Unpicking the Health Care Home model - How is it being described and implemented in New Zealand (and overseas) Les Toop Professor and Head of the Department of General Practice - University of Otago, Christchurch
Definitions - Finding Common Ground Health care home Patient centred medical home Integrated family health centre Are these entities or simply a recognised collection of ways of working models of care? "When I use a word," Humpty Dumpty said, in rather a scornful tone, "it means just what I choose it to mean neither more nor less.
NZ health care home collaborative definition The Health Care Home is a fully integrated multidisciplinary team of providers with General Practice at the core which is accountable for the health and wellness of an enrolled population
Some Questions to Ponder on What are the problems that the HCH model seeks to address? What are the key elements that all agree on? How many of these are new vs business as usual (evolving anyway)? How many of these are required to use the HCH name / brand? Who sets the standard? Why would you want to change to this model? Will it be better for patients, for providers and / or for the system? Signs are encouraging, but it is early days and..
Are the Drivers for Change Smouldering or Burning in your area?
Any Of These Sound Familiar? Demand > Supply for acute care Ageing population and increasingly tired and stressed ageing workforce Increased complexity of care Increasing inequity in health outcomes Unacceptable variations in practice by postcode and by practitioner Access barriers to primary care Emerg, Depts and hospitals close to being overwhelmed Unnecessary face to face consultations Stuck on a fee for service treadmill Fast moving and growing virtual health offerings threatening traditional models Provider centric system that is inconvenient and unresponsive to changing expectations of users Increased non clinical bureaucracy Add you own here and here Cost shifting and perverse incentives perhaps?
The pressure points in the system are variably distributed across New Zealand Increasing Demand is outstripping Supply using traditional model with one size fits all face to face consultations In some areas, especially rural and dispersed, Access to basic primary care is particularly problematic : Geography, cost, timeliness and in some places it is culturally difficult to deliver In other areas, including the main centres, same day and after hours GP access can be difficult and this results in increasing pressure on Emergency Departments and on avoidable hospital admissions for acute care. This in turn impacts on elective care
The Health Care Home Movement in New Zealand The System Basics: More than 90% population (~5 million) enrolled since early 2000 s Funding - partial capitation (~half) through a formula cascading through DHBs (20) to PHOs (30) to practices and practitioners Rest made up from patient copayments which are variable plus ACC and other miscellaneous sources. Most still small private businesses, some Trusts and a few Corporates (increasing) PHOS / Networks are self selected and form partnerships with other groupings e.g. N4 which set up the Health Care Home Collaborative (which other groups and organisations can and have joined)
District Alliances Promote the Integration Agenda PHOs / Networks are in Alliances with funders, other primary care groups,consumers, other agencies and with secondary care These have a series of service level alliances that report to an alliance leadership team who in turn recommend to the funder (who are partners in the alliance) how services should be developed and evolved Works very well in some areas less well in others All about relationships See http://ccn.health.nz/ as an example
The Beginnings of the HCH Movement in NZ Pinnacle in the Midland region of the North Island proposed and then in 2010 began implementing a NZ adaptation of the Group Health model from Seattle They have pursued a fairly standardised pro forma approach, initially with practices they purchased, the elements of which I will outline shortly. They have partnered with others to design and build a complementary (to the new Model of care) new patient management system (INDICI) on a cloud based platform. It is being rolled out in the Midland region now. Other areas of the country have adopted a more organic approach with practices adopting or planning to adopt elements rather than the whole package Additional national funding to push out the model at scale remains elusive, The NZ Minister and Ministry of Health were initially keen but now appear less so
Top down vs Bottom up? Most innovation in NZ primary care over the last 25 years has been bottom up, with brief windows of national permissive policy and / or regional collaborations with enlightened local funders (being the exception rather than the rule)
The Pinnacle story so far is worth a read http://www.healthcare home.co.nz/wpcontent/uploads/2017/ 03/EY-Health-Care- Home-Evaluation- 2017.pdf
There are four key elements in the Model as proposed by Pinnacle Timely unplanned care Proactive Care Routine and Preventative care Business efficiency
And a flow on of implementation activities Centralised access point of first contact and manages recall and billing Telephone Triage at start of day Senior Clinician to determine if a Face to face consultation is needed & if so, with whom and for how long Pre work completed, e.g. routine tests, opportunistic care etc. Time set aside for telephone consulting with clinicians Web based portal, interactive and two way (shared EHR eventually) Facilities, standardisation of rooms, off stage space etc. Development of clinical roles e.g. Pharmacists, MC assistants, NPs etc.
The Most Recent Pinnacle Evaluation Used a Programme logic model which tracked key elements of the model through to outcomes This is being used by the wider HCH collaborative to create a performance framework with a set of benchmarking indicators and work continues with the College (RNZCGP) on a HCH Standard that fits in with the College s Aiming for Excellence Cornerstone Standard
The Conclusion of the Pinnacle Evaluation The evaluation findings have generally been positive with regards to the implementation of the model although quantitative analysis of hospital data has not shown significant changes. [It was unlikely to do so as the population under the Midland model is still too small to reliably show changes to secondary care utilisation]
The Wider HCH Collaborative Description Is Similar Acute care Call management GP triage Same day appointment Extended hours Web GP services/options Extended workforce response Shared single health record Enhanced services in primary care e.g. IV therapy at home
Proactive Care Risk stratification Year of care planning Care coordination Shared care plans Patient centric scheduling Patient Portal Extended GP Team (PCA, CP, NP, DN, allied health)
Preventive Care Screening [loosely used term] Health checks [Dubious] Health promotion / health advice Support for self care / self management Population health and wellbeing monitoring
Courtesy Compass Health http://gpnz.org.nz/wp-content/uploads/health-care-home.pdf
In other areas a more flexible approach taken Several practices In Auckland, Northland and in and around Wellington adopting some or all of the elements of the full HCH model In Canterbury the majority of GPs and practices are part of the Pegasus Network / PHO Integrated Family Health Centre (IHFS) programme is co funded by the DHB and Pegasus. So far approximately 55 practices (of 100) completed or taking part How does this ground up individualised programme work?
Canterbury Integrated Family Health Service
Our Aims Integrating care around individual patients Building sustainable capacity, capability and efficiency of primary care teams Supporting proactive and coordinated care for those patients who need it Linking the primary care teams with other health and social service providers and starting the process of relationship building
What are GPs Telling Us? I would like to improve my clinical service Would like to link with hospital colleagues around our patients Spend more time with patients who need it Have the space to allow more flexibility in the care we provide I would like to change my lifestyle Spend more time with my family rather than at work Be able to take leave when it suits me and my family I would like to leave a healthy legacy to my successors Have time to teach young doctors Be able to exit my practice when the time is right for me and be assured the care for my patients continues Have the ability to afford a new premises without impacting on my income
The IFHS Project Process Five Stages: 1.Engagement / Vision 2.Integrated Model of Care 3.Workforce/Financial/Space Model of Care Impact for Owners 4.Implementation 5.Evaluation
Current Status Interest from practices covering 76% of Canterbury Enrolment Practices covering 56% at various stages of implementation Approx. 30% steadily making changes.
IFHS Engagement DATA PACK
Pink = core Blue = peripheral
Can be quite surprising to Practices Most of our patients don t come from close by and most of the patients close by don t come to our practice
Understanding the dynamics of the enrolled population Practice growing, esp. in younger age groups Seasonality has differential effects by age
Sample Medical Centre Outcomes
What lessons have we learned? Integration is about relationships & partnerships Focussing on the patient removes boundaries and equalises partners Intelligent people in the same room working on the same problem will arrive at a great answer - then back them Our role is to facilitate not impose solutions Bottom up approach has been essential in our experience Primary Care reconfiguration is part of whole of system change Incremental change The IFHS process provides : a structure a safe environment for discussion a way for everyone to win
What has Made the Changes Possible? DEFINED MODEL O F CARE CAPITAT ION A ND E NHANCED CAPITAT I O N COMPLEX CARE: Coordination Care Plans ID Patient cohort ACUTE CARE: Triage Intelligent scheduling SUPPORT FOR NURSE DEVELO PMENT CANTERBURY D HB S U PPORT FOR WHOLE O F S Y S T E M A P P R OACH E.G. ACUTE D E MAND, CREST, HEALT HONE, HEALT HPAT HWAY S
Looking Further Afield
United States perspective on How Health Care Homes are different Current care Health Care Home My patients are those who make appointments to see me Our patients are those who are enrolled in our Health Care Home Care is determined by today s problem and time available today Care is determined by a proactive plan to meet health needs, with or without face-to- face visits Patients are responsible for coordinating their own care A team of health professionals coordinate all of a patient s care It's up to the patient to tell us what happened to them We track tests and consultations and follow-up after ED visits and hospitalisations Practice operations centre on meeting the doctors need Our multidisciplinary team works at the top of our license to serve patients. Source: Adapted from F.Daniel Duffy, MD, MACP, University of Oklahoma School of Community Medicine
Sound familiar? CURRENT CARE My patients are those who make appointments to see me Care is determined by today s problem and time available today Patients are responsible for coordinating their own care It's up to the patient to tell us what happened to them Practice operations centre on meeting the doctors need HEALTH CARE HOME Our patients are those who are enrolled in our Health Care Home Care is determined by a proactive plan to meet health needs, with or without face-to- face visits A team of health professionals coordinate all of a patient s care We track tests and consultations and follow-up after ED visits and hospitalisations Our multidisciplinary team works at the top of our license to serve patients.
In Summary NZ approach to HCH responding to a number of drivers Many of the elements are already happening, but piecemeal Packaging these appears to have advantages as does the enthusiasm generated in the organic change process Some of the desired outcomes are already being managed in other ways e.g. Acute Demand Management & Alliance led integration projects Others drivers and emerging digital innovations require new models and new ways of thinking (quickly) Business model not clear for the new way of working
Enablers Ground up ownership there is appetite to look at new ways of working Sector led innovation in Clinical pathways, in IT development Local Alliancing to redesign the system One budget Enrolment (mutual responsibility and better denominators) Access to good data and capability and capacity to interpret it Education, encouraging reflective quality improvement approach Elimination of perverse targets and removal of reductionist, pay for performance, single disease surrogate outcomes System level QI measures that promote integration
Challenges Apparent disengagement of current politicians Unhelpful Ministry of Health preoccupied with nano solutions to whole of system problems Current funding model outdated with poor targeting. DHBs increasingly under resourced under pop n based funding (alternative is worse) Movement towards greater care closer to home has not yet been matched by resource reallocation in many areas (Canterbury an exception) Distraction of clinicians drowning in ever increasing transaction costs (time) of administering secondary care rationing (by product of HPW) Shared electronic health record (EHR) and patient portals not fully functional and not fully deployed
Further Questions to Consider
One size Fits All? Or...
Are Health Care Homes the ultimate solution to all our problems?
If they are, how should we proceed? Evolution or Revolution?