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

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1 Expression of Interest Western NSW Integrated Care Strategy Third Wave Demonstrator Sites Closing Date 13 June 2017

$ICS as a third wave demonstrator site. Background Western NSW is one of the most vulnerable regions in Australia with a fractured service network and poor health outcomes.$

2 Third Wave Demonstrator Sites P a g e 2 Introduction and Overview The Western NSW Integrated Care Strategy (ICS) is seeking expressions of interest (EOI) from interested parties to participate in the ICS as a third wave demonstrator site. Background Western NSW is one of the most vulnerable regions in Australia with a fractured service network and poor health outcomes. A strategy to transform current services into a patient centred, coherent system of care is well into its fourth year with Western NSW Local Health District (LHD) leading the way as a NSW Health Integrated Care Demonstrator Site. The WNSW ICS is a locally driven, place-based, regionally enabled approach to integrated health and social care in the region covered by WNSW Local Health District (LHD). It is being implemented collaboratively through a jointly governed partnership between Western NSW LHD, WNSW Primary Health Network (PHN) and Bila Muuji Aboriginal Health Services. Map of NSW - Western NSW Local Health District The ICS has achieved some ground breaking changes in how local communities address the care of people with complex care needs. The strategy has successfully demonstrated that a placebased, general practice led, locally driven strategy can work in the rural setting. The lessons have successfully been applied to additional sites with the integrated model of care applied to additional priority areas eg antenatal care, the 1 st 2000 days of life, as well as expanding chronic and aged care to include asthma, dementia and mental health.

Third Wave Demonstrator Sites P a g e 3 Western NSW Integrated Care Strategy Local Demonstrator Sites Local demonstrator sites are a key element of the Western NSW ICS and enable testing and trialing

3 Third Wave Demonstrator Sites P a g e 3 Western NSW Integrated Care Strategy Local Demonstrator Sites Local demonstrator sites are a key element of the Western NSW ICS and enable testing and trialing of integrated models of care at a locality level. Local Demonstrator Sites redesign delivery models across general practice, LHD primary & community health services, Aboriginal Medical Services, local rural hospital/multi-purpose Health Service and specialist outpatient services. The mix of these varied by locality. However, strong clinical leadership and change management is essential to support service redesign and implementation. Wave 1 sites commenced in November 2015 and developed place-based solutions to address the needs of people with chronic conditions in Cowra, Cobar, Molong, Wellington and Dubbo. Wave 2 sites in Blayney, Mudgee, Coonamble and Walgett commenced in February 2016 and have extended the reach of the strategy to address the needs of mothers, babies and families, again using a place-based, locally driven approach. Western NSW Integrated Care Strategy Local Demonstrator Sites First Wave demonstrator sites Commenced implementation Nov 2014 Second Wave demonstrator sites Commenced implementation Jan 2016 The integrated model of care at demonstrator sites is locally developed, locally led and locally driven. It is tailored to the local context but has the following common elements to provide planned and structured proactive care that address all of a patient s identified health and social care needs: Risk stratification of the targeted cohort Identification and enrolment of identified patients Comprehensive assessment of the patient s health and social care needs Tailored individual care plans which are shared with the identified care team Team based case conferencing for identified patients to address complex health and social care needs

4 Third Wave Demonstrator Sites P a g e 4 Targeted integrated care interventions for patients, including care coordination and navigation, social and community care coordination, self-management support and health coaching Structured recall and review. Although the model of care is standard across sites it can and has been transferred to other priority conditions ie Mental Health, antenatal care, the 1 st 2000 days of life, Aboriginal Health and Aged Care. Our initial focus in the IC strategy has been supporting and developing high performing primary care and supporting community based services including social care. Other key elements of the ICS are: Investment in project support and change management, Leadership by local general practices and Aboriginal Medical Services Involvement of local social care providers Increasing engagement with the private sector The model represents a unique opportunity to develop local community capacity and implement place-based solutions to complex health and social wellbeing issues. The WNSW ICS achievements to date: The Strategy has been recognised internationally with abstracts accepted and presented at the 16 th Integrated Care Conference in Barcelona, Spain in May 2016 and the 4th World Congress of Integrated Care in Wellington, New Zealand in November Below we list some of the achievements of the IC strategy to date: Growing enrolments in the IC Strategy Since the strategy began enrolling people in the ICS in late 2014 numbers continue to grow with over 1150 people enrolled across the 9 local demonstrator sites with 24% of the integrated care enrolled cohort identifying as Aboriginal WNSW IC Strategy Cumulative Enrolments Changes in general practice The strategy has fundamentally changed how general practices deliver chronic care, providing patients with planned and structured proactive care. Changes include:

5 Third Wave Demonstrator Sites P a g e 5 - Risk stratification, to identify those most at risk of future health decline and target care to identify and manage early deterioration of a patient s condition. - Increased use of shared care planning which includes hospital, community health and social care providers - Establishing a care team that is wider than the general practice alone to provide comprehensive primary based care that addresses all of a patient s identified health and social care needs. - The use of social care navigation as a key element of care to manage a person s identified social care needs. Expansion into more sites An additional four Wave 2 sites were established allowing testing of the model with pregnant women, children and families, increasing engagement with Aboriginal communities and services and addressing additional chronic conditions (asthma and mental health). Lessons learnt from the Wave 1 implementation were applied in Wave 2 sites a focus on project and change management support, and assistance with design and implementation of new models. Changes in LHD practices As part of local demonstrator site projects and Ambulatory Care / Hospital in the Home (HiTH) district initiatives, the primary and community health nursing workforce has been aligned to better support contemporary models of care, including integrated care. Changes in hospital demand Over 400 Emergency Department (ED) presentations were recorded for the enrolled cohort 18 months prior to enrolment, peaking at almost 600 ED presentations six months prior to enrolment. After 12 months of enrolment in the Strategy the ED presentations have reduced to 323. The graphs on the next page show the changes in health service utilisation across all Wave 1 sites as at November 2016.

6 Third Wave Demonstrator Sites P a g e 6 The ICS is looking to transfer models currently being tested in the first wave sites and test new models of care with a focus on the following priority areas: Chronic disease Mental Health 1st 2000 days of life, including antenatal and children 0 to 5 years. Aboriginal Health Aged Care Short term funding is available to support implementation of agreed local models of care, including project management and change management support.

7 Third Wave Demonstrator Sites P a g e 7 Submission Details Interested parties are to complete the EOI Application Kit (Appendix 1) and forward electronically to the Integrated Care Program Manager Louise Robinson louise.robinson@health.nsw.gov.au by 5pm Tuesday 13 June All EOIs will be considered by the WNSW Integrated Care Steering Committee and sites will be notified of an outcome in writing by 5pm Friday 30 June A response lodged wholly or partly after the closing time will be registered as a late response and may be excluded from evaluation. The WNSW Integrated Care Steering Committee, at its discretion, may allow the evaluation of a late response, if it judges that the lateness is due to circumstances outside the control of the Applicant. EOI Questions and Clarifications You may contact the following if you have any questions or require clarification on any topics covered in this EOI: Louise Robinson Integrated Care Program Manager Western NSW LHD Telephone: louise.robinson@health.nsw.gov.au

8 Third Wave Demonstrator Sites P a g e 8 Deliverables and Timelines The WNSW Integrated Care Steering Committee will consider all EOIs and determine which sites will progress to third wave local demonstrator sites. Once third wave local demonstrator sites have been selected, a designated project lead will work with each site to develop a detailed project plan, including identifying resources to support implementation of the project. Deliverables and Timelines Name Date EOI Issued 30 May 2017 EOI closes 13 June 2017 Assessment of proposals 14 June 2017 Third wave demonstrator sites notified By 23 June 2017 Detailed project plan due By 1 September 2017 Detailed project plan assessed and approved 13 September 2017 Commencement of project By 1 October 2017

9 Third Wave Demonstrator Sites P a g e 9 Evaluation Criteria Selection will be based on the completion and submission of the EOI application. The WNSW Integrated Care Steering Committee will assess submissions in accordance with the evaluation criteria specified below: Process for selecting and progressing third wave demonstrator sites The EOI must demonstrate: 1) The site s readiness to develop and progress local integrated care initiatives. 2) A focus area for the project that aligns with the regions health need priorities and aims to: a) Improve the patient and provider experience b) Improve health outcomes for people in WNSW. c) Improve efficiency by delivering better value care Site readiness to develop and progress as a third wave demonstrator sites Significant learnings have emerged from first and second wave local demonstrator sites especially around a site s readiness to develop and progress implementation of new integrated models of care in a locality. To progress as a third wave demonstrator site all stakeholders will: a) Work together to ensure that the local demonstrator site complies with the following minimum requirements: Local clinical leaders will be committed to innovative service redesign Commitment to development and implementation of initiatives that align with the key directions of the Western NSW Integrated Care Strategy and on improved health outcomes for patients Co-operative working relationships with key locality providers stakeholders including the WNSW Primary Health Network, WNSW LHD and non-government organisations Initiatives will have a significant impact in a prioritised service/population health need area Learnings will be transferrable Commitment to participation in a reporting and performance framework that will include monitoring and reporting against agreed KPIs and performance targets Active engagement in whole of practice quality framework development, and health outcome KPIs Support for the shift of service from secondary to primary care (especially for chronic disease management) Development and implementation of initiatives that will enhance the role of multidisciplinary teams through workforce support, development and innovation

10 Third Wave Demonstrator Sites P a g e 10 Commitment to effective use of ehealth, including shared health records through use of the My Health Record, shared care platforms, patient reported measures, telehealth and other identified ehealth enablers Willingness to participate in shared learning fora and to share performance information including clinical information across sites. b) Explore the core dimensions of locality solutions in planning and implementing the local demonstrator site initiatives: Physical and virtual integration to provide a critical mass of the local workforce GP clinical leadership of the multi-disciplinary team Risk stratification of the locality population to identify the user groups and services where the potential benefits from integrated care are greatest Standardised ways of working (eg, coordinated care for risk groups; shared care planning) New workforce roles, including development of higher skills within scopes of practice, and delegation of clinical functions within the team Locality planning to meet prioritised local needs and service gaps, and the required future capacity IT connectivity and sharing of patient information Structures and processes that support: - appropriate skills-based clinical and corporate governance; - engagement of clinical and community stakeholders; and - performance accountability Transparent performance reporting of an agreed KPI set, and support for evaluation c) Respond to each other in a timely and robust manner to requests for information and decision-making. e) Work closely with the Health Intelligence Unit in the provision and delivery of data, analysis and information reports.

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12 Third Wave Demonstrator Sites P a g e 12 Appendix 1: Expression of Interest Application Contact Details Contact Names (please provide key contacts from the Local Health Service, General Practice/s and or Aboriginal Medical Service) Individual Contact Details: Name Organisation Contact number Integrated Care Readiness Assessment Criteria Self-Assessment (Provide rating 0 3) 0: Criteria not met 1: Criteria partially met 2: Criteria almost fully met 3: Criteria fully met Provide Details/Comments 1. Local clinical champions will be committed to innovative service redesign to develop place based systems of care (this includes identifying clinical champions from general practice/ams and across sectors) 2. Commitment to development and implementation of initiatives that align with the key directions of the Western NSW Integrated Care Strategy and on improved health outcomes for patients in our region 3. Co-operative working the WNSW PHN and the WNSW LHD 4. Co-operative working relationships with local care providers, including non-government organisations

13 Third Wave Demonstrator Sites P a g e 13 Primary Care Readiness Assessment Primary Care Readiness (please provide answers for all general practices involved) Provide Details/Comments 1. How long have the current GPs been working in the practice/ams? 2. How many practice nurses work in the practice and what are their general roles/titles? 3. On a scale of 0 3, where 0 is not organised at all, and 3 is highly systematic approach that utilizes all available team members and MBS item numbers, where do you rank your practice for its management of patients chronic disease such as diabetes, COPD, CHF etc? 4. How many of your current GPs also work as VMOs at your local hospital? Residential Aged Care Facility? Other LHD facility or equivalent? 5. Do you currently have a system for receiving electronic records from LHD facilities, including your local hospital, and other care providers, including residential aged care facilities?

14 Third Wave Demonstrator Sites P a g e 14 Third Wave Demonstrator Site Commitment Assessment All parties will be committed to the following if selected as a third wave demonstrator site Yes/No 1. Project will have a significant impact in a prioritised service/population health need area 2. Providers are committed to working together to develop place based systems of care tailored to the locality needs 3. Commitment to participation in a reporting and performance framework that will include monitoring and reporting against agreed KPIs and performance targets 4. Active engagement in whole of practice quality framework development, and health outcome KPIs 5. Support for the shift of service from secondary to primary care (especially for chronic disease management) 6. Development and implementation of initiatives will enhance the role of multi-disciplinary teams through workforce support, development and innovation 7. Commitment to effective use of ehealth, including shared health records through use my Health Record, shared care platforms, patient reported measures, telehealth and other identified ehealth enablers 8. Willingness to participate in shared learning fora and to share performance information, including clinical information across sites.

15 Third Wave Demonstrator Sites P a g e 15 Signatures Key Stakeholders Name: Organisation Date: Signature: Name: Organisation Date: Signature: Name: Organisation Date: Signature: Name: Organisation Date: Signature:

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Delivering an integrated system of care in Western NSW, Australia

Delivering an integrated system of care in Western NSW, Australia Louise Robinson 1 1 Western NSW Integrated Care Strategy Introduction Western NSW is one of the most vulnerable regions in Australia with