Health Care Home Lessons from the Vanguards Dr Jeff Lowe Shifting care Closer to Home How Do we Transform Te Papa Wellington 27 th February 2018
PERSPECTIVES Chair General Practice NZ HCH National Collaborative Governance Group HCH Governance and Oversight Groups CCDHB Director Karori Medical Centre
PATIENT STORY PRE HEALTH CARE HOME
Why Health Care Home? Ageing Burnout Complexity Demand Emerging Technologies
Why Health Care Home? UNSUSTAINABLE Not Just General Practice The Whole of Our Health and Care System N
Why Health Care Home? Current Model of Care is No Longer Fit for Purpose Loss of the Joy of Practice
International Themes Integration Moving Care closer to home Enhanced Models of Care Patient participation Restoring the Joy of Practice
The Answer?
Health Care Home Design Building Blocks/Principles
Alma Ata Declaration 1978
Barbara Starfield
DOMAINS Timely Unplanned Care Proactive Care for High Needs Routine and Preventative Care Business Efficiency Key elements of the model
IPAC CONFERENCE Wellington 2008 Wellington 2012 Matt Handley, Group Health Seattle Midlands Health Network
Fertile Land Policy and Legislation Strategies Structures Funding?
How to Build a Health Care Home BUILDING Renovation v Rebuild WORKFORCE Re-Purpose v Restructure BUDGET Joint Investment PHOs and DHB $14/pt $16/pt
Capital and Coast DHB Approach
Started Jul 2016 80% Coverage October 2018
Commitment not just involved
Early Results Look Good
FROM GOOD TO GREAT From My Survival to Survival of the System What Part can I Play
The Karori Medical Centre Experience
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KARORI MEDICAL CENTRE LIMITED 14,468 enrolled and funded 9% High needs Has Altered the way patients can comnicate with our and we can 5% Maoricommunicate with 3% PI our patients Practice Profile 16% Asian 9787 enrolled in MMH = 86 %, 6971 activated = 68%
14 GPs (8.25 FTE) KARORI MEDICAL CENTRE LIMITED Staff 8 Nurses Has Altered the way patients can comnicate with our and we can communicate 13 Support with our patients Staff(8.5FTE) Counsellor (1FTE) Practice Assistant
KARORI MEDICAL CENTRE LIMITED History of Innovation 1976 established 1984 computerised 1987 capitated 1993 IPA Has 2002 Altered PHO the 35,000 way patients patients can comnicate 2016 Health with Care our Home and we can communicate with our patients
The Manhattan Skyline
The Manhattan Skyline
PATIENT PORTAL PARTNERSHIP Has Altered the way patients can communicate with our and we can communicate with our patients Partners in care verses recipients of care
PATIENT PORTAL ACCESS Breaks the Constraints of the 15 min face to face appointment Easier Access to timely advice
MEANWHILE BACK AT KMC Culture for Change
The Path Enrolled Population and Community Timely Access Extended Range of Services Enhanced Workforce Facility Business Model and Funding Integrated into the Health and Care System To meet the challenges Now and in the Future
Welcome to the Karori Medical Centre KARORI MEDICAL CENTRE LTD
The Front Door to Karori Medical Centre
ACCESS Services *Sign Posting *Advice *Results *OpenNotes *Repeats *Appointments *e-consultations *telephone-consultations
CREATING CAPACITY
The Receptionist The Appointment Book The 15 Minute Appointment
THE TYRANNY OF THE 15 MINUTE APPOINTMENT
TRIAGE 100% Reception Nurse Doctor Creating on day Capacity to do the work that matters the most 25%
PATIENT PORTAL DEMAND UNPLANNED CARE Getting further up the pipeline of acute demand CAPACITY
Patient Portal 13% Patient makes appointment 6% Virtual consult prescription 6% Refer to other services Secure Emails Into Practise Virtual consult advice 35% 40% Refer to diagnostics SECURE EMAILS INWARD
THE BUILDING *Phones off the Front Desk *Standardisation of Clinical Rooms *Non clinical Co working space *LEAN *Extended Hours
WORKFORCE Knowledge and Expertise CURRENT WORKFORCE REPURPOSE Doctors Nurses Primary Health care Assistents TOP OF SCOPE Pharmacy Facilitator Health Care Co Ordinator Reception Manager Accountant PATIENTS SELF CARE
THE WORK *Doing the Work that matters the most *Minimise suffering *Minimise Burden on the System
SERVICE ELEMENTS
Extended Hours Reception Triage Doctor Triage Morning Huddle Extended service(poac) DVT, IV Cellulitis, Renal Colic and Retention, Minor Gynae Risk Stratification, Year of Care Planning On day appointments with Acute/Duty Doctor Team Boards Health Care Co Ordinator Patient Portal appointments, labs, repeats, open notes,secure e mails, e- consultation MDT Meetings Monitoring dropped call rate,tnaa, health targets, ED attendance, ASH rates
HEALTH CARE NEIGHBOURHOOD HCH MDT CSI ALLIANCE
1 2 3 4 Concerned she has osteoporosis DEXA scan ordered Discussion DEXA scan result ordered via MMH YOC Polypharmacy at risk of osteoporosis DEXA ordered Osteoporosis on DEXA IV zoledronic acid with Nurse Patient Story post HCH
Great Start to the Finished Product
Our approach to HCH programme In partnership with the local hospital Jointly funded GP practices applied and were selected against set criteria Gathering evidence and learning as we go Access to subject experts Detailed scoping the gap against national model of care requirements Support and guidance to write HCH implementation plan (inc. resources) Establishing regular monitoring meetings with practice HCH leads Plugging into peer support groups (both clinical & non-clinical Regular workshops and seminars as required
Becoming a HCH practice EOI Preparation phase HCH launch Business as usual Submission Evaluation Acceptance Readiness assessment & Scoping the Gap Workshops participation Initial necessary set up First 3 month targets Monthly visits Regular support (training, workshops) Resources Reporting Progress review
LEAN Peer Review sessions GPs/Nurses Peer group HCH visits Practice Managers Peer group A shared learning journey Trainings/workshops
Locking in accountability Agreed business rules (first 3-month achievement) Agreed health targets (8-month immunization and smoking brief advice) Monitoring progress against annual plan and budget expenditure A variety of reports e.g. quality indicator reports, Performance trend data, year two targets, etc.
Reports & results
Reports & Results (cont.)
Staff experience Overall improved efficiency To cope in times of great demand Role expansion & development Better workplace relationship Perceived better care for patients Higher satisfaction I m learning about things that I would not have had the opportunity to learn before I suppose the biggest change is always learning We are in a good place to handle times when we have decreased capacity with less impact on patients as we can provide other options of accessing care
Critical factors for a successful HCH implementation Clinical leadership & sponsorship Project Management Coordination & Collaboration Change Management Measurement & review Continuous quality improvement Access to knowledge & support
The HCH National Collaborative Group - Members ProCare Pinnacle Health Compass Health Pegasus Health Northland DHB alliance (Manaia and Te Tai Tokerau) Central PHO Hutt Valley DHB (Te Awakairangi & Cosine) Comprehensive Care Nelson Marlborough DHB (including Nelson Bays Primary Health and Marlborough PHO) WellSouth Primary Health Network Supporting organisations: GPNZ RNZCGP
The HCH National Collaborative Group - Background The HCH - elements of which were adopted from Group Health, US - was first introduced in NZ in 2011 at Pinnacle, MHN In 2015, a business case was prepared for MoH by the N4 (Compass, Pegasus, Pinnacle and ProCare) The business case requested funding over three years to support the establishment of the model, supplemented by PHO flexible funding.
What does the Collaborative offer? Programme support Access to HCH resources Credentialing and certification process Access to the national data set Access to PHO leads working group Learning symposium Standards development, accreditation and brand protection Advocacy for national investment Support for training, shared learning and problem solving between implementation teams
Where we are at Number of practices: 128 practices Population coverage: 845,187 patients Three members joined last year, and one newest member (WellSouth) joined last month International interest (LEAN conference at Stanford, Health Care Home Australia)
Where we are going HCH Certification Reaching a one-million coverage mark More members joining Increasing publicity: newsletter, websites, conferences, media, etc Collaborative projects: - HCH National Dataset - Reviewing HCH Model of Care Requirements - HCH Patient Experience Survey
HCH sign-off process Credentialing Certification Accreditation Implementation plan to achieve HCH indicators at level 4 Providing GP triage and alternatives to face-to-face consults Same-day appointment available Call management Extended hours Patient portal in place Credentialing criteria Population stratification and proactive care planning introduced Progressing all four domains