effective X Skin Caner & wounds clinic Efficient X X Impact X X X x Sustainable X X

11 Where up to TRGS submitted Finalisation of the IC evaluation plan Dissemination Implementation (staged approach, dependent on resources)

Expression of Interest. Western NSW Integrated Care Strategy Third Wave Demonstrator Sites

Expression of Interest. Western NSW Integrated Care Strategy Third Wave Demonstrator Sites Expression of Interest Western NSW Integrated Care Strategy Third Wave Demonstrator Sites Closing Date 13 June 2017 Third Wave Demonstrator Sites P a g e 2 Introduction and Overview The Western NSW Integrated