A short report on integrated care initiatives in selected New Zealand Health Networks. Prepared by John Baird & Peter Smith

Transcription

1 A short report on integrated care initiatives in selected New Zealand Health Networks Prepared by John Baird & Peter Smith November 2011

2 Executive Summary Seven sites were visited in order to provide the GAIHN with examples of how other health networks are integrating their services. While the review did not attempt to cover all examples of integration, information gathering was targeted to initiatives where significant progress had been made with operational implementation. The following conclusions have been drawn from the site visits and are arranged under five headings: Service-related changes process changes to the model of care required to deliver integrated care; Service location changes changes to where the patient is treated; Integration type - whether it is horizontal integration (collaborative relationships between clinicians) or vertical integration (contractual relationships and/or ownership of supply chain); Drivers of change what preconditions and ongoing support enable integrated care initiatives to get traction; and Opportunities for GAIHN what GAIHN can do to create momentum for its integrated care initiatives. The service-related conclusions are: The importance of a stratified approach to service planning and integrated delivery: Good aged care examples exist and could be usefully applied more widely Value in targeting more intensive approaches to patients (higher potential for gain) Initiatives show a shift to a greater degree of primary care based proactive management: THG most developed example for aged care MHN most developed example for general practice redesign Canterbury Initiative demonstrates significant shift in service activity and associated pathway development most developed example of reconfiguration across primary and secondary care Initiatives enable a wider scope for reactive management: Evidence for extended POAC from Canterbury CREST has proactive and reactive components Networks have developed detailed agreed service processes across providers with individual team member roles clearly understood: Template tools for assessment, care planning and review to improve information sharing, B1 April 201

3 create a care record and enable tracking, include a clear quality improvement process Approach taken reflects stratification and reflects the intensity of integration principle Preliminary work is available from East Health, Shared Care, THG and CNN (CREST/Chain) The key enablers for service-related changes are: Shared information between clinicians (templated and electronic) most developed example CREST/Chain but very similar to the shared care pilot; and Good patient engagement and self management (supported) most developed example is Te Whiringa Ora (Eastern Bay of Plenty) but ETHC, East Health and Midlands have useful general practice-based models. The service location changes conclusions are: It is currently more about service development than a service shift (may reflect stage of development) - as participants are in many cases collaborating on an informal and voluntary basis: Most developed example is Canterbury Initiative largely an example of an activity shift but includes some service shift aspects Significant process redesign for core general practice in the context of wider clinical inputs: Most developed examples are ETHC and MHN Interaction between services needs to be sorted either through vertical or horizontal integration: Clearest articulation of this tension is in THG but exists at some level in all sites Key enablers for service location changes include; access to diagnostics, consult liaison from specialist services, agreed interactions and roles between clinicians needing to work together and access to a range of technologies. The type of integration conclusions are: Most of the examples of integrated care are examples of horizontal (collaborative) integration Some vertical organisational integration on small scale but this may be highly enabling Horizontal integration: Highly dependent on funder cooperation Good examples exist of clinically lead service design, management support to articulate supporting changes, funder support to make changes Fits with a DHB model where the DHB is not operating as master - servant Alliance approach starting to work for horizontal integration at service delivery / local network level and in districts with developed relationships C1 April 201

4 Supporting network roles can add significant value: shared learning innovation development and diffusion quality and peer review based case and process improvement The following drivers appeared to be important in achieving progress in the current environment: a well-articulated burning platform rationale clinically led change re-design involving those who understand the potential and implications of any changes to the process decent facilitation of clinical discussions good process and project management change approach based on significant stakeholder engagement in any process redesign and proof of concept sites an enabling and flexible funder IT enablers There are opportunities for GAIHN to progress its own integrated care initiatives as long as it: accesses the key contacts across the country to share learning champions clinically-led design gathers management support from DHBs in the region negotiates a change to the funding and contractual models based on the success of the initiatives above ensures that it has sufficient organising capability and the roles of general practice, primary care organisations, primary and community providers, networks, alliances and DHBs are correctly specified and understood D1 April 201

5 Glossary of abbreviations and terms ARC Capitation CARE Ladder Care Plan CCN Chain CREST DN EBPHA ERMS ESCRV ETHC Fishing HOP IFHC MHN MURs NASC Aged residential care Payment is based on the enrolled PHO population and its make-up not the number of times a provider sees patients CCN description of its care plan A plan for a patient to achieve certain goals (often determined by the patient themselves) Canterbury Clinical Network Electronic care plan (same product as Shared Care) which unlike ESCRV is interactive in Canterbury Community Rehabilitation, Enablement and Support Team District Nursing Eastern Bay Primary Health Alliance Electronic Referral Management System - a Canterbury-wide, Pegasus Health-developed referral system Electronic Shared Care Record View - a view-only health record that can be accessed by authorised clinicians in Canterbury East Tamaki Healthcare Limited MHN term for proactively contacting patients about their health needs Health of Older People (THG/CNN term for programme for caring for the elderly) Integrated Family Health Centre Midlands Health Network Medicine use reviews - MUR as part of the needs assessment would prevent patients from being referred for Medication Oversight Services Needs Assessment Services Co-ordination - establishes what clients are eligible for in the way of services/supports and which are funded PaC POAC SSOP Te Whiringa Ora THG Patient Access Centre MHN s term for the first point of contact for the patient/proactive campaigns Primary Options for Acute Care - a service allowing doctors to access investigations, care, or treatment for their patient, as an alternative to an acute hospital admission in the 3 Auckland DHB areas Specialist Services for Older People A network including EBPHA, Healthcare New Zealand, Bay of Plenty DHB, and National Hauora Coalition designed to assist patients with chronic conditions at home Tararua Health Group Ltd E1 April 201

6 Contents Executive Summary Glossary of abbreviations and terms B E 1. Introduction and purpose of this report Introduction Purpose of this report Process Structure of the report High level literature review of integrated care What is integrated care? Requirements for successful integration Horizontal and vertical integration Key lessons Relevant documents Canterbury Clinical Network (CCN) Description Focus of the visit CREST Other CNN initiatives of interest Observations Relevant documents Shared Care Description Focus of the visit Key features Observations East Health Trust Description Focus of the visit Key existing features 21 F1 April 201

7 5.4 Intended future developments for ElderCare Observations Relevant documents East Tamaki Healthcare Limited (ETHC) Description Focus of the visit Key features Observations Relevant documents Tararua Health Group Limited Description Focus of the visit Key features Observations Relevant documents Eastern Bay Primary Health Alliance (EBPHA) Focus of attendance Key features Observations Relevant documents Midlands Health Network (MHN) Description Focus of visit Key features Observations Relevant documents Conclusions Examples of integrated care and categories Service-related changes Service location Type of integration Drivers of change 38 G1 April 201

8 10.6 Opportunities for GAIHN 39 Appendix A People visited 41 Appendix B CCN Workstreams 42 H1 April 201

9 1. Introduction and purpose of this report 1.1 Introduction The Greater Auckland Integrated Health Network (GAIHN) was keen to examine examples of integrated care occurring in New Zealand in order to progress its own integration efforts in the Auckland region. It was especially keen to learn about any concrete implementation experience and for it to be provided with any verification of the efficacy such initiatives GAIHN was also interested in a brief overview of the international literature defining what is meant by integrated care and the rationale for pursuing it as an efficient and quality-driven approach to the considerable demands being placed on the health sector in New Zealand Hence prior to reporting on the examples of integrated care in the New Zealand context, section 2 briefly explores what is meant by integrated care, its aims, factors required for successful implementation, the difference between horizontal and vertical integration and why it matters, and the key lessons learnt from overseas examples of integrated care. 1.2 Purpose of this report To provide the GAIHN with information on examples of how other health networks are integrating their services. 1.3 Process Seven site visits were arranged (a list of meeting attendees is attached as Appendix A). Information gathering was targeted to initiatives where significant progress hade been made with operational implementation The site visits were not intended to cover all examples of integration but to provide some points of interest to GAIHN. The organisations visited were: (f) Canterbury Clinical Network (CCN) aged care; Grey Lynn Family Medical Centre - shared care pilot; East Health Trust (East Heath) - aged care; East Tamaki Healthcare Limited (ETHC) IFHC; Tararua Health Group Limited (THG) (Dannevirke) aged care; and Midlands Health Network (MHN) (Hamilton) IFHC; In addition to the site visits, the writers attended a workshop 1 on integrated care with presentations by: 1 Health in the home re-imagined Wednesday 5 October 2011 Tauranga

10 Eastern Bay Primary Health Alliance (EBPHA) (Te Whiringa Ora) and Healthcare New Zealand Limited on IT support for the EBPHA; and Canterbury DHB (CREST). 1.4 Structure of the report The rest of the report is structured as follows: a brief literature review; each network has a separate section and contained in each section is/are: (i) (ii) (iii) (iv) (v) a brief description of the network visited; the focus of the visit that aspect of integrated care that the writers were particularly interested in; the key features of the integrated care initiative; observations on the integrated care initiative; and referenced documentation on the integrated care initiatives.

11 2. High level literature review of integrated care 2.1 What is integrated care? While there is no single accepted definition of integrated care, most commentators would agree that most definitions include references to coordination, complementarity, seamlessness and continuity for the client. Grone and Garcia-Barbero have defined it as the: bringing together of inputs, delivery, management and organisation of services as a means of improving access, quality, user satisfaction and efficiency Kodner and Spreeuwenberg suggest that: Integration is a coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors. The goal of these methods and models is to enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients with complex, long term problems cutting across multiple services, providers and settings. The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called integrated care The proof of concept for integrated care has been documented extensively. Why integrated care matters from an economic efficiency and patient well-being viewpoint (quality) is well documented 3. It would appear that primary and community focussed, fully integrated health systems improve health outcomes, access to and delivery of care and an improved quality of life, for patients 4, While the most of the evidence is qualitative (survey results centred on providers and users views on quality) there is increasing quantitative evidence of reduced health spend and better outcomes for patients The underlying reason why there is a significant opportunity for improvements in efficiency is that the patients being targeted by integrated care are costly. Therefore, the benefits are significant if collaborative, targeted and intensive care of the chronically ill and older people (with the consequential reduction of avoidable hospital admissions, lower spend on medicines and rest-home costs) can be implemented Integration can take a variety of forms but there are common attributes where such integration has achieved demonstrable benefits. These include: 2 Gröne O, Garcia-Barbero M. Integrated care: a position paper of the WHO European Office for Integrated Health Care Services. International Journal of Integrated Care Jun Shaw S, Rosen R, Rumbold B, What is integrated care? Research Report Nuffield Trust June Starfield, B, 2005, World Health Organisation, See appendix C for Draft Primary Health Care Literature Review [report to CNN - 15 November 2011]

12 (f) general practices with multiple specialities; aligned incentives; greater use of information technology (IT); good accountability mechanisms; stratification of the population; and close collaboration between clinicians and health management Curry & Ham (2010) demonstrate that there is: value in pursuing closer integration of care; and the integration effort should focus on clinical and service integration because organisational integration alone is unlikely to achieve a net gain from the status quo; and the approach should be both bottom-up and top-down. 2.2 Requirements for successful integration There is general acceptance that integrated care 6 aims to: improve patients experience of the health system; achieve greater efficiency and value; address fragmentation in patient services; and enable better coordinated and more continuous care These aims provide an indication on what would likely be the primary requirements for successful integration 7 which are: deciding the most important integrative processes: (i) (ii) (iii) whether there are joint administrative processes; identifying and aligning the incentives needed to support integration across professional groups, teams or organisations. Commissioning arrangements that support and enhance integration rather than perversely incentivise it; how much coordination of clinical services; and 6 Nuffield Trust Ibid

13 (iv) the development of shared values including what existing structures, partnerships and processes can you build on or what is needed to start from scratch. effective data sharing and management of information; focussing on both vertical or horizontal integration (this is further elaborated on in section 2.3 below); addressing issues of choice, competition and contestability; and keeping momentum to ensure a sustained focus on integrated care Rosen and others, 2011 add that it is also important to be clear what a specific integration initiative seeks to achieve: to generate shared objectives; and to provide ongoing momentum Notwithstanding general agreement about what it is, what it seeks to achieve and what to focus on to be successful, it is also widely accepted that there is no one model of integrated care that is suited to all contexts, settings and circumstances 8. Careful analysis is needed about the different integrative processes that can support integration within a particular care setting. Decisions about which approaches are most relevant to a particular setting will be guided by the goals of the project, the needs of service users and other stakeholders involved, existing provision and available resources Integration projects driven by a focus on reducing service fragmentation for a group of patients are often more successful than top-down attempts to integrate care (Ramsey and Fulop, 2008) These dimensions of integrated care are captured in the diagram below. 8 Nuffield Trust 2011

14 Pooling of resources with a comprehensive service offering through a new organisation Coordination of existing organisations using shared information and agreed pathways to manage patients Full Integration Coordination Use of existing organisations but improved communication e.g. to ensure patients are referred to the right organisation. No cost shifting Linkage Source: What is integrated care? Nuffield Trust Horizontal and vertical integration As noted above integration decisions are a critical determinant of successful integration. The terms horizontal and vertical integration are used variably to mean: horizontal pathways (e.g. between primary providers) versus vertical pathways (e.g. between primary and secondary care); and collaboration between providers versus bringing together aspects of service delivery in one organisation Both considerations are important for how integration might best occur but initiatives often focus on one dimension or approach. For instance, rather than encouraging detachment of vertical and horizontal pathways by simply diverting referrals away from hospital-based clinics to community settings, it may be more beneficial to integrate generalists and specialists via care networks (Nuffield Trust 2011) or alternatively do both This is similar to Cory and Hamm s advice that changes should be both bottomup and top-down to achieve the optimal outcomes. 2.4 Key lessons The key lessons can be distilled from the literature search are: Integrated care is best understood as a strategy for improving patient care: Integrated care is concerned with improving patient care through better coordination.

15 A decision about the intensity of integration is essential: Integration that is focused largely on bringing organisations together is unlikely to create improvements in care for patients. The service user is the organising principle of integrated care: Careful analysis of the goals of integration is critical in order to establish what might help or hinder progress. There is a need for a shared vision in which the service user perspective and patient experience is central. Achieving integrated care requires those involved with planning, financing and providing services to: have a shared vision, employ a combination of processes and mechanisms dependant on the local context, ensure that the patient s perspective remains a central organising principle throughout. It is only possible to improve what you measure: There is a shortfall in evidence of the impact of integrated care and further work is needed. 2.5 Relevant documents Relevant documents can be located at the following web addresses: An overview of integrated care in the NHZ - What is integrated care? Research report Sara Shaw, Rebecca Rosen, Benedict Rumbold Nuffield Trust June Clinical and service integration - The route to improved outcomes - Natasha Curry and Chris Hamm The King s Fund Long Term Conditions Collaborative Improving Complex Care NHS Scotland/Scottish Government March

16 3. Canterbury Clinical Network (CCN) 3.1 Description The CCN comprises urban and rural GPs, practice nurses, pharmacists, allied health professionals, community nurses, the Canterbury District Health Board, Primary Health Organisations and GP groups (IPAs). It has 13 workstreams relating to primary health (see Appendix B for details of workstreams). CCN very focussed on establishing collaborative relationships as a platform for integrated service development. 3.2 Focus of the visit The focus of the discussion was on the Community Rehabilitation, Enablement and Support Team (CREST) service. 3.3 CREST The key features of CREST (Community Rehabilitation, Enablement and Support Team) are: Community based rehabilitative supported discharge service. It has three service components (one of which has been fully implemented): (i) (ii) (iii) supported discharge (implemented); rapid response for admission avoidance (implementation has recently commenced); intake prior to long term support (to be implemented). It comprises a multidisciplinary team (general practice, community service providers and older person health specialist services). It was set up to reduce the length of stay in hospital and avoid hospital and ARC admission. CREST will provide clients with up to 4 visits a day, 7 days a week (for up to six weeks) The key functions of CREST are: Supported discharge for older people being discharged home from the Christchurch, Burwood and Princess Margaret Hospitals. Direct referral from Primary Care to avoid an Emergency Department (ED) attendance or hospital. Rapid response for older people attending Christchurch Hospital ED.

17 Intake service for all older people referred for long term home care or requiring rest home placement, if clinical discretion allows The key targets of CREST are: Improvement in client function and independence. Reduced length of stay in hospital. Increased time spent at home over a year. Reduction in residential care placement. Reduction in the need for long-term residential care The foundations for CREST were established already with a base of collaborative relationships between clinicians (general practice, primary, community and specialist services and others) within the Aged Care Workstream. In addition the model chosen was adapted from an evidence-based model from overseas which had some early implementation experience in New Zealand 9. The aged care workstream had established a history of developing initiatives aimed at improving care systems within Canterbury. Its activity was motivated by the understanding that increasing demand over time will not be able to be met merely by ramping up the existing systems of care. There was a clear understanding that systems needed to change in order to respond to increased demand and head of a relative constriction of supply However there was rapid development to suit Canterbury s particular context and in response to the February 2011 earthquake. CREST was implemented after only three meetings of 30 people over three weeks. The expectation at the outset was to learn by doing, making ongoing improvements as more experience was gained and clear communication channels to enable effective quality improvements. In this regard a quality improvement regime was put in place, including a formalised project structure. The project structure included a steering group, an operational \working group and a peer review group. CCN adopted phased approach to roll-out, starting with general medicine and AMAU and then moving out to other medical specialties and hospitals The quality improvement regime also included the collection of input and output data, monitoring of performance and comparative review of CREST. A cooperative network based approach was adopted with discussions and feedback being used to drive process improvement, training and development and tool development. 3.4 Other CNN initiatives of interest There are additional examples of integrated care in the Canterbury region including: 9 Start programme initiated by WDHB.

18 (f) Community based Acute Demand Management Services. Integrated respiratory service including shifting the delivery to GP practice (e.g. sleep studies, pulmonary rehab, spirometry being undertaken outside of the hospital), extensive pathways, education and liaison functions. Community pharmacy General practice integration. Canterbury initiative encompasses service shift, expanded primary care activity and pathways. Plant to develop 10 IFHS sites. Ongoing development of the principle enablers ESCRV, ERMS and Chain. 3.5 Observations The key observations of the CCN : It is highly functional alliance with extensive clinical engagement across broad spectrum. While there are examples of vertical and horizontal integration, the main focus is on cooperative relationships sponsored by the CDHB and Primary Care Organisations. There are a large range of integrated care initiatives some established for up to 10 years. The scale of development activity in the Canterbury region is significant with multiple initiatives underway (see Appendix B for the list of workstreams). It is an example of accelerated execution because of the earthquake (sudden reduction in capacity) but the model is equally relevant to other regions experiencing capacity pressure from organic growth. Initial success and ongoing viability is highly dependant on cooperative DHB funder. 3.6 Relevant documents Relevant documents outlining CCN s method, process etc are : Community Rehabilitation Enablement & Support Team (CREST (Version 3.1); Respiratory Services; Coordinated Medicine Management System; Final Goal Ladder (template care plan); Guide to access to community services for the aged.

19 4. Shared Care 4.1 Description There are 8 practices involved in a shared care pilot study in the Auckland region. One site was visited Shared care has been described as - a person-centric approach, which involves all health professionals that have a role in the patient s care working to a common care plan and sharing information between them 4.2 Focus of the visit The focus of the visit was the practical implementation of the shared care initiative, including understanding the interactions between clinicians in the treatment of a chronically ill patient. 4.3 Key features The key features of the shared care initiative are: The key contact is the patient s GP. There is an electronic shared care plan able to be accessed by the clinicians treating the patient. There is early involvement by wide range of specialist health professionals with access to the shared care plan. There is patient engagement with the shared care plan (goal setting) The key expected benefits include: improved efficiency (e.g. turnaround of test results, specialist input); increased patient involvement in managing their care. stronger patient relationships, improved safety, and better communication between clinicians. 4.4 Observations The key observations of the shared care pilot are that it: demonstrates enhanced proactive and reactive case management; targets highly complex patients; demonstrates how a shared care plan across remote team involving GP, specialist nursing, specialist medical can work;

20 technology enabled communication and agreed roles can lead to much more rapid liaison activity from team (e.g. nurse practitioner aged care, respiratory nurse specialist and cardiologist responding quickly to updated information in care plan); and requires more work to develop common processes for similar patient issues (initial templating of care plan has commenced).

21 5. East Health Trust 5.1 Description East Health Trust (East Health) is a PHO operating in the Howick, Pakuranga, Beachlands, Maraetai and Clevedon regions. It has an enrolled population of approximately 84,000. East Health has been running a programme (ElderCare) to provide coordinated care for the elderly since It has two full time coordinators. 5.2 Focus of the visit The focus of the discussion was on ElderCare. 5.3 Key existing features The key features of ElderCare are: co-ordination of services; a process oriented around supporting general practice to deliver improved care for the elderly; the availability of clinical pharmacist input; some involvement from a community geriatrician; Coordinator roles are to: (i) (ii) (iii) (iv) respond to patient issues arising at the general practices; coordinate patient interaction with clinical services and NGOs; extend the GP role; and to follow-up of all over 65 hospital discharges to ensure reconnection with general practice and other services as required The key benefits include: (f) achieving patient-determined goals care plans and updates; reducing admission and readmission rates; reducing duplication of assessment; increased referrals to POAC; number of multidisciplinary case conferences; and improved communication between health professionals.

22 5.4 Intended future developments for ElderCare The ElderCare initiative is being extended to include: establishing a Care Cluster of general practices from East Health integrated with Counties-Manukau DHB Community Health Services including: (i) (ii) (iii) (iv) (v) Home Health Care (District Nurses and Allied Health); needs assessment and service coordination; Community Geriatric Service; Very High Intensity User (VIHU) programme; ElderCare PHO coordinator. determining the feasibility of a 24 hour observation unit within East Care and the Botany community health hub to service a number of Care Clusters and prevent admissions to hospital; and establishing a Service Level Alliance with key stakeholders to ensure effective implementation of the proposed model. 5.5 Observations The key observations of ElderCare are that it: is a well established coordinated care regime for elderly people with proactive risk stratification; demonstrates what can be achieved across a local network; demonstrates how the Navigator role supports general practice. Is a good example of specialist consult liaison within a primary care setting; should bring together existing primary care development with hospital and community services with its intended future developments. 5.6 Relevant documents Relevant documents outlining East Health s method, process etc are: Better Sooner More Convenient and Integrated Models of Care Auckland Final Draft Report August 2011; and Description of Counties-Manukau/East Health pilot Older People s Health (Care Cluster) a proposal for 24 hour observation unit.

23 6. East Tamaki Healthcare Limited (ETHC) 6.1 Description East Tamaki owns 15 practices, mostly in South Auckland. GPs are salaried workers but also have shares in the company. ETHC provides services for 105,000 enrolled patients and 180,000 casual consultations a month. It owns 9 A&E clinics and works in partnership at locality levels with pharmacies. It is the largest primary healthcare provider for Māori (15.000) and Pacifica people (45.000). 6.2 Focus of the visit The focus of the discussion was on ETHC s approach to developing an IFHC. 6.3 Key features ETHC s model for an IFHC encompassed three centres: Mother and Child Centre which includes the following clinics; Women s clinic (maternity, wellness, adolescent & menopause) and Children s. Chronic Disease Management Centre includes the following clinics: diabetes and endocrine, cardiovascular, pulmonary, musculoskeletal, skin, depression and integrated CDM (management). Ambulatory Surgery & Special Procedure Centre includes the following clinics: general outpatient surgery, orthopaedic and sports, pain management, physiotherapy, ENT and eye, colorectal and urology These centres would be serviced by a multidisciplinary team comprising: a clinical lead; GPs on rotation; clinical support; and speciality champions ETHC s model of care (health management system) can be integrated with the Whānau Ora programme (see diagram below). All programmes are supported by comprehensive planning, including a documented business plan, health promotion plans and a Māori health plan. The Māori Health Action Plan had been developed in consultation with Māori. The Chairman of the THO Board was Māori and led the development of the plan in consultation with the General Manager for Māori Health, CMDHB Staff represent a number of ethnic groups within the local community and are fluent in a number of languages. Translation services are available. Additional

24 cultural support was available by referral to community health workers and health promotion programmes at Otara Health Incorporated (OHI). Community health workers included people of Māori, Pacific and Indian cultures. There is 50% community participation at governance level Performance monitoring data was shared between CMDHB and the THO on a regular basis. An audit report noted that the PHO demonstrated well developed governance, business and healthcare management systems and processes. The health management system Whānau Ora dimension Patient Data Base Primary care services Clinical Information Speciality care services Occupational health wellness services Emergency and urgent care services Social and family conditions Psychological profile Ambulatory Surgery and special procedures Clinical Team Preventive and health maintenance screening Whānau Ora case manager Community and home health services Clinical family navigators Self management Patient and family Care integration systems 6.4 Observations Source: East Tamaki Healthcare Limited Presentation The key observations of ETHC s IFHC model are that it: is a stratified model of care operating in general practice with developed guidelines and protocols; is supported by a well-developed PMS supporting guidelines and protocol implementation; provides low cost access which allows opportunistic treatment activity;

25 (f) (g) (h) uses navigator type (a three stage triage and patient care system) roles to retain and gain connection with patients and provide value for money; and walk in service with no appointments required; clinics located in shopping centres with adjacent public transport; availability of cultural support provided by the Community Health Workers is a potential model for extended primary care activity that would reduce secondary care utilisation. 6.5 Relevant documents Relevant documents outlining ETHC s method, process etc are: Slide Presentation Transforming Primary Healthcare from within; and Slide Presentation Sustainable high quality healthcare.

26 7. Tararua Health Group Limited 7.1 Description THG was established in It is a network of 3 GP practices (two in Dannevirke and one in Pahiatua) and a community hospital. It operates a hub and spoke arrangement across wide geography. The hospital provides 8 GP beds (care for by those GPs on a roster system), is a maternity facility (3 beds), has an x-ray service and provides ultrasound service 2 days per week. An afterhours telephone triage system is provided by the hospital It has 100 staff with 60 clinicians (37.5 FTE) serving 14.6k patients (of a possible 16k in the area). It has a single patient management system linked by 90 kms of fibre optic cable. The software is a Medtech supported framework and patient records from all four sites are integrated to allow sharing of information between the practices, linkages to a radiology service and MidCentral health enables participation from specialists. 7.2 Focus of the visit The focus of the discussion was on THG s approach to providing aged care. 7.3 Key features The key features of THG s aged care model are: general practice-based model (allows smooth transition back to the GP once support is put in place) with multi-disciplinary case management. In addition to the input of the Central PHO clinical pharmacist the HOP service agreement enabled the following team positions: (i) (ii) (iii) (iv) (v) GP with Special Interest (0.2 FTE); Clinical Nurse Specialist (0.8 FTE); RN with Special Interest (0.2 FTE); Allied Health (0.3 FTE) yet to be appointed; Two InterRAI assessors completing Contact and MDS-HC assessments. the adoption of a stratified approach aimed at high needs/high risk patients - entire over 55 Māori/Pacifica and over 65 Pākehā population according to risk of event. A score of 8-11 means the patient is a priority 1 and the HOP team will proactively work these patients. The current weightings applied to the practice profile to flag those most at risk of harm, injury and/or admission is as follows: (i) Ethnicity: Other = 0, Maori = 1, Pacific = 1;

27 (ii) Long term medications: 0-5 = 0, 6-10 = 1, = 2, 21+ = 3; (iii) Resident in ARC: Yes = 0, No = 1; (iv) Number of acute admissions: 1-2 = 1, 3-4 = 2, 5+ = 3; (v) Number of reported falls: 1-2 = 1, 3-4 = 2, 5+ = 3; (vi) Living alone: No = 0, Yes = 1; (vii) Primary care presentations: 0-5 = 1, 6-10 = 1, 11+ = 2; (viii) Care Plus: Yes = 0, No = 1; (f) proactive assessment [InterRAI] to match stratified risk level with inform NASC process. proactive care planning to match assessment. reviews by a clinical pharmacist and joint MUR CNS/community pharmacists. Community pharmacists have full access to THG s PMS; and standardised standing orders for aged residential care. 7.4 Observations The key observations of THG s aged care model are that it: (f) (g) demonstrates a stratified approach with proactive management of entire over 55/65 population; is a consistently applied approach across GP practices with a solid base infrastructure (IT and buildings) in hub and spoke arrangement; has high potential for prevention of ED and inpatient, ARC and long term HBS but evidence only anecdotal at the moment; provides horizontal career development and contributes to maintaining core competencies in a semi-rural area; InterRAI in team with high follow up on CAPS; demonstrates that change to the model of care was enabled by local risk taking and driven by local personnel; and Is supported by DHB key enabling contracts e.g. Aged care team and InterRAI assessment In order to ensure long-term sustainability of the THG model it is necessary to understand how to support further change notional ARC, HBS, ED and inpatient budgets versus further enabling contracts. A local alliance will be required to support further integration Issues that remain to be addressed by THG are:

28 interaction with Specialist Services for Older People (SSOP); allied health access to services to assist with aged care; duplication and alignment is not sorted with DN, Short term supports; the NASC interface; and how much further integration and the opportunities presented by pursuing horizontal versus vertical integration. 7.5 Relevant documents Relevant documents that relate to THG s activities are: Presentation: General Practice Redesign; Integrated Family Health Centre Action Plan (version 1) September 2011; Presentation: Alliance Leadership; and Integrated Family Health Centre Implementation Plan (version 2) March 2011.

29 8. Eastern Bay Primary Health Alliance (EBPHA) EBPHA was formed from three PHOs. It has ten GP practices in partnership with several Iwi services and community organisations. EBPHA, Healthcare New Zealand, Bay of Plenty DHB, and National Hauora Coalition are part of the Alliance responsible for implementing the BSMC business case. One component of that is the Te Whiringa Ora (integrated family health network) service designed and implemented by Healthcare of NZ, which is a programme to assist patients improve their ability to self manage their chronic conditions, delivered in the home setting. A case study describing the activities of Te Whiringa Ora was presented at a workshop 10 in Tauranga. 8.2 Focus of attendance The focus of the attendance at the workshop was the concept of delivering health services in the home setting, which is this network s approach to providing care to the chronically ill. 8.3 Key features The key features of the Te Whiringa Ora model is that: it is focussed on improving self-management; it is patient-centric (includes their Whānau); facilitates interdisciplinary care, for those with complex health needs and high users of hospital services. provides a web of care [meaning of Te Whiringa] to connect what exists already, over a time-limited support phase of 3 6 months; and it builds on a 24 month HealthRight outreach service that was provided by Healthcare New Zealand and the Kawerau PHO which improved patient self-management The drivers for the model of care is to: improve use of existing resources; make greater use of supervised but unregulated staff; make greater use of patients own personal resources where the patient is encouraged and supported to understand their own condition, set goals, self-monitor progress, and take some responsibility for their own health; and deliver more care in the patient s own home. 10 Health in the home re-imagined Tauranga - 5 October 2011 (presentations available on disk).

30 8.3.3 The measures of success of Te Whiringa Ora are: (f) early identification of any barriers to care; cost efficiency; independent healthy population; better information sharing across a range of health and social services; fewer unplanned hospital admissions; and shorter hospital stays, due to more effective home support options. 8.4 Observations The key observations on Te Whiringa Ora are: intensive case management programme with 129 clients over the first 7 months; significant Healthcare New Zealand support delivered as part of the Eastern Bay of Plenty Health Alliance; trained support workers (Kaitautoko) with clinical oversight; use of telemonitoring and a shared care record; and navigation through social and clinical services It is too early to evaluate how successful this initiative but this approach may provide a highly cost effective support for highly complex cases. Integration with general practice needs further work. It is possible that a combination of this type of navigation and technology supported approach with an extended general practice model may be highly successful. 8.5 Relevant documents Relevant documents that relate to EPPHA s activities are: Presentation by Nancy Chapman: Presentation by Don Robertson.

31 9. Midlands Health Network (MHN) 9.1 Description The Midlands Health Network (MHN) is a relatively large network of primary care organisations in the central North Island regions of the East Coast, Coromandel, Waikato, Taupo, King Country and Taranaki, covering nearly 500,000 people. 9.2 Focus of visit The focus of the visit was MHN s redesign of primary care to deliver IFHCs. 9.3 Key features MHN considers that a new model of care was necessary as current model of general practice (see diagram below) was not sustainable due to: Population increasing faster with different expectations than the what can be practically delivered by the current system confronting a 20 percent increase in demand from an aging population. Workforce is aging (average age of GPs in area is 57). Infrastructure - much of the primary care infrastructure is being run down and/or is not necessarily in the right location with aging owners reluctant to invest in the new facilities in semi rural locations MHN s solution is to design a new model of care based on the IFHC concept. It has not set out simply to establish large buildings with co-located services but a new model of care.

32 9.3.3 The redesign of the process involved examining: How patient contact is initiated; How resources are allocated to meet patient needs; and Ongoing support The redesigned process is seeking to better meet patient needs and increase primary care s ability to provide more patient interactions. This new model of care is shown in the diagram below. Source: MHN presentation The key changes from the previous model of care are: a redesign of the physical space - all onstage space shared between all clinical staff (i.e. consultation rooms are standardised and not allocated to individual doctors); standardised processes for supplies/trolleys; introduction of Lean methodology; more space for training and clinical services;

33 (f) (g) (h) Extended General Practice Team including the introduction of the Medical Centre Assistants role and Clinical Pharmacist; offstage space for all staff (for virtual contact with patients including telephone consultations and secure s). tripled the number of terminals. reduced waiting space; Patient Access Centre including: (i) (ii) (iii) use of Smart phone system allowing PAC staff to see which clinicians can take calls; single phone system across all sites; access across all sites to patient information including online portal enabling access for patients to their health records; (i) (j) (k) a broader range of available responses to patient needs (e.g. direct access to doctors for telephone consultations or contacts, clinical pharmacist consults, etc; self service kiosk for patients in waiting area; and reconfiguration of daily schedules to incorporate dedicated virtual consultation and administration time for clinicians MHN have replicated the Patient Access Centre (PAC) which will handle all phone calls to the practice including general enquires, scheduling and connecting patients in real time to clinical staff and communicating the results and managing out bound campaigns. Access to care includes a number of interactions making sure the right patient is seen at the right time using the most appropriate response and includes: (f) 8-10am Dr triage taking calls referred directly from PAC; Virtual consultations (i.e. telephone) and contacts (secure messaging) with nurse, pharmacist and Dr; planned virtual consultations (nurse, pharmacist, Dr); face to face (nurse, pharmacist, Dr); and relaying DHB Clinical information CWS (to be implemented). Maximising the potential of every consult by being prepared.

34 9.3.7 MHN considers that it could achieve similar benefits to those realised in Seattle. MHN s model is based on the approach implemented in Seattle. The results achieved there were a: (f) (g) (h) 9% decrease in F2F primary care consultations; 90% increase in secure messaging/e health; 12% increase in telephone consults; 8% increase in speciality referrals; 5% decrease in medical and surgical referrals; 29% decrease ED and urgent care; 11% decrease in avoidable hospitalisation; and cost neutral position across the whole system MHN has adopted a staggered process to deliver the integration (see diagram below) with the following progress made to date: Focussing first on developing IFHCs for Hamilton followed by Taranaki; mapped population and workforce through to 2031; developed a matrix of primary, community and secondary services; developed an understanding of clustering for IFHC development; and designed three levels of IFHC with different functionality to support effective clustering. Source: MHN presentation

35 9.3.9 MHN considers that locality planning is essential as planning for any future development need to understand: Demographics population changes and supply of clinicians; Current and future NGO services; Current and future DHB services; and Quality of existing primary and secondary health infrastructure. 9.4 Observations The key observations on MHN are: (f) its focus on the GP model of care and managing of this interaction by the introduction of PAC and clinician triage. it involves a significant process redesign in general practice setting and it is the most developed model of general practice redesign in pilot sites; the PAC is a key enabler; that it is contributing to the viability of general practice in the region; it streamlines the patient interaction with GP; and it is focussing on wider integration with locality planning including colocation of DHB community nursing services (district nurses) as part of locality planning. 9.5 Relevant documents Relevant documents that relate to MHN s activities are: Slide Presentation Model of Care Midlands IFHC 2010; Integrated Family Health Centres Midlands Health Network; and Change Update (web page August 2011).

36 10. Conclusions 10.1 Examples of integrated care and categories The review attempted to investigate and report on examples of integrated care where implementation was advanced enough to draw some tentative conclusions around the practicality of such initiatives and their efficacy. There were other examples of integration in the networks visited that are not covered by this report The following conclusions have been drawn from the site visits and are arranged under five categories: service-related changes process changes to the model of care required to deliver integrated care; service location changes changes to where the patient is treated; integration type - whether it is horizontal integration (collaborative relationships between clinicians) or vertical integration (contractual relationships and/or ownership); drivers of change what preconditions and ongoing support enable integrated care initiatives to get traction; and opportunities for GAIHN to make progress Service-related changes Service-related changes relate principally to process changes in the way patients are treated in the particular locality. Process changes of significance were: A formal stratified (targeted) approach to service planning and integrated delivery: (i) (ii) good aged care examples exist (e.g. THG) which could be used more widely; and target more intensive approaches to patients where there is higher potential for gain. Shifting the model of care where there is a greater reliance on primary care-based proactive management of patients: (i) (ii) (iii) THG most developed example for aged care; MHN most developed example for general practice redesign; and Canterbury initiative demonstrates significant shift in service activity and associated pathway development most developed example of reconfiguration across primary and secondary care. Enabling a wider scope for reactive management: