Self-Management & Shared Care Evaluation Report

Transcription

1 Self-Management & Shared Care Evaluation Report May 2016

2 ProCare Self-Management & Shared Care Evaluation Report Page 1

3 Table of Contents 1.0 EXECUTIVE SUMMARY INTRODUCTION Context Programme Objectives and Care Model Overview PROGRAMME METHODOLOGY At Risk Individuals and Change Management Programme Approach Participating Practices The Self-Management and Shared Care Programmes Programme requirements Programme requirements for patient enrolment Programme requirements for practices Supporting the new model of care Change Management Initiatives Funding Model Implications EVALUATION METHODOLOGY Evaluation Framework Data Sources Age Sex Register (ASR) ProExtra Collaborative Care Management Solution (CCMS) Partners in Health (PIH) Assessment of Primary Care Resources and Supports for Patient Self-Management (PCRS) Combined Predictive Risk Model Algorithm (CPRM) Patient Survey Provider Interview Secondary Care Utilisation Data RESULTS Individual improved quality, safety and experience of care Programme Enrolment Partners in Health Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS) Patient Survey quantitative ProCare Self-Management & Shared Care Evaluation Report Page 2

4 5.1.5 Patient survey qualitative feedback Provider Interviews Population Improved clinical outcomes and equity for all populations Clinical outcomes Demographic Information/Equity of Access System Improved value for public health system resources Existing Services Sustainability Primary care utilisation Sustainability Secondary care utilisation Workforce Improved workforce engagement and workforce skill DISCUSSION Achievements Challenges Future Development Recommendations Effective executive sponsorship Building relationships Training and support Care planning Operational technology Intervention funding Self-management review APPENDIX A GLOSSARY APPENDIX B - HOUSE OF CARE MODEL Putting the patient at the centre The foundation The walls The roof APPENDIX C - PLANNED PROACTIVE MODEL OF CARE APPENDIX D - PARTNERS IN HEALTH QUESTIONNAIRE APPENDIX E - CHANGE MANAGER CASE STUDY OF PFHC APPENDIX E1 - WELLNESS WHEEL PATIENT ASSESSMENT TOOL APPENDIX E2 - PFHC OTHER PATIENT CASE STUDIES Case 1 - DB ProCare Self-Management & Shared Care Evaluation Report Page 3

5 Case 2 - MF Case 3 - AB APPENDIX F PCRS PRIMARY CARE RESOURCES AND SUPPORTS FOR CHRONIC DISEASE SELF- MANAGEMENT APPENDIX G PATIENT SURVEY APPENDIX H PROVIDER INTERVIEW APPENDIX I PROVIDER INTERVIEW ANALYSIS ProCare Self-Management & Shared Care Evaluation Report Page 4

6 1.0 Executive Summary The Self-management and Shared Care (SMSC) pilot was carried out with two practices in the Counties Manukau District Health Board from July 2014 until October The aim of the pilot was to: build a patient centric model of care for patients with long term conditions integrate self-management, delivery system design, decision support, quality clinical information systems and multidisciplinary teams target a range of patient groups with long term conditions develop a model of care that is applicable to general practice and can be established and transferred across New Zealand provide value for money The pilot was rolled out in conjunction with the At Risk Individuals (ARI) programme being implemented in Counties practices. Each patient enrolled on the programme was assigned a care coordinator who helped them to create a care plan with goals that they would like to achieve. They were supported by their practice to become self-managing as well as providing them with problem solving skills. A key difference between the SMSC pilot and the ARI programme was the more intensive change management support offered to the two practices. ProCare provided training for the practice executive sponsor and coached them in how to undertake their role, using the Prosci methodology. This pilot has received positive feedback from both patients and practice teams. The patients have really appreciated having the support and guidance from their care coordinator and team to listen and develop a care plan. Practice staff have enjoyed working closely with patients and having the opportunity to spend more time with them to understand issues impacting on their health. Seeing patients achieve their goals motivated them to continue with the programme despite the teething issues of learning a new model of care and IT system. GPs also reported improved access to services for patients. They also noted improved collaboration and communication with allied health workers, including multi-disciplinary team meetings. ProCare Self-Management & Shared Care Evaluation Report Page 5

7 Figure 1 Summary of results from the SMSC pilot Upon enrolment, each patient completed a Partners in Health assessment. This was again repeated at an annual review. Significant changes were observed for many of the domains measured by the assessment, and the average change in total score for the two practices was greater than those doing ARI alone, suggesting the SMSC model of care provides additional benefit compared to the ARI model alone. The model of care is associated with improvement in HbA1c levels for patients with diabetes. Practice processes for supporting self-management improved. Both practices managed to enrol 3% of their enrolled population on the programme. Each patient was assigned a name care coordinator and was supported to create a shared care plan. These care plans were stored electronically on a secure website that was accessible to all care team members looking after the patient. This pilot has highlighted seven key recommendations to ensure success and sustainability of a programme such as this. These are: Effective executive sponsorship Building relationships Training and support ProCare Self-Management & Shared Care Evaluation Report Page 6

8 Care planning Operational technology Intervention funding Self-management review Practices will need support and coaching to ensure the success of a change of this complexity. Releasing of clinical staff from a practice to attend training can often be a financial and human resource barrier to small businesses, so consideration needs to be given to the financial model to support this. 2.0 Introduction 2.1 Context In 2014, the New Zealand Ministry of Health (MoH) released a Request for Proposal seeking to test a model of care that enables healthcare providers to better coordinate care and promote patient selfmanagement. This model is based on the NHS Year of Care and would be adapted to the local context. By applying intensive change management support to two practices we are able to develop a comprehensive model of care and identify barriers and enablers that contribute to successful implementation. This knowledge would support adoption of the model by other practices. ProCare was successful in securing a contract and began the programme evaluation from October Part of the evaluation process, was to identify the project outcomes and benefits that aligned to the New Zealand Triple Aim focussing on: Improving quality, safety and patients experience of care; Improving health and equity for all populations and; Maximising value for public health system resources. The impact on health care professionals improved knowledge and satisfaction was also examined. This final evaluation report provides an evaluation for the one year programme and aims to consolidate findings and lessons learnt from the programme to feed back to the MoH as considerations for future implementation. 2.2 Programme Objectives and Care Model Overview The proposed new model of care was based on the House of Care model originally developed by National Health Service in UK. The model of care puts patients at the centre of the healthcare system supporting them to develop a care plan with shared care and self-management initiatives to improve health outcomes (Appendix B). Evidence from the UK experience suggests that this model improves care for people with long term conditions (LTC) delivering overall better health outcomes for patients, their families and the wider healthcare system. This programme sought to understand whether the positive outcomes demonstrated in the UK would be realised when a comparable model was implemented in New Zealand. Recognising that the new pilot model deviated significantly from the traditional model of care, the MoH was also keen to ProCare Self-Management & Shared Care Evaluation Report Page 7

9 understand the change management initiatives and the business model modifications required to create a truly sustainable, long lasting care approach. This approach is outlined in Figure 2. Figure 2 Practice process for Shared Care and Self-Management Patients most likely to benefit from the programme are identified and invited to take part. Those that agree are assessed using the Partners in Health (PIH) questionnaire (Appendix D) and a care plan is developed with support from the health care professional at the practice. The plan is stored in a shared repository to allow secure access by multiple health professionals across the health system who are involved in the patients care. The patient can also access the care plan through a secure patient portal. The clinicians can then apply resource to support the patient to achieve their goals. There is a wide degree of autonomy in the application of resource. Depending on patient need this resource could cover time with a doctor or nurse at the practice, home visits, and services not easily available through existing programmes such as dentistry or health psychology. It can also be used to help fund goods required for a patient to achieve their care plan goals, such as sneakers or scales. In order to generate well-balanced insights from the programme evaluation, two practices from the ProCare network were selected with each representing general practice with different characteristics in terms of their location, demographics, care approach and business model. Setting up the programme this way also enabled ProCare to understand how differences in business and funding models would affect the programme implementation and consequently determine the benefits and outcomes realised from their shared care and self-management initiatives. 3.0 Programme Methodology 3.1 At Risk Individuals and Change Management This programme was rolled out in conjunction with the At Risk Individuals (ARI) project. The ARI project commenced at the start of July 2014, and involves a three-stage patient journey: ProCare Self-Management & Shared Care Evaluation Report Page 8

10 Assessment and enrolment Up to 12 months of coordinated care Transition off ARI or reenrolment as needed ARI recognises that primary care is the best place for patient-centred care and subsequently has a broad criteria for patient selection. The programme utilises the Collaborative Care Management Solution (CCMS) eshared Care tool which allows clinicians to develop and manage a patient-centred care plan that can be accessed by other clinical specialties not necessarily linked to the practice. Patients benefit from enhanced collaboration between primary, secondary and allied health care, as well as a flexible funding model that allows funding to be spent in a way that helps a patient achieve the goals. The ARI intervention funding ensures clinical autonomy to apply resources as appropriate for each patient, to achieve the overall programme goal of keeping patients well in the community. As part of implementation of the ARI programme, practices were supported through a change management process to inform and upskill team members. The change management support for the Self-Management and Shared Care (SMSC) project was significantly greater than for practices doing ARI alone. The SMSC project offered a dedicated in practice change manager to work with the practices, as well as offering funded practice meetings to support the change. 3.2 Programme Approach To successfully conduct the one year programme and ensure outcomes of the new model of care could be effectively captured, a three stage approach was followed: Service Enablement Service Rollout Service/Pilot Evaluation Service Enablement: This was the planning and organisation phase of the pilot when shared care and self-management programmes were designed, supporting materials were developed and programme resources were trained and recruited to ensure the initiatives could be smoothly run during the pilot period. Service Rollout: This was the rollout phase of the new care model when the shared care and selfmanagement initiatives commenced to be implemented and incorporated as part of the practices core offering. Enrolments for the shared care and self-management initiatives began during this phase in a staggered fashion to facilitate data collection and administration processes. Service/Pilot Evaluation: This was the evaluation phase at the end of the one year pilot period when data collected were consolidated, analysed and presented back to the MoH and the participating practices. Data collection was carried out throughout the programme to ensure sufficient data were available to support the evaluation of outcomes and benefits at the end of the pilot. These included collecting data before the programme started as benchmark indicators, throughout and at the end of the programme. 3.3 Participating Practices In order to evaluate the feasibility and scalability of the new model of care, two practices with very distinct characteristics were selected from the ProCare network as the demonstrators for the one ProCare Self-Management & Shared Care Evaluation Report Page 9

11 year programme. Summarised below in Table 1 are some high level differences between the two practices. Table 1 SMSC practice descriptions Practice CMC PFHC Business Type Ltd company with multiple stakeholders Ltd company with multiple stakeholders Geographic Classification Urban Rural Enrolled Population (as at /10/15) Business Model Partnership Very Low Cost Access (VLCA) Salaried GPs Regular Fee-for Service Demographics Pacific peoples are the most common ethnic group in CMC. Mainly of European descent, with significant Māori and ethnic Indian and East Asian communities Social-Economic Profile Social - high rates of poverty and complex health issues in the population. Good mix of people from different social-economic classes. 3.4 The Self-Management and Shared Care Programmes To cater for differences in their target patient groups, existing business and funding models, each practice has designed and tailored a unique wellness programme to meet their individual needs. The different programmes are shown below. Table 2 SMSC programme descriptions for both practices SMSC Programme Description CMC CMC was introduced to care planning as part of an earlier High Risk Individuals (HRI) project being trailed in Counties Manukau Health (CMH). Following implementation of SMSC, CMC s programme highlighted how a patient centred care model delivered within the general practice can provide the tools and support for people with long term conditions to successfully manage their health. They achieved this by working in partnership with patients to develop care plans with mutually agreed health goals and providing patients with access to complimentary services and input from a multidisciplinary team. PFHC PFHC had a more structured approach to managing the Chronic Care Management (CCM) programme which was transitioned through to ARI. This structure included scheduled quarterly recalls for patients enrolled on CCM. The PFHC SMSC programme piloted how a patient-centred care model delivered within the general practice can help patients better manage their chronic conditions. The practice established a working partnership with patients to develop care plans with mutually agreed health goals, introducing broader access to health services and coordinating social and other complimentary support to provide a more holistic primary health care approach. ProCare Self-Management & Shared Care Evaluation Report Page 10

12 Shared Care and Self-Management Initiatives (SMSC) Implemented ARI Onsite health psychologist Community health coordinator / social worker Group self-management education ( my health my life course) Mindfulness course Implemented ARI Health psychologist Community health coordinator or social worker Group self-management education ( my health my life course) Pharmacy medication support services Palliative patient care Member of the Locality Implementation Group 3.5 Programme requirements Programme requirements for patient enrolment Patients were identified by members of the clinical team as being potential candidates for the SMSC programme. The decision to invite patients to take part was made based on clinical judgement of risk of a poor health outcome, the modifiability of the patient s condition and likely amenability of the patient to adopt the behaviour changes necessary to benefit from the programme. Consideration was given to patients enrolled on the recently discontinued Chronic Care Management (CCM) programme. A Combined Predictive Risk (CPRM) algorithm was developed to guide enrolment. See section This tool was not available for routine use due to challenges in its development. It was used sporadically towards the end of the programme For each patient enrolled the programme was required to meet set criteria. These criteria were: Patient consent A named care coordinator An electronic shared care plan A Partners in Health (PIH) assessment (Appendix D) Each of these elements was recorded electronically, through either the ProCare ProExtra tool or the CCMS Shared Care website. The Partners in Health assessment is a tool was developed by Flinders University as part of The Flinders Programme TM for Chronic Condition Management. Patients complete the questionnaire which covers 13 areas such as knowledge of the condition, ability to take medication, and their ability to navigate the health system. Upon completion of the programme, patients undertook a second PIH assessment to understand how their understanding and management of their health care had changed. A patient s care plan is a living document so is intended to remain current and up to date even though they are no longer actively enrolled on the programme. The care plan can be updated as part of a regular consult with their GP or nurse Programme requirements for practices During implementation, all clinicians within each practice undertook an Assessment of Primary Care Resources and Supports for Chronic Disease Self-management (PCRS) questionnaire to understand ProCare Self-Management & Shared Care Evaluation Report Page 11

13 the level of self-management integration in the practice. This assessment was carried out again at the end of the pilot period to demonstrate how practice had changed. 3.6 Supporting the new model of care Change Management Initiatives A change manager was assigned to work one day per week at each practice to help facilitate and implement change based on the Prosci change management framework. The Prosci framework uses the ADKAR model Awareness, Desire, Knowledge, Ability, and Reinforcement to implement change. A post evaluation case study of the change initiatives in PFHC is attached as Appendix E. A description of the implemented change management strategies is shown below in Table 3. ProCare Self-Management & Shared Care Evaluation Report Page 12

14 Table 3 ADKAR Change management approach ADKAR principle Challenges for successful change in general practice Activities implemented to drive change Awareness of why change is Dissemination of communication that is clear, simple, timely and Programme information evenings for practice staff needed understood by recipient as intended Practice presentations Programme training initially focussed on nurses gap in awareness ProCare practice engagement staff and on-site change manager for GPs and others (eg, practice managers, health care assistants and Sharing of patient case studies admin staff) Care planning process (allowing patients to work in partnership with Time and ability required for general practice to capture regular health professionals to manage their health) patient feedback/input that can inform service design Desire to support and Size of practice impact on communication/awareness across whole Identify and engage the executive sponsor in practice participate in the change practice Assessment of Primary Care Resources and Supports for Chronic Change in nursing role for no/minimal increase in remuneration Disease Self-Management (PCRS) Perception of reduced capacity for nurses to support GPs as per previous operational processes (patient centred care model vs. Group discussion based on the 10 Building Blocks of High Performing Primary Care business as usual) Engage respected clinical leaders (Dr Allan Moffitt, Dr Janine Bycroft, Variation in ways of operating across clinical teams Dr Tim Hou) Fee for service business model Sharing of patient case studies History and perceptions of short-term programme approaches Team huddles to discuss patient centred care model as part of whole Personal motivators of staff practice meetings Nurse meetings without management staff to problem solve issues (resistance management) Practice values and performance management Knowledge on how to Understanding the training requirements of all stakeholders Comprehensive one-on-one care planning training provided (ProCare change Practice size larger practices require more structure and processes + DHB) and training resources Care coordination training (DHB) Variations in experience within clinical teams training needs to be Practice notice board for sharing resource information adaptable to the audiences targeted Dedicated care coordinators employed to work with complex patients Patient feedback/focus group Ability to implement the Technology problems eg; Dedicated time in practice meetings for new model of care change Slow connectivity/timing out Paid time for clinical team huddles to identify patients and plan care Data transfer between software Paid time for staff to attend additional meetings Change management resource (on-site change manager and funding allocated) ProCare Self-Management & Shared Care Evaluation Report Page 13

15 Reinforcement to sustain the change Rules around access to eshared Care for some practice staff (non-registered health professionals eg, health care assistants, practice managers not being able to access care plans) Timely communication and resolution of issues delay in solving problems can cause disengagement Agreement within practice of processes that fit operationally with resources and structures available Fee for service business model deters practice from accessing external services/intervention options for patients Awareness of community partnerships and/or access to external resources referral processes and feedback mechanisms not always clearly defined Flexibility of the patient centred model (ARI) vs very structured CCM programme Size of the practice and change required Time needed to implement change Existing communication channels Clinical leadership (executive sponsor) role established Practice weekly ARI project team meeting to problem solve programme issues Process mapping Developing community partnerships and processes for referral (social work, mental health, district nurses, pharmacy) Competition between clinical teams Dedicated time for care planning peer review / coaching Monthly whole practice meeting Online nurse tasking system (Medtech) Development of nursing pathways Intranet forums ProCare Self-Management & Shared Care Evaluation Report Page 14

16 3.6.2 Funding Model Implications Due to the differences in funding and business models adopted by the practices, funding for the ARI/SMSC initiatives were allocated differently between the two practices. Table 4 below summarises the difference in funding arrangement for each practice and its impacts to the workforce. Table 4 Practice funding models Funding Arrangement for ARI/SMSC Consultations GP - CMC GP - PFHC Nurse - CMC Nurse - PFHC No patient co-payment Quarterly visit funded through ARI interventions Patient pays co-payment No patient co-payment Funded through ARI interventions Cost to Patient Free Patient to pay Free Free Impacts on Current Role Increased workload from additional documentation and paper work. Doctor consultation not funded, therefore patients will have to pay if required to see the doctor. For this reason, patients often reached out to their care coordinator directly when experiencing health related issues. Initially no additional time was allocated for nurses to conduct consultation. They will often have to squeeze in their consultation time with the patients right before or after patients' regular GP visit. The care coordination responsibilities were considered additional work to their day-to-day job. Towards the later part the programme, nurses were given 2-3 hours per week to catch up on some of the outstanding paperwork related to the SMSC programme. No patient co-payment Funded through ARI interventions Nurses have been given additional time and resources at their discretion to facilitate shared care and selfmanagement activities. This gave the nurses some degree of autonomy to organise their own work. Benefits GP is able to provide regular consultation services without patients needing to worry about financial issues. A nurse-led model provides additional support for GPs to deliver more holistic patient care by relieving the burden off GPs from some of the less clinical aspects of patient care e.g. administrative and care coordination activities. Minimum additional expenses incurred for the practice to fund for extra nurse staff activities. The fully funded nurse-led model increased the nurses' sense of ownership and accountability. ProCare Self-Management & Shared Care Evaluation Report Page 15

17 Risks No major changes to GPs routines - minimal risk. GP - CMC GP - PFHC Nurse - CMC Nurse - PFHC GP unable to provide timely clinical input or interventions when patient circumvents them or when there is a lack of communication with the nurses. Additional pressure placed on nurses to deliver more work with the same amount of time. This could lead to over utilisation of the nursing workforce. Identification of health issues that need to be escalated to a GP with a robust escalation process in place. ProCare Self-Management & Shared Care Evaluation Report Page 16

18 4.0 Evaluation Methodology 4.1 Evaluation Framework The evaluation sought to measure outcomes from the application of a flexible model of patient centred care planning, shared care and self-management. These outcomes were aligned to the Triple Aim specified by the Health Quality & Safety Commission New Zealand, which are: Individual - Improved quality, safety and experience of care Population - Improved clinical outcomes and equity for all populations System - Improved value for public health system resources In addition, the evaluation also assessed the programme and its impact on workforce. Workforce - Improved workforce engagement and workforce skills To effectively assess the programme outcomes, each outcome was broken down further into anticipated benefits that were measurable. The Evaluation Framework (Table 5) summarises the anticipated benefits associated with each of the programme outcomes and demonstrates how these benefits were measured. ProCare Self-Management & Shared Care Evaluation Report Page 17

19 Table 5 Evaluation framework Outcomes Benefits Data source INDIVIDUAL: Improved quality, safety and experience of care Improved ability for patients to choose and access health services ProExtra CCMS Patient survey Provider interview PIH POPULATION: Improved clinical outcomes and equity for all populations SYSTEM: Improved value for public health system resources WORKFORCE: Improved workforce engagement and workforce skills Improved ability of patients to self-manage and educate themselves about their health Increased quality and safety of health services Enhanced customer experience within the health system Improved clinical outcomes Increased equity of healthcare services for all populations Appropriate utilization of existing healthcare services Increased sustainability of practices Reduced unplanned hospitalisations Improved shared accountability with secondary care Increased knowledge of the work force Increased skills of the work force Increased satisfaction and engagement of the workforce PCRS PIH Patient survey PCRS Provider interview Patient survey PCRS Provider interview Patient survey TBD Provider interview ASR ProExtra CPRM CCMS Provider interview TBD DHB data Provider interview Provider interview Provider interview Provider interview Provider interview 4.2 Data Sources Age Sex Register (ASR) This refers to the practice register which was the source for demographic information for the practice population and individuals enrolled on the programme ProExtra ProExtra is a tool which assists with the provision of primary care services to eligible patients either through general practice or through referral to other contracted providers. It effectively incorporates clinical triage criteria, real time business intelligence, and manages demand and budget for the ARI ProCare Self-Management & Shared Care Evaluation Report Page 18

20 programme. The system allows sequential recording of PIH, enrolment numbers and dates, supporting interventions ordered by clinicians Collaborative Care Management Solution (CCMS) CCMS is the electronic shared care plan. It stores a shared health record and the patients plan. This system records activity on the plan and who the patients assigned care coordinator is. This plan and information can be shared with health care providers agreed to by the patient Partners in Health (PIH) PIH is a generic measure of self-rated self-management knowledge and skills. It is primarily a care planning tool that allows support and coordination to be targeted more appropriately but has also been used sequentially as an outcome measure. Flinders University Human Behaviour and Health Research Unit developed the tool which was based on six principles of self-management: 1. Improved knowledge of their condition 2. Following a structured treatment plan agreed with the health provider 3. Actively share in decision making about their health 4. Monitor and manage signs and symptoms of the condition 5. Manage the impact of their condition on the physical, emotional and social aspects of life 6. Adopt behaviour that promotes healthy lifestyles The tool has been confirmed to have construct validity and internal reliability Assessment of Primary Care Resources and Supports for Patient Self- Management (PCRS) The PCRS is a self-assessment tool for use in primary care settings. Its purpose is to provide a focus on actions that can be taken to support patients with long term conditions. The measure has two components: Patient support. This assessment at the micro system level of the patient, provider and care team addresses characteristics of service delivery found to enhance patient selfmanagement. Organisational support. This assessment at a more macro system level addresses characteristics of organisations that support delivery of self-management services. Specifically the PCRS: 1. Defines characteristics and levels of capacity for patient and organizational supports of self-management 2. Provides a way for patient care teams to assess current capacity in both areas patient support and organizational support 3. Helps identify specific gaps in capacity and/or lack of agreement about capacity so that team members know where to focus their improvement efforts 4. Promotes discussion among patient care team members that can help build consensus for change and plans for improvement 5. Gives teams a way to measure progress over time. A baseline measure was taken just prior to commencement of the project and repeated as the project ended. ProCare Self-Management & Shared Care Evaluation Report Page 19

21 4.2.6 Combined Predictive Risk Model Algorithm (CPRM) Risk stratification is essentially a method of screening to identify a cohort of individuals who are more likely to respond to a treatment or model of care. The combined predictive risk model (CPRM) is designed to predict the risk of an individual having an unplanned hospital admission in the next six months. The algorithm was developed by the Greater Auckland Integrated Health Network in conjunction with Sapere Consulting Ltd. CPRM takes a multi-morbidity approach rather than disease specific one and considers future risk rather than only patients currently at risk. The model therefore allows a risk score to be calculated for an entire enrolled population. The variables included in the algorithm are listed in Table 7 below. Table 6 CPRM variables and data sources Demographics Secondary care utilisation Primary care utilisation Variable Ethnicity Age Quintile Distance to nearest ED Inpatient admissions in the last 1,3,6,12 & 24 months ED attendance in the last 1,3,6,12 & 24 months GP consultations (not immunisations) in the last 1,3,6,12 & 24 months Data source Age sex register (ASR) DHB Clinical performance indicator (CPI) extract from the practice management system (PMS) It was intended that this tool would be available to clinicians to aid in the appropriate selection of patients to be invited to enrol in the programme. Development challenges precluded the tool being available. It has been used retrospectively to determine if patients have been enrolled in the programme in proportion to their calculated risk Patient Survey A short patient survey was developed to assess the patients experience of being in the programme and also the perceived benefits. See Appendix G. Patients were sampled opportunistically when they came to the practice in the last few months of the programme Provider Interview Provider interviews were carried out at the conclusion of the programme. Data came from 67 interviews from both practices consisting of 24 doctors, 25 practice nurses, 10 administration staff and 8 healthcare assistants. The analysis was conducted by an independent qualitative researcher who was blind to any other findings from the evaluation Secondary Care Utilisation Data Counties Manukau Health supplied data for: Emergency department Attendance Acute inpatient medical admissions Ambulatory Sensitive Hospitalisations The date range was 1 July 2013 until 31 October This extended date range would allow seasonal variation to be included in the analysis of use of secondary services. ProCare Self-Management & Shared Care Evaluation Report Page 20

22 Data was collected for both participating practices and at an aggregated level for the DHB. 5.0 Results 5.1 Individual improved quality, safety and experience of care Programme Enrolment For patients to be enrolled in the programme the requirements outlined in were met. The enrolment numbers below represent patients who have formally consented to take part in the programme, have completed the self-assessment PIH, have an assigned care coordinator and have a personalised care plan created in partnership with the nurse or doctor. Enrolment onto the SMSC/ARI programme was tracked through ProExtra. The SMSC/ARI programme commenced July 2014 however, due to delays with the IT launch patients were not enrolled onto the electronic system until September The ARI enrolment target to end of June 2015 was 3% of the total enrolled population in each practice. There was a financial incentive to achieve this target. Figure 3 Monthly enrolment progress - CMC During the 16 month pilot 332 patients at CMC were enrolled into the programme. CMC achieved the 3% enrolment target June 2015 and 3.8% enrolment at the end of October 2015 Initial uptake was slower in this practice due to turnover of key clinical staff. This meant other staff needed training and mentoring to fulfil these roles. This may have resulted in a longer period before processes were sufficiently embedded in the practice workflow and the programme gained momentum. ProCare Self-Management & Shared Care Evaluation Report Page 21

23 Figure 4 Monthly enrolment progress - PFHC During the 16 month pilot 792 patients from PFHC were enrolled into the programme. PFHC achieved the 3% enrolment target June 2015 and 4.1% enrolment at the end of October Due to the size of this practice a more systematic implementation process was adopted which appears to have resulted in a consistent and therefore more sustainable growth in enrolment numbers. Both practices experienced challenges at the start of the programme with a less than optimal IT platform for enrolment of patients Partners in Health PIH was used to collect scores at the time of enrolment in the ARI programme and again in ten to twelve months when individuals were either re-enrolled or graduated from the programme. Both the change in total score and the change in individual questions was considered. Table 7 Partners in Health results Practice CMC PFHC Average change per question score 10months - baseline Average change in total score 10months - baseline %CI (0.41, 10.40) %CI (3.14, 6.69) The average change in total score for all practices doing the ARI model of care (not the more comprehensive SMSC programme) was %CI (2.43, 4.52), suggesting the more comprehensive SMSC model of care provides additional benefit compared to the ARI model alone. The observed changes in total PIH scores are statistically significant for each observed cohort. The smaller numbers from CMC give rise to larger confidence intervals. ProCare Self-Management & Shared Care Evaluation Report Page 22

24 Both practices demonstrated an improvement in knowledge of health condition and knowledge of medications (Q1&2) Shared decision making (Q4) improved in both cohorts although did not quite achieve statistical significance in CMC. Knowledge of early warning signs of acute deterioration of long term conditions (Q7) and acting on these signs (Q8) also improved in both sites. The PFHC cohort also showed significant improvement in management of how the long term conditions effected the patients emotions and spiritual wellbeing (Q10), social life and personal relationships (Q11a). This was not seen in the CMC cohort. Most individual questions showed statistically significant improvement and total scores improved Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS) The Primary Care Resources and Supports for Chronic Disease Self-Management questionnaire (Appendix F) was undertaken at the start of the programme and repeated upon conclusion of the SMSC pilot. At CMC four GPs and five nurses took part in the survey. At PFHC 12 GPs and 18 nurses took part in the survey. The average of the before and after scores for each practice is shown below and further broken down by professional group. Both practices showed a general self-reported improvement in the characteristics of good selfmanagement processes at both the patient and clinical team (microsystem) and organisational (macrosystem) levels. ProCare Self-Management & Shared Care Evaluation Report Page 23

25 Figure 5 PCRS scores for patient support CMC Both nurses and GPs at CMC perceived an improvement in practice processes that support patients to better self-manage. ProCare Self-Management & Shared Care Evaluation Report Page 24

26 Figure 6 PCRS scores for organisational support CMC CMC clinicians reported an overall improvement in organisational processes that support selfmanagement. The greatest perceived change was from nurses with GPs reporting little or no change. ProCare Self-Management & Shared Care Evaluation Report Page 25

27 Figure 7 PCRS scores for patient support PFHC Practice processes that support patients improved in PHFC as reported by both nurses and doctors. Doctors perceived little change in the level of patient involvement over the course of the pilot. ProCare Self-Management & Shared Care Evaluation Report Page 26

28 Figure 8 PCRS scores for organisational support PFHC Patient Survey - quantitative Patients were given the option to feedback on the programme in each practice via a short questionnaire. They were asked 10 questions relating to their overall experience, access to services, ProCare Self-Management & Shared Care Evaluation Report Page 27

29 quality of care and the impact of the programme on their wellbeing. There was also the option for a free text comment after each question. Thirty six patients in CMC and 108 patients in PFHC chose to complete the patient survey. 100% of CMC and 91% of PFHC respondents either agreed or strongly agreed that their care plans have helped them change the way they care for themselves and become more organised. 95% of CMC and 94% of PFHC survey respondents agreed that the programme had improved their health and well being For all questions over 90% of responses indicated that the programme had a favourable impact. At CMC, 14% of respondents had a negative experience on the programme. This represents five patients. Of these three added a free text comment. Two patients had difficulty with the programme because of language barriers. I want to do the programme but my English not very well but I can move on It was in English and I cannot understand very well but I am slowly learning One patient felt the content of the care plan was too large and was more than they could cope with If I was to have done everything fully I would have focused on nothing else Of the four patients (3%) from PFHC who reported a negative experience two left supporting comments. One did not like a support programme to which they were referred. Green prescription no good One probably did not feel engaged in the programme. Had not really got off the ground Figure 9 Figure 10 Figure 11 Figure 12 ProCare Self-Management & Shared Care Evaluation Report Page 28

30 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure Patient survey qualitative feedback When participants were asked about what they thought the best part of the programme was, three main theme responses were communicated: Improved relationship and communication between the patient and their care team Being able to give feedback and be involved in brain storming Being able to discuss my health issues, easier to carry out The continual interest in my wellbeing, the fact that I am called to see how I am coping Improved understanding and confidence to manage their health Made me conscious of how to better my health ProCare Self-Management & Shared Care Evaluation Report Page 29

31 A better understanding of my illness and medication Improved overall wellbeing Looking how far I have come with my illness in a positive way I cannot remember all but I am in better shape than before When asked what they thought could be improved with the programme, overwhelmingly patients endorsed this new model of care. The recommendations that were provided were: Patients recognising they must be more motivated to achieve their goals More effort from me Follow the plan whole heartedly More support and information from their care team To talk about my condition more More time with care coordinators for appointments and follow up Perhaps more general check-ups to make sure things are on track Provider Interviews The provider interview report (Appendix H) suggested access for patients had improved from the providers perspective. They also reported improved patient knowledge and confidence. These are summarised here: Doctors reported improved access to services and direct benefits to patients Stronger relationships especially with nurses Better access through longer consultation times More opportunities to access care. Better access to a wider range of health services Better access by removing payment barriers to some services Better access to a wider range of social services Inclusion of consideration of social determinants helps with attainment of medical goals o Home visits and follow-up o Psychological support o Dietician o Social support Access to higher value services through training in areas such as motivational interviewing Balancing factor may be access to some services that were previously funded such as structured diabetes checks Better patient knowledge about symptoms and conditions. Corroborated with PIH results Greater confidence to self-manage. More empowered. More responsive 5.2 Population Improved clinical outcomes and equity for all populations Clinical outcomes Clinical outcomes for a complex and broad programme are difficult to demonstrate. An analysis of data on glycaemic control suggests a benefit associated with the ARI programme. Further analysis is being done to determine if the benefit can be demonstrated to the practice level. ProCare Self-Management & Shared Care Evaluation Report Page 30

32 Patients enrolled in ProCare practices were identified using a data extract from the practice management system. Patients were included if there was a record of a recent HbA1c at both reference points. Current HbA1c results were compared to results recorded approximately one year previous. We looked at the proportion of patients who had an HbA1c of 64mmol/mol or less at each point. The process for data extraction is new and more work needs to be done on data validation and coding. These results should be treated as preliminary. Figure 19 Change in HbA1c over 12 months WDHB and ADHB combined Figure 20 Change in HbA1c over 12 months CMH ProCare Self-Management & Shared Care Evaluation Report Page 31

33 Figure 21 Change in HbA1c over 12 months all ARI patients Table 8 Improvement in glycaemic control Cohort Number of patients Good control previously % (<64mmol/mol) Good control currently % (<64mmol/mol) Change (%) Average change (mmol/mol) ADHB/WDHB %CI (0.50, 0.97) CMDHB all patients %CI (0.98, 1.70) CMDHB ARI patients %CI (1.79, 3.81) CMC non-ari CMC SMSC/ARI PFHC non-ari PFHC SMSC/ARI ADHB and WDHB had a 2% increase in the number of patients with good control, as defined by an HbA1c of less than 64mmol/mol. This represents a statistically significant reduction of 0.74 mmol/mol. Significant reductions were also observed in CMDHB, for patients enrolled on ARI and all others. For ARI patients, there has been a threefold increase compared to ADHB/WDHB. The confidence intervals show the three cohorts are significantly different from each other. The ARI programme in CMDHB does not specifically target patients with diabetes and this cohort represents only 24% of all ARI enrolled patients Demographic Information/Equity of Access Enrolment into the programme was considered by deprivation, ethnicity and age. Deprivation was measured using the Ministry of Health quintiles. Ethnicity considered Maori, Pacific and other. Enrolment was compared to the practice demographics and also to the demographic profile of the practice cohort with the highest predicted risk of acute hospitalisation. This was calculated using the CPRM. This algorithm is weighted towards higher quintile, age below 5 years, age over 75 years and Maori or Pacific ethnicity. A higher risk score is calculated for individuals in these cohorts. ProCare Self-Management & Shared Care Evaluation Report Page 32

34 Deprivation Figure 22 Social Deprivation for CMC CMC has high numbers of quintile 5 patients and enrolled in proportion to practice demographics and calculated risk. There was a slightly greater enrolment of patients from the most deprived areas (Q5) Figure 23 Social Deprivation for PFHC PFHC serves a less deprived population. Their enrolment profile matched their higher calculated risk profile albeit with a tendency to enrol more individuals from more deprived areas Ethnicity ProCare Self-Management & Shared Care Evaluation Report Page 33

35 Figure 24 Ethnicity for CMC CMC enrolled a proportion of Maori patients that matched the practice demographics and the demographics of the highest risk cohort. They enrolled marginally more Pacific and marginally less other patients. Figure 25 Ethnicity for PFHC PFHC had higher enrolment of both Maori and Pacific people. They enrolled less Other when considering both practice demographics and calculated risk. Age Figure 26 Age Distribution for CMC ProCare Self-Management & Shared Care Evaluation Report Page 34

36 Figure 27 Age Distribution for PFHC Both practices showed strong enrolment in the 45 to 75 year age group with patients in this age band being over represented when compared to practice demographics or calculated risk. The CPRM predicts greater risk for patients under 5 years or over 75 years. Patients in the younger age group were under represented. Patients in the older age group 75+ were enrolled in greater proportion than the demographics of the practice but the profile of the high risk group contains more patients in this age band. 5.3 System Improved value for public health system resources Existing Services Figure 28 Interventions for SMSC patients Both practices showed a high rate of utilisation for follow up consults Sustainability Primary care utilisation Analysis is being conducted on the change in utilisation of primary care health providers caring for SMSC patients over the course of the trial. This will be available at a later date ProCare Self-Management & Shared Care Evaluation Report Page 35

37 5.3.3 Sustainability Secondary care utilisation Emergency department (ED) attendances and in-patient admissions show seasonal variation as indicated in figures below. There has been no discernible change in ED usage or acute admission including those for ambulatory sensitive conditions. Seasonal variation appears consistent for the three cohorts below. Figure 29 Rate of emergency department attendances Figure 30 Rate of acute medical inpatient admissions Figure 31 Rate of ambulatory sensitive hospitalisations (ASH) ProCare Self-Management & Shared Care Evaluation Report Page 36

38 5.4 Workforce Improved workforce engagement and workforce skill Question 8 in the provider interviews looked at increased knowledge of health care providers and found the programme built knowledge of community resources. These were of benefit to patients and whanau. The training provided to both GPs and nurses was useful and gave greater confidence for referring to external providers. Question 9 examined effective utilisation by various health care providers. It showed that the providers successfully interacted with a greater range of external health care providers and social services. Some findings suggest the programme could be strengthened by further focus on patient centeredness and cultural competence training. Multidisciplinary team meetings were found to be beneficial and strengthened relationships with secondary care and community providers. The findings highlight the potential to increase the efficiency of the meetings. Question 10 explored the level of job satisfaction. The majority of nurses agreed they had a higher level of job satisfaction despite the increased work load and were motivated by patient success and achieving goals. Nurses have adopted this new programme despite the challenges of a changing role and additional administrative burden. Processes and IT were reported as being a barrier by nurses and GPs. ProCare Self-Management & Shared Care Evaluation Report Page 37

39 6.0 Discussion 6.1 Achievements SMSC has been a beneficial programme for patients and primary care providers despite the challenges involved with implementation of a new model of care in a complex environment. The programme has reported measureable benefits for patients and improved job satisfaction for practice staff. A 3% enrolment target by the end of year 1 was set for each practice. This was an ambitious target given the training and education that was required for this change. Practices needed to learn new IT systems and processes as well as implementing a new model of care. If a higher enrolment target had been set, this would have been at the expense of programme quality. The observed changes in total PIH scores are statistically significant for each observed cohort. The SMSC practices both achieved a greater overall shift in PIH scores compared to other practices implementing ARI. Most individual questions showed statistically significant improvement and total scores improved suggesting that people felt better able to manage their health conditions. A recent study showed significant association between PIH scores and mental health quality of life, selfefficacy, energy levels and health distress (Battersby, Harris, Smith, Reed, & Woodman, 2015). The lack of a matched control group or randomised sample means we cannot conclude that the observed improvement is due to interventions from the ARI programme. It is possible that the Hawthorne effect where individuals may modify their behaviour in response to their awareness of being observed may have contributed to the observed improvement. These issues highlight the importance of a study with more robust design to test for outcomes for patients enrolled in the SMSC programme. Both nurses and GPs at CMC perceived an improvement in practice processes that support patients to better self-manage. The SMSC programme is a nurse led process to enable patients to become better at self-managing. Differences in some PCRS results between GPs and nurses reflects this changing role in care delivery. At PFHC GPs perceived that patients were much more involved about decisions relating to their care at the start of the pilot compared with nurses. As nurses became more involved with care planning, patient involvement became much more integral to the system of care. GPs felt they were already actively involving patients in their care, therefore did not perceive as great a shift PCRS score. At CMC, only the nurses perceived a change in organisational support. This may have been more to do with feeling enabled to perform their roles or having permission to spend the time needed with a targeted group of patients, hence allowing the patients to express their wishes rather than just being done to. In effect the care planning process was a tool that enabled patients to have more control of their care. This may have been perceived as organisational support whereas GPs may have believed that this was happening anyway, when it may not have been. The Wellness programme at PFHC was implemented as a team based approach. Patients were allocated to care teams which included GPs and nurses. This team approach may reflect the difference in results for organisational support. Patients were invited to make comments on the programme. Because patients were identified opportunistically, sampling methodology could be more robust in order to provide a more generalizable result. Despite this, the overwhelming response from patients for the programme has ProCare Self-Management & Shared Care Evaluation Report Page 38

40 been positive and those who provided comments would like to see it continue. This favourable response from patients is consistent with the provider interviews which indicated better relationships with patients and better access to services. In the provider interviews, providers indicated that patients had a better understanding of their conditions and symptoms. This was also reflected in the patient PIH results which indicated significant improvement in these domains. Both practices are enrolling large numbers of patients in the age group. This may reflect enrolment of long term conditions on the programme. The model of care utilised may still reflect a strongly medical approach. It is anticipated that as practices gain experience with the care planning and goal setting model of care that they will shift to a more holistic view. The PIH results for domains 1 and 2 reflect this, as patients are seeing improvement in knowledge of their conditions and treatment including medications. Domains highlighting a holistic approach are 11a, 11b and 12 so these may be points for practices to focus on in the future. Due to delays in developing the CPRM reports, practices were not able to utilise these to identify patients to enrol on the programme. Clinical judgement therefore drove enrolment. Results indicate that practices enrolled patients at least in proportion to the demographics of their practice when considering social deprivation. This pattern was also seem for the high needs ethnicities of Maori and Pacific patients for both practices. When considering a cohort of patients with the highest predicted risk of acute hospitalisation those from deprived areas as well as Maori and Pacific patients were well represented. Previous LTC programmes have not included patients under 18 years of age, so practices may not have experience working with these age groups. This is reflected in the small numbers of patients aged 0 to 5 years who are enrolled, despite the high calculated risk of acute hospital admission. Routine use of the CPRM reports may result in further improvements in targeting resources to this high risk group. It is too early to show whether or not there has been a decrease in the use of secondary services for these patients as a results of the programme. A separate preliminary analysis of the data shows both seasonal and all cause variation with no discernible increase or decrease in Emergency Department utilisation or acute medical admission. Further detailed analysis is warranted. To implement a change project with the degree of complexity, scale and pace of the SMSC pilot, effective visible executive sponsorship is essential for the practice. This key person is responsible for on boarding the team to the change, removing barriers and championing the new way of doing things. A common theme from the provider interviews, patient surveys and the onsite change manager is the enhanced relationship that has been built between patients and their care team. Nurses noted the hour of dedicated time for the initial care plan helped to develop this relationship. PFHC piloted having an onsite health psychologist and community health coordinator (CHC). The health psychologist was considered one of the most valuable interventions available to help support patient goals, and both GPs and nurses reported positive patient feedback as well as a positive change in the patients themselves. This was also noted by patients in the patient surveys. The CHC was another successful initiative, and the practice team felt that having someone onsite led to greater understanding and better communication. CHCs were better placed to connect patients with social services. The practice undertook MDT meetings with both the health psychologist and the CHC to feedback on patient progress. It was noted that these conversations added greater value and understanding than relying on patient notes and progress reports alone. ProCare Self-Management & Shared Care Evaluation Report Page 39

41 PFHC also implemented MDT meetings with external providers and within their practice teams. They noted that meeting with external health practitioners helped to build relationships and trust, while the in practice meetings helped to develop the team based approach to caring for their patients. The programme has strengthened relationships with external providers. Historically, PFHC would provide patients with information on providers they could contact. Following introduction of SMSC, the practice now facilitates the relationship between the patient and provider. This was the case for health and psycho-social needs. The SMSC pilot did highlight for the practice that there was a need to have an up to date source of current community providers that the practice could use. This programme saw a significant change in the scope and breadth of nurse practice which highlights the importance of appropriate training in both delivery of care and required skill set. Practices were allocated funding to release time for this training which included care coordination, motivational interviewing and care planning and goal setting. Recognition of the need for and sufficient resourcing of this training is critical to the success of a programme such as this. Some nurses reported the programme highlighted areas for professional development, as they came across conditions they wanted to know more about. This led to self-directed learning. A process for nurse peer review was established at PFHC to improve the quality of care plans. Although GPs regularly undertake peer review, this was a new skill for nurses. Patient achievements are an important factor in the initial stages of the programme. PFHC shared these outcomes which helped to engage staff that had not yet brought into the change. As the programme progressed personal satisfaction from working with patients to help them achieve their goals increased motivation and job satisfaction. One frustration for the practice teams was being unable to prove quantitatively that they had made a difference, as the goal they wanted to achieve may not have been directly health related, instead laying the foundation for future health improvements. 6.2 Challenges SMSC provided a very flexible means to fund patient care. Because of its size, PFHC found it difficult to budget for the care that would be required for patients as this approach was so new. To help alleviate budget issues, the practice had strict guidelines on what could and could not be claimed through the funding. This programme also had a practice level budget to manage rather than a patient level one historically used under other programmes. Systems needed to be established for the finance team to monitor how claim choices affected the overall practice budget. Each practice had a different approach to what they would and wouldn t fund for patients. PFHC chose to charge patients each time they saw a GP, and on reflection felt that patients were side stepping them for clinical concerns and going straight to their care coordinator. They felt this posed a clinical risk if the nurse did not escalate issues when appropriate. Clear communication between nurses and GPs as well as guidelines on escalation of issues needs to be discussed with teams to ensure this isn t a risk for quality of care. CMC did not charge for GP visits and it remains yet to be seen if this impacts on patients behaviour. There was great value in being able to use external providers (including services funded by the DHB and NGOs). In order to do this however, there needs to be a process to identify local providers, a means to keep a list of providers up to date, certainty of funding to ensure the service is available ongoing, clear processes to report back to the clinical team (which raises issues around confidentiality). Feedback needs to be timely with appropriate content to support patient care. Understanding what community resources were available has been a challenge for practices. They ProCare Self-Management & Shared Care Evaluation Report Page 40

42 have expressed frustration at not knowing who provided funded services, as a provider may only be funded for a short period of time. PFHC set up regular meetings with social work providers to establish regular information sharing. A significant learning for the practice team was around what community support was actually available for patients. One practice viewed the programme as being nurse driven and therefore did not involve GPs in the training. As a result, GPs were slower to adopt the change. In order to overcome this, it was necessary to run combined workshops to raise awareness, followed by one on one training for GPs. IT infrastructure and associated software was a big challenge for practices. As the CCMS tool works across a secure health network, practices experience a delay in the sending of information which has resulted in frustration. Close attention for this type of pilot needs to be paid to effective IT including internal practice systems and external shared tools. Broadband capability played a significant role in the frustration of one practice as it resulted in a slow claims process and care planning. This added to the administrative burden reported by the practices. 6.3 Future Development Some nurses felt patients were dissatisfied if they couldn t contact their care coordinator. In order to alleviate this, they have recommended having two nurses sharing the care coordination role for each patient. This is particularly useful when a nurse only works part time. Both practices had a target of enrolling 3% of their population on the programme within twelve months of starting the pilot. The onsite change manager observed that having a target helped to drive the change within the practice, although noted that reducing the target slightly may help to optimise enrolment. This highlights the need for balance between a manageable work load and achieving sufficient numbers to embed this model. 7.0 Recommendations This pilot has highlighted seven key recommendations when implementing a change of this nature. 7.1 Effective executive sponsorship In order for change to be embraced and adopted by a practice, the practice team needs to have an executive sponsor who champions the change. This person needs to be someone with the authority to make decisions on what will happen and have the ability to secure necessary resource. The nominated executive sponsor will need coaching and support from their PHO to understand what their role entails. PHO understanding of change management and the ability to support practices with complex change programmes is essential for success. 7.2 Building relationships Building relationships both within the practice team and with external providers was noted by practice staff as being a real highlight from the programme. Having an onsite health psychologist and community health coordinator was highly valued by the practice that trialed it. The positive feedback was also reflected by the patients that were referred to them. The community health coordinators also provide an invaluable role in navigating social services ProCare Self-Management & Shared Care Evaluation Report Page 41

43 for patients. Nurses recognized their specialist skills in this area. Practices need to be able to commission these services for those patients most at need. This pilot has highlighted the need to know what external providers are available in the practices community and what services are offered and funded. It is important to have an understanding of all allied health providers that are available to a patient. Practices need to understand the benefit that each provider can offer and to have processes for referral and feedback as well as being able to keep the list current. They need certainty of funding to ensure a service be able to provide the care they referred for. In order to manage this, practices could develop a community directory within their team to advise of providers used and services available. Forming links and introducing multi-disciplinary team meetings with these providers gave a greater understanding of patient progress with the service. This pilot strengthens the relationship between a patient and their care coordinator. In order to successfully build this, practice teams needing training on motivational interviewing and building rapport to understand the patient perspective. 7.3 Training and support As part of the pilot practices were provided funding to release staff for training courses and fund training needs as appropriate. A one day care coordinator course was delivered by Counties Manukau Health which was free of charge. Although this was initially intended to be a train the train approach, many practices have sent multiple staff members to the training as it covers the essentials for care planning. Releasing of clinical staff from a practice to attend training can often be a financial and human resource barrier to small businesses, so consideration needs to be given to the financial model to support this. 7.4 Care planning Providing funded time to understand the patients concerns and develop a care plan with them was an essential way of building the relationship between the patient and their care team. It also allowed the practice to understand other issues and concerns that the patient was facing that may be impacting on the health. This pilot funded approximately an hours worth of nurse time to undertake the initial review and development of the care plan. Dedicated nurse time and minimizing payment barriers for patients is an important enabler for this model of care. 7.5 Operational technology The technology for this programme initially faced many challenges. The shared care tool used to create and manage the care plans underwent many changes in the first year to make it fit for purpose which frustrated practices. Due to the security measures in place with the shared care tool, the system can be slow with all the checks it has in place. This led to care plans taking a couple of minutes to load in some instances. Internal practice infrastructure is also an important consideration. One practice had issues with their internet speed which further slowed down their IT processes. A fit for practice tool needs to be accessible to the patient and their extended care team. Future consideration needs to be given to integrating allied health and secondary care to ensure all are using the same shared platform and templates. 7.6 Intervention funding An intervention fund that can be spent as necessary to help a patient achieve their care plan goals has been essential. The flexibility of the funding was a challenge initially for practices as they were used to ProCare Self-Management & Shared Care Evaluation Report Page 42

44 prescriptive long term condition programmes that only funded quarterly visits. The practices were given autonomy to apply resource according to need. Clinicians need the autonomy to direct resources to the areas of greatest need and greatest benefit. The practice team needs to develop capability and capacity to best utilize available resource. 7.7 Self-management review Neither practice were regularly referring patients to self-management courses. It is unclear why this service is not utilized given positive feedback from patients. We recommend undertaking a review of the service, including both patients and practices to understand the barriers to referral. ProCare Self-Management & Shared Care Evaluation Report Page 43

45 Appendix A Glossary Concept Definition ASR Age Sex Register PCRS Primary Care Resources and Supports for Chronic Disease Self-Management questionnaire CCMS Collaborative Care Management Solution CHC Community Health Coordinator ProExtra ARI At Risk Individuals programme HRI High Risk Individuals Programme PIH Partners in Health questionnaire CPRM Combined Predictive Risk Model CMH Counties Manukau Health SMSC Shared Care and Self Management project LTCs Long Term Conditions HCA Health Care Assisstant MDT Multidisciplinary Team CCM Chronic Care Management PMS Practice Management System ProCare Self-Management & Shared Care Evaluation Report Page 44

46 Appendix B - House of Care Model The UK model uses the metaphor of a house to explain the approach to the care of people with LTCs. To build the House of Care, we have extended the model to include a toolkit for practices to use to bring about organisational change. The toolkit is transferable, to be used during the change management process, and then moved to other contexts as needed. Putting the patient at the centre Each Care Plan is developed in conjunction with a multidisciplinary team for a specific individual at a defined place in time. Goals are set by the patient in conjunction with their Care Coordinator. The Care Plan will provide each participant in the pilot project with a Year of Care, identifying the services and support needed to keep the patient well. The foundation Defining services to be included and how they will be funded is the foundation of the House of Care. In our implementation, we are recognising funding streams which are already in place in the region. The walls The walls of the house are made up of the multidisciplinary team (MDT) and the patient. We will look to build the skills, capability, attitudes and approaches for the practices to enable them to work within the model. We will build on the communication and coordination links already existing in PFHC, and we will build on our existing relationships and capability to further develop the team in CMC, using virtual resources and consults where necessary. We will place each patient firmly at the centre of their care, informing and engaging them in their Year of Care. We will provide them with the knowledge, skills and support to participate in the implementation and development of their Care Plan to the level of their capability. Self-management, communication and problem solving skills will be enhanced, promoting patient resilience. The roof The organisational processes of the practice make up the roof of the house. The project will provide each practice with the knowledge, skills and tools to make long term changes to the way they do business. ProCare Self-Management & Shared Care Evaluation Report Page 45

47 Locus of control Care plans GP/Practice Nurse Consults External support Education resources Allied Health Secondary care Description Current approach GP-centric process The GP: is in charge of the Care Plan assesses progress holds the patient record in their PMS shares information with other service providers shares information with patient refers patient to Secondary Services and Allied Health as appropriate The GP: defines Care Plan and goals using a medical model assesses progress Each GP or Practice Nurse visits is 15 minutes Last test results are reviewed Health checks are completed Discussion about progress and selfcare Prescriptions are written, potentially including a green prescription New tests are ordered Patients may seek support from: MoH programmes Patient support groups Helplines/websites Resources available to the patient may include: A discussion with the Practice Nurse about self-care Access to information about their condition LTC Websites and online chatrooms The patient may be referred by GP to an Allied Health practitioner e.g. physiotherapist, counsellor. Following GP referral, the DHB: Manages acute conditions Sends records to GP Description The House of Care Patient-centric process The patient: is jointly responsible for their Care Plan has joint control of who has access to their e-shared Care Plan accesses Secondary Services Allied Health as specified in their Care Plan is a part of the progress assessment process Care Plan and SMARTER goals are defined by patient and Care Coordinator A Biopsychosocial model is used Progress is assessed by patient and MDT as well as the GP Tests are ordered before the visit, a letter is sent to the patient with results, questions and prompts for patient to consider Health checks are done by Practice Nurse /assistant before GP session Extended GP or Practice Nurse consults Other MDT members may be present Patients may seek support from: Allied Health NGOs and voluntary groups MoH programmes Patient support groups Helplines/websites Resources available to the patient may include: Local support groups, shared sessions with other LTC patients, evening meetings Education sessions with MDT members, some group sessions Access to information about their condition LTC Websites and online chatrooms Allied Health professionals are part of MDT, involved in care planning and assessments as required. The DHB: Provides improved access to secondary care and supports and participates in MDT meetings ProCare Self-Management & Shared Care Evaluation Report Page 46

48 Resource stewardship Patients who arrive at the practice are provided with episodic care. Monitors use of acute resources by LTC patients An ability to proactively manage patients depending on their need. The capacity to view both a patient-based and practiced-based budget allows allocation of resource to those most in need and recognises the impact that these decisions have on the ability to care for other patients in the population. ProCare Self-Management & Shared Care Evaluation Report Page 47

49 Appendix C - Planned Proactive Model of Care ProCare Self-Management & Shared Care Evaluation Report Page 48