Review of the Implementation of Care Plus

Review of the Implementation of Care Plus 22 August 2006

Published in December 2006 by the Ministry of Health PO Box 5013, Wellington, New Zealand ISBN 978-0-478-30714-6 (Internet) HP This document is available on the Ministry of Health s website: http://www.moh.govt.nz

CONTENTS ABBREVIATIONS...IV EXECUTIVE SUMMARY... 1 BACKGROUND... 1 IMPLEMENTATION... 1 WHO IS GETTING CARE PLUS?... 2 IMPACT... 2 DISCUSSION...3 1 BACKGROUND... 6 2 DESIGN OF THE CARE PLUS IMPLEMENTATION REVIEW... 8 3 IMPLEMENTING CARE PLUS... 11 PROVIDER PERSPECTIVES... 13 Attitudes to Care Plus...14 Uptake of Care Plus...15 Identifying potential Care Plus patients...15 DHB PERSPECTIVES... 16 DESCRIPTION OF SERVICE DELIVERY MODELS... 17 Payment structures and service models...17 Impact of funding changes...20 Teamwork...21 PROVIDER SURVEY... 22 4: WHO IS GETTING CARE PLUS NOW?... 27 PRACTITIONERS VIEWS... 27 DHB PERSPECTIVE... 28 NATIONAL DATA... 29 PRACTICE DATA... 30 Hospital discharges profile...34 HUHC patients to Care Plus...35 ESTIMATING THE POTENTIAL CARE PLUS POPULATION... 36 IS THE CURRENT CARE PLUS FORMULA FAIR?... 39 Comparative characteristics of Care Plus patients...39 5 IMPACT OF CARE PLUS... 41 PATIENTS PERCEPTIONS OF CARE PLUS: IN-DEPTH SURVEY... 41 PATIENTS PERCEPTIONS OF CARE PLUS: BRIEF TELEPHONE SURVEY... 42 PROVIDER PERSPECTIVES... 45 PRACTICE DATA... 45

Consultation rates...45 Quality of primary health care...46 OUTPATIENTS AND EMERGENCY DEPARTMENTS (EDS)... 47 HOSPITAL DISCHARGES... 48 6 CONCLUSIONS AND IMPLICATIONS... 49 THE ROLE OF THE MINISTRY OF HEALTH AND DHBS... 50 THE ROLE OF PHOS AND PRACTICES... 51 NATIONAL FUNDING... 52 DELIVERING CARE PLUS IN THE PRACTICE... 53 WHO GETS CARE PLUS?... 56 THE KEY ROLE OF NURSES... 57 APPENDICES... 60 APPENDIX 1: SUMMARY OF FINDINGS FROM PILOT EVALUATION.... 60 APPENDIX 2: REVIEW METHODS... 63 APPENDIX 3: CARE PLUS CONDITIONS... 69 APPENDIX 5: QUALITATIVE RESEARCH REPORT... 73 APPENDIX 6: PATIENT SURVEY: SUMMARY OF RESPONSES... 74

Tables Table 1: Care Plus enrolments at April 2006...13 Table 2: Payment structures...18 Table 3: Features of payment structures...19 Table 4: Provider survey response rate...22 Table 5: Care Plus patients, by age and ethnicity...29 Table 6: Access and Interim Care Plus rates, by ethnicity...30 Table 7: Practice sample Care Plus rates, by ethnicity...31 Table 8: Practice sample Care Plus age by ethnicity breakdown...31 Table 9: Care Plus criteria...32 Table 10: Care Plus conditions...33 Table 11: Care Plus conditions...34 Table 12: Hospital discharge profile...35 Table 13: Estimated seven most common chronic conditions...37 Table 14: Number of chronic conditions...37 Table 15: Potential Care Plus population revised estimates...38 Table 16: Care Plus patient clinical need surrogates...39 Table 17: PMS-based Care Plus allocation table...40 Table 23: Care Plus impact on consultation rates...46 Table 24: Sample prescribing data for patients with diabetes...46 Table 25: Prescribing quality-of-care indicators...47 Table 27: Care Plus impact on hospital admission rates...48 Table 28: Summary of practitioners suggestions for improving Care Plus...55 Figures Figure 1: Care Plus recruitment, number of patients...13 Figure 2: Expected Care Plus and HUHC shifts...24

Abbreviations CCM DHB ED GP HUHC OP PHO PMS chronic care management District Health Board emergency department general practitioner High User Health Card outpatients primary health organisation patient management system

Executive Summary Background Care Plus was rolled out nationally on 1 July 2004 as a new primary health care initiative targeting people with high health needs due to chronic conditions, acute medical or mental health needs, or terminal illness. The programme aims to improve chronic care management, reduce inequalities, improve primary health care teamwork and reduce the cost of services for high-need primary health users. To be eligible for Care Plus funding a patient has to meet specified criteria. Funding is provided to primary health organisations (PHOs) based on a capitation formula and distributed by PHOs to practices in a variety of arrangements. Implementation The concept of Care Plus is supported by most practices (general practitioners and nurses), by PHOs and by District Health Boards (DHBs). Eighty percent of PHOs were delivering Care Plus in some or all of their practices by April 2006. Significant resources are needed for setting up Care Plus, to identify patients that may be eligible for the service and to establish clinical and business processes for delivering Care Plus, both within a practice and at the PHO level. Even in practices that have been delivering Care Plus for some time, enrolment growth has been much slower than expected. By April 2006 only 39 percent (range 3 to 122 percent) of predicted eligible 1 patients were enrolled in PHOs that had started Care Plus. Funding models employed by PHOs varied widely. All PHOs received funding according to the national agreement, but varied in the extent of the initial practice payment and how the per visit reimbursement was distributed to the member practices. Although PHOs receive 50 percent up-front funding, ongoing PHO income is dependent on adequate enrolments and HealthPac accepting practice claims. Patient co-payments cited by the practices surveyed ranged from 0 to $42 (242 randomly selected practices). The mean was $6.61, and the median was zero. Eight percent of practices charged more than $30 for a Care Plus visit. Patient co-payments ranged from 0 to $20 in the patient survey (300 patients from 30 practices). Care Plus is equally likely to be delivered by doctors and nurses, either solely or in combination. Eighty-seven percent of practices give patients a Care Plan. Two-thirds of practices surveyed run Care Plus in conjunction with a chronic care management (CCM) programme. 1 Eligible patients means the estimated maximum number of potential Care Plus patients for which a PHO received Care Plus funding according to the Care Plus funding formula. Evaluation of the roll out of Care Plus p 1

Although there was support for the concept of Care Plus, many practices felt that it is administratively complex, not flexible enough and under-funded (surveyed practices felt a payment of $290 to the practice would meet most concerns about funding). Who is getting Care Plus? Practitioners reported that Care Plus is being targeted at patients with chronic high need. According to DHB and PHO interviewees, easy-to-contact patients are probably enrolled first, so there may be some bias towards patients who already have reasonable access to care within this group. Care Plus may not be well suited to patients who need intense interventions (more than four per year). Māori and Pacific patients appear more frequently than their population rates in Care Plus enrolments, as would be expected from known greater need. Care Plus is generally not being used as a replacement for the High User Health Card (HUHC), although this was an early Ministry of Health expectation. The commonest Care Plus entry criterion is two-plus chronic conditions. Diabetes and ischaemic heart disease are the commonest chronic conditions. Some commonly recorded Care Plus chronic conditions may not have been originally anticipated (eg, hypertension, elevated lipids). A previous estimate 2 of approximately 8 percent of the population being eligible for Care Plus was confirmed. The age, gender and quintile distributions of the current Care Plus funding formula were broadly confirmed in an analysis of patient management system (PMS) data from 30 sample practices. Impact Patients felt their care had improved, and in particular that it was more structured. Most patients appreciated having dedicated time specifically to talk about their condition, rather than having discussion about the condition as part of a wider general consultation. Eighty percent of patients received a written Care Plan. Once enrolled in Care Plus, consultation rates increased by an average of four visits per annum compared with the previous year. Based on an analysis of prescribing patterns for specific chronic conditions there is as yet no clear evidence of improvements in prescribing quality for Care Plus patients. Hospital admissions for those enrolled in Care Plus rose 40 percent in the following year. This may have been due to improved monitoring of conditions (and subsequent appropriate referral) and/or the natural history of certain chronic illnesses. 2 CBG Health Research, Care Plus Investigation: Estimating case loads, Prepared for Ministry of Health, 2003. Evaluation of the roll out of Care Plus p 2

Discussion The slow uptake of Care Plus, the relative complexity of care delivery with written Care Plans and changes in practice processes and the difficulties some PHOs have experienced managing cash flow mean that Care Plus has taken longer than expected to become incorporated into the day-to-day delivery of primary health care. Nevertheless, the programme is regarded positively by most PHOs, practices, practitioners and patients, and does fill a gap in the range of subsidised services that have been offered by primary health care. Although uptake has been slower than expected, the patients who are enrolled in Care Plus appear to be from the major intended recipient groups, especially those with chronic illness. However, Care Plus is probably not the best method of improving access for patients who need intensive interventions requiring multiple primary health care contacts over a short period of time. Limited funding per patient, and limited space, time and nursing staff, may be reducing the potential uptake and impact of Care Plus. Mechanisms for encouraging the use of pooled resources could be explored, such as providing incentives for PHOs to maintain a Care Plus workforce and operating via referrals or practice visiting. The average fee for a Care Plus visit charged by the sampled practices was $6.However, with some patient co-payments of up to $45, some patients on Care Plus may still be facing a significant financial access barrier. Many practices are embracing a more team-oriented approach to delivering chronic care, which has the potential to lead to improved outcomes, and continued funding through Care Plus will support this paradigm shift. In an environment where some patients without subsidies can be charged high fees (eg, $65) for a consultation, it is only to be expected that some practices will use Care Plus to subsidise a patient visit. In this case the income to the practice might stay the same the only thing that has changed is the fee barrier faced by the patient. The extent to which improved quality of care is delivered depends on the balance between these competing uses for the funding: how much of the extra resource provided by Care Plus is used to reduce co-payments, increase profit or provide increased resources. Given that increased funding for primary health care is provided from other sources (e.g., extending increased subsidies to adults aged 45 64 years), we would expect to see increased Evaluation of the roll out of Care Plus p 3

opportunities for more fully implementing those aspects of Care Plus that relate to improved quality of clinical care. It has been noted throughout this review that Care Plus seems to work best, in terms of improved care, when linked to a CCM programme. It was suggested by DHB and PHO interviewees that this might be because of the increased structuring of care that formal CCM programmes require. If Care Plus were to continue it would be worth considering whether some specific elements should be required in order to qualify for funding. Enrolment in a CCM programme could be one requirement, or at least the construction of a detailed Care Plan, possibly with specified components. Although a structured CCM programme is useful for patients with specific conditions, it would also be important to have a generic template available for other Care Plus patients. There will always be high-needs patients (eg, mental health patients or those with disabilities) who do not fit into rigid templates, and such an approach would not be desirable for many conditions. In addition, some chronic conditions would be too rare to warrant a detailed template. However, even a generic template could provide a useful structure for CCM (e.g., for exploring access to social welfare benefits, screening for depression, medication review). Although many providers felt that the level of overall funding for Care Plus should be increased, this review has not found any strong evidence to suggest the Care Plus funding model itself should be significantly altered. Some providers reported difficulties managing cash flow, which might be helped by larger payments, but the general concept of up-front establishment payments was supported, and subsequent staged payments over the year seems sensible (and consistent with all other funding). Earlier estimates of Care Plus numbers have been confirmed, and the general structure of the Care Plus funding matrix has also been validated. It seems clear that Care Plus does not always overlap well with the perceived needs of HUHC patients. Many HUHC patients are regarded as requiring frequent monitoring or episodic care, even if they have a chronic condition. This suggests that it may be desirable to maintain a separate funding stream for these patients, although it may be possible to incorporate these patients into the general capitation funding calculation. In view of the significant concerns about administration overheads and other transaction costs, it may be more efficient to add Care Plus payments to capitation funding, and pay them at some proportion of the estimated total uptake, with regular review of the evidence for improved care from practice data sources, possibly monitored through an enhanced performance management framework. Evaluation of the roll out of Care Plus p 4

The philosophical thrust of Care Plus, as a mechanism for facilitating care planning and increasing primary health care teamwork, probably requires a broader range of sector interventions than the current Care Plus initiative. It is notable here that one of the recommendations from providers was that Care Plus visits be aligned with medication repeat visits. Unless a nurse is merely handing a standing order to a general practitioner (GP) to sign, this should be an opportunity to titrate medication 3 while reviewing overall management, and this requires prescribing rights. Primary health care nurses need access to short, affordable training courses to allow them to deliver chronic care services most effectively including prescribing. For many patients with chronic conditions, physical access to services is difficult. This also suggests that the development of the nurse home visitor role to undertake chronic care management in the home, which is often the best place to undertake comprehensive needs assessments, could be valuable. A large proportion of chronic care management is concerned with developing strategies to live with a condition, and an assessment of the living situation including social supports, family dynamics and physical environment is often essential. 3 Titration involves adjusting the dose of the medication until the desired effect is achieved. Evaluation of the roll out of Care Plus p 5

1 Background Care Plus was rolled out nationally on 1 July 2004 as a new primary health care initiative targeting people with high health need due to chronic conditions, acute medical or mental health needs, or terminal illness. The programme aims to improve chronic care management, reduce inequalities, improve primary health care teamwork and reduce the cost of services for highneed primary health users. To be eligible for Care Plus a patient must be enrolled with a PHO and meet a number of criteria, as follows. The potential Care Plus patient is assessed by a doctor or nurse at their general practice as being able to benefit from intensive clinical management in primary health care (at least two hours of care from one or more members of the primary health care team) over the following six months, and either: has two or more chronic health conditions, so long as each condition is one that: is a significant disability or has a significant burden of morbidity; and creates a significant cost to the health system; and has agreed and objective diagnostic criteria; and continuity of care and a primary health care team approach has an important role in management; or has a terminal illness (defined as someone who has advanced, progressive disease whose death is likely within 12 months); or has had two acute medical or mental health-related admissions in the past 12 months (excluding surgical admissions); or has had six first-level service or similar primary health care visits in the past six months (including emergency department visits); or is on active review for elective services. PHOs receive Care Plus funding as a separate funding stream. The amount a PHO receives is determined on the basis of estimated numbers of Care Plus patients, which is calculated from the size and demographic profile of a PHO s register. Nationally, funding has been allocated to cover 5 percent of the population, but this varies at the PHO level from 3.2 to 9.5 percent. The exact form in which Care Plus is being delivered varies from PHO to PHO, and even from practice to practice within a PHO. In general, a Care Plus patient can expect to receive an extended initial appointment with a nurse or doctor, in which their health needs are explored in more depth than is possible in a normal consultation. One of the features of this consultation will Evaluation of the roll out of Care Plus p 6

be the development of a Care Plan. After this initial consultation, it is expected that a patient will be seen on at least a further three occasions over the next year, usually to monitor their ongoing care. Care Plus was developed as a result of a proposal from the Independent Practice Association Council (IPAC) in 2002 to improve access to services for people with high health care needs who might be relatively disadvantaged by the newly established Access and Interim PHO funding formulas. The scheme was originally conceived as a method of delivering targeted funding at priority patients. The Ministry of Health worked closely with provider groups, and IPAC in particular, to develop the Care Plus proposal into the form in which it was rolled out to PHOs. Key events in developing Care Plus were 4 : the development, in consultation with IPAC, of preliminary proposals for service delivery and funding based on the distribution of high-needs patients, derived by examining general practice records in three PHOs during 2003/04 external evaluation of the pilots three reports: September 2003, December 2003 and March 2004 (see Appendix 1) setting up the Care Plus reference group in October 2003, with membership from PHOs (both Interim and Access), District Health Boards New Zealand, Royal New Zealand College of General Practitioners, Independent Practice Associations, First Health, Net Care and Health Care Aotearoa to advise on service specifications, a funding formula and a process for national roll-out running six Ministry-led regional workshops to help prepare PHOs and DHBs for Care Plus in South Auckland, West Auckland, Rotorua, Wellington, Christchurch and Dunedin during March 2004 using feedback from individual pilots, workshops and evaluations to fine-tune the Care Plus funding formula and services specifications a joint PHO, DHB and Ministry of Health agreement to changes to contracts for Care Plus (April and July 2004) 25 PHOs entered the three-month preparatory phase for Care Plus on 1 April 2004. By 1 July 2004, 43 out of 73 PHOs were being funded at some stage of Care Plus development. At that stage the Ministry commissioned a review of the national implementation of Care Plus, which was carried out by CBG Health Research, after some delays due to the slow roll-out of Care Plus, between November 2004 and May 2006. 4 See: http://www.moh.govt.nz/primaryhealthcare Evaluation of the roll out of Care Plus p 7

2 Design of the Care Plus Implementation Review This review of the implementation of Care Plus was commissioned by the Ministry to get answers to three broad questions: Is Care Plus reaching those individuals with high primary health care need? What are the effects of the Care Plus programme? What are the best ways of organising and delivering Care Plus services? Prior to undertaking this review of the national implementation of Care Plus, CBG completed a review of the 2003/2004 Care Plus pilots. A summary of the findings is provided in Appendix 1. The key issues for the roll-out, as perceived by practitioners then, were: the payment for the time required to deliver Care Plus as intended, including Care Plans and in-depth reviews of conditions, was not sufficient. for some practices there was no financial incentive to change HUHC patients to Care Plus delivery of Care Plus required significant training of nursing staff in some practices there was resistance to allowing nurses to practise autonomously the transfer of HUHC patients to Care Plus meant loss of prescription subsidies. The level of patient involvement in Care Plus expected by practitioners varied from practice to practice. The main barriers to implementation experienced in the pilots were described as the large time commitment required for both patients and practitioners, patient lack of interest in intensive monitoring, and the lack of staff to deliver Care Plus services. Two patient groups were identified as less likely to engage with Care Plus: older males and the very elderly. Most practices thought there should be a Care Plus nurse co-ordinator at the PHO and/or national level. The majority of pilot practices thought that Care Plus was not an easy scheme to run in the busy and time-restricted environment of general practice. Getting the right staff involved in the Care Plus programme at a practice level was the strongest determinant for successful implementation. Nurses appeared to take a lead in care planning in most practices, but the input of GPs and nurses in Care Plus visits, particularly reviews, was varied and constrained by funding, time, and the extent to which practices supported autonomous nursing practice. Establishing the number of nursing and GP hours required in relation to patient numbers and implementing a plan to stagger the introduction of the programme were also seen as factors contributing to success. Evaluation of the roll out of Care Plus p 8

During the pilots, some practices experienced problems with patient drop out, sometimes as high as 50 percent at the follow-up review stage. The reasons for this included lack of active recall for review appointments, negative perceptions of nursing consultations, and Care Plus being offered at limited times because of the need for extra nursing cover. While these findings contributed to the design of the current project, this national implementation review is focused on how well Care Plus is reaching those individuals with high primary health care needs, and on understanding the overall impact of the programme. Data were collected from: patient focus groups PHO case studies DHB interviews Ministry of Health interviews key informant interviews with practices in participating PHOs PMS and clinical management analyses PMS data extract correlation with hospital discharge data in the National Minimum Dataset secondary care utilisation review from hospital records (emergency departments and outpatients) a computer-assisted telephone survey (CATI) of 300 patients a survey of 250 providers. More details on the methods employed are provided in Appendix 2. The selection of the PHO and practice participants for the focus groups and interviews was undertaken in consultation with the Ministry, in order to get a representative sample of providers covering small and large PHOs, Access and Interim, and urban and rural. Twelve PHOs were chosen, and within each PHO a practice was invited to take part in the focus groups to explore how Care Plus was implemented on the ground. Practices invited 24 Care Plus patients to take part in four patient focus groups to describe their experience of Care Plus. Representatives of the seven DHBs that contracted with each PHO were also interviewed. All qualitative research was conducted by an experienced researcher who was familiar with the development of Care Plus. The findings of interviews were supplied to participants for validation. From each PHO two to three practices were chosen to build a sample of 30 practices for further research. Each of these practices invited the next 10 Care Plus patients they saw, after a nominated start date, to take part in a phone interview with a researcher, for which they received a small koha. These same practices provided downloads of data from their PMS, which could be used to assess the impact of Care Plus and how well it was achieving its original Evaluation of the roll out of Care Plus p 9

goals in terms of targeted assistance. National Health Index numbers were forwarded to the New Zealand Health Information Service to extract hospital discharge dates and codes for registered patients of these practices from the National Minimum Dataset. This data was used to assess the impact of Care Plus on secondary care utilisation, and specifically on ambulatorysensitive hospitalisations. These same National Health Index numbers were supplied to the seven DHBs, and a record of outpatient (OP) and emergency department (ED) attendances was requested. The last piece of research was a survey of 250 randomly selected general practices, asking questions about the implementation of Care Plus in each practice. Evaluation of the roll out of Care Plus p 10

3 Implementing Care Plus Key points The concept of Care Plus is supported by most practices (GPs and nurses), PHOs and DHBs. Eighty percent of PHOs were delivering Care Plus in some or all of their practices by April 2006. Significant resources are needed for setting up Care Plus to identify patients who may be eligible for the service and to establish clinical and business processes for delivering Care Plus, both within a practice and at the PHO level. Even in practices that have been delivering Care Plus for some time, enrolment growth has been much slower than expected. By April 2006 only 39 percent (range 3 122 percent) of predicted eligible 5 patients were enrolled in PHOs that had started Care Plus. Funding models employed by PHOs vary widely. All PHOs receive funding according to the national agreement, but there are variations in the extent of the initial practice payment and how the per visit reimbursement is distributed to the member practices. Although PHOs receive 50 percent up-front funding, ongoing PHO income is dependent on adequate enrolments and HealthPac accepting practice claims. Patient co-payments cited by practices surveyed ranged from 0 to $42 (242 randomly selected practices). The mean was $6.61, and the median was zero. Eight percent of practices charged more than $30 for a Care Plus visit. Patient co-payments ranged from 0 to $20 in the patient survey (300 patients from 30 practices). Care Plus services are equally likely to be delivered by doctors and nurses, either solely or in combination. Eighty-seven percent of practices give patients a Care Plan. Two-thirds of practices surveyed run Care Plus in conjunction with a CCM programme. The Ministry devoted significant resources to helping DHBs and PHOs to implement Care Plus. As mentioned earlier, the concept itself was originally proposed by IPAC, and the details of the Care Plus programme were developed in close collaboration with the Care Plus reference group, representing a wide range of health sector stakeholders. The Ministry held a series of workshops around the country to assist DHBs and PHOs with their Care Plus planning. All publications, discussion documents and summaries of the workshop findings were available on the Ministry of Health website. 5 Eligible patients means the estimated number of potential Care Plus patients for which a PHO received Care Plus funding according to the Care Plus funding formula. Evaluation of the roll out of Care Plus p 11

Before a PHO could receive Care Plus funding they were required to undertake a three-month preparatory period. PHOs received a small base allocation ($11,000) plus $1.14 per eligible PHO enrollee to assist them with the required tasks, which were to: set up PHO systems including PHO-wide billing systems for claiming Care Plus payments, training PHO staff about Care Plus, (in some cases) developing Care Plan templates, and establishing teams to help practices deliver Care Plus set up practice systems including systems for identifying patients, setting up Care Plus clinics, and establishing protocols for Care Plus reviews help identify Care Plus patients constructing lists of possible Care Plus patients, either from practitioner memory of patients or from queries of PMS (this often involved merging various sources of information and was not necessarily an easy task) train practitioners particularly when implementing CCM programmes, so that practitioners knew how to complete Care Plans, print them out and fill in templates complete business plans (for subsequent approval by the DHB) notify and consult on fees to reach agreement between PHOs and practices on the schedule for payments (these were wide and varied) complete, and have approved by the DHB, a Care Plus plan. Twenty-five PHOs entered the three-month preparatory phase for Care Plus on 1 April 2004, and by 1 July 2004 43 out of the then 73 PHOs were being funded at some stage of Care Plus development. When a PHO commenced delivering the Care Plus programme they were paid 50 percent of the annual allocation according to the funding formula 6 up-front, with payment of the remainder contingent on Care Plus enrolment rates. Growth in Care Plus enrolments has been steady, although slower than anticipated, as discussed later in this section. By April 2006 64 out of the then 81 PHOs had commenced the programme, and in those PHOs 39 percent of the estimated eligible patients had been enrolled in Care Plus. The following table shows the populations in these groups of PHOs. Seventy-nine percent of all registered patients in New Zealand were enrolled in a PHO that had started Care Plus; nationally 32 percent of the estimated number of Care Plus patients were enrolled. The residual column is calculated as the number of estimated Care Plus patients, less the number of HUHC patients. 6 See Appendix 4 for details of the Care Plus funding formula. Evaluation of the roll out of Care Plus p 12

Table 1: Care Plus enrolments at April 2006 N Population Eligible 1 CP HUHC Residual Care Plus not HUHC Enrolled Care Plus 2 % eligible enrolled All PHOs 81 3,909,791 212,178 63,447 148,731 46,959 32 Care Plus PHOs 64 3,128,001 166,865 45,890 120,975 46,959 39 Care Plus PHO data as % of all 79% 80% 79% 72% 81% (100%) N.a. 1 Eligible means the Care Plus population a PHO is funded for under the current funding formula (approximately 5.4 percent of the PHO population). 2 Care Plus patients are only from PHOs delivering Care Plus; the top line shows the uptake of Care Plus based on the nationally eligible population (ie, all PHOs). The pattern of enrolment is shown in Figure 1. Different numbers of PHOs contribute to each bar as more PHOs rolled out Care Plus (42 in January 2005, increasing to 64 in April 2006). Figure 1: Care Plus recruitment, number of patients, for PHOs implementing Care Plus Percent of target 50 40 30 20 10 0 Jan 05 Apr 05 Jul 05 Oct 05 Jan 06 Apr 06 The rate of uptake of Care Plus nationally reflects both the size of the PHOs that commenced Care Plus at various times and their rate of uptake. Provider perspectives Focus groups and interviews were held with the doctors and nurses providing Care Plus (see Appendix 2 for full details of the methods used). Evaluation of the roll out of Care Plus p 13

Attitudes to Care Plus Overall, practices and PHOs were very supportive of the concept of Care Plus. It was viewed as a significant improvement in the delivery of primary health care, providing access to services it had not been previously possible to access, or financially viable for practices to provide. We can get them in more regularly, and ensure that they get the care and medications at the same time. However, participants differed in their views of the purpose of the programme. Some of the doctors and nurses interviewed regarded Care Plus as an important case management initiative that could enhance the patient practice relationship and could become the basic model for delivering all chronic care. Others perceived that it was simply offering low-cost access to GP services for chronic care patients. In this instance, there appeared to be more interest in Care Plus as a funding stream as opposed to a system of care. Many participants perceived the programme as being a link between Access- and Interimfunded practices, which meant all practices could offer increased access for high-needs patients. We have been right behind it from the start. It s a bridge between Access and Interim funded practices. Practices and PHOs varied greatly in their organisation and delivery of Care Plus. Most described a nurse/gp-focused model, with varying degrees of involvement of other professionals. Some explained that Care Plus is nurse driven, with GP input. Others described Care Plus as GP driven, with or without the help of nurses. At the practice level practitioners often planned Care Plus visits to coincide with patients medication requirements. PHOs varied in the priority they assigned to Care Plus as a replacement for HUHC. Some reported that it had not been a high priority relative to other initiatives, and that they had not actively encouraged the transfer of HUHC patients onto Care Plus. Others viewed Care Plus as a higher priority, and provided funding incentives to encourage practitioners to transfer HUHC patients. These were the organisations that strongly supported Care Plus as a new model for chronic care. At the time of provider interviews (late 2005), seven of the twelve selected PHOs were implementing Care Plus as part of an existing or new CCM programme. The programme was typically targeting people with diabetes, chronic obstructive pulmonary disease, cardiovascular disease, asthma and arthritis. Evaluation of the roll out of Care Plus p 14

Uptake of Care Plus PHOs reported wide variations in the proportions of practices delivering Care Plus (25 to 96 percent), and within practices there were even wider variations in practice enrolment figures (0 to 80 percent of estimated Care Plus patients). There is no doubt that overall the uptake of Care Plus has been slower than anticipated. Participants thought that practices with some spare capacity (ie, not extremely busy), good IT systems, experience with other chronic care programmes, and enthusiastic practice staff more readily embraced Care Plus. Practices with more limited resources, including IT and nursing staff, had been slower and required more support to start the programme. PHOs that had been involved in the Care Plus pilots have higher rates of enrolment and more developed Care Plus systems. All of these organisations had linked Care Plus to a CCM system. Some had previously failed to reach quarterly targets, but at the time of interview most expected to have enrolled their full quota within the next six months. Identifying potential Care Plus patients Most practices used their knowledge of their patients and information contained in the PMS to identify eligible patients. The selection of Care Plus patients is mainly left to the practitioners, who described some use of subjective criteria when choosing patients for Care Plus. Most explained that they would usually consider social status and patients own motivation to decide who would most benefit from reduced fees or the Care Plus approach. The doctors pick them up through their records when they come in. It s also who can afford to come and who can t. It s targeting those people that can t afford to come to the doctor. The majority of practitioners reported that they had opportunistically recruited Care Plus patients when they presented for routine visits or telephoned to obtain a prescription. They saw the advantage of this method being that it fits within current practice workloads. The key disadvantage was the extra time required to manage the introduction of the concept within the scheduled consultation period For us it s been opportunistic but some have targeted and invited using the systems. Few PHOs and practices reported specifically inviting patients, by letter or phone call, to enrol in the programme. Of those that did send out invitations, most felt that few patients had responded immediately, but that they or the practitioner had instigated the enrolment at the next surgery visit. We did send out letters to the eligible patients as a first step. Then, they would come in to see the doctor and usually they would then be recruited. Evaluation of the roll out of Care Plus p 15

To date, organisations advised that the chronic care enrolment criteria (more specifically, the conditions diabetes, chronic obstructive pulmonary disease, cardiovascular disease, asthma and arthritis) are commonly used to enter patients into the programme. PHO managers also advised that practitioners have enrolled patients who have had hospital admissions and/or are awaiting elective surgery. However, there appears to be little or no active use of ED/hospital lists, as few organisations had received them from hospitals/dhbs. Participants said they preferred to select from PMS or practice knowledge of the patients. The chronic conditions has been by far the most popular criteria a small number of elective services waiting criteria. This was a very natural use of quarterly visits, given that prescriptions for chronic illnesses are usually issued every three months. If Care Plus visits didn t coincide with re-issuing prescriptions, the patient would need a further visit, or at least a phone contact, to have their medication renewed. In addition, the issuing of new prescriptions is the natural time to discuss medication dose titration or other alterations. DHB perspectives Representatives from the seven DHBs contracting with the 12 PHOs selected for closer study were interviewed. DHB representatives were also supportive of Care Plus as a concept. They generally regarded it as a fairly centrally driven initiative (ie, from the Ministry), with limited input from DHBs. The views of the DHB representatives mirrored the range of views from PHOs and practices: some viewed it as an important disease management approach, while others treated it simply as a mechanism to lower the cost of GP access. DHB representatives felt that the definition of Care Plus is critical. They reported that PHOs that had regarded Care Plus as a mechanism to lower access costs had not seriously focused on implementing teamwork and/or a patientcentred / care-planning approach. Most reported that within the DHBs, staff expected the programme would become increasingly important because of its association with chronic care. Four of the seven DHBs had approved Care Plus as part of their CCM programmes. These organisations expressed the most support for Care Plus. Representatives from regions where no such CCM/Care Plus alignments were apparent were not as supportive of the programme. These participants reported lower levels of PHO engagement and commonly felt Care Plus implementation had come on top of a range of other Evaluation of the roll out of Care Plus p 16

services. This group conveyed that they left the PHOs to decide whether to be involved in Care Plus without attempting to persuade them in any way. Some participants reported that Care Plus had met with some cynicism because of IPAC s involvement in its conception. These representatives felt that DHBs were not sufficiently included in the early discussions and subsequent negotiations with PHOs. They perceived that, following the non-performance of many PHOs, the Ministry had handed Care Plus problems over to regional bodies. DHB representatives were able to report on the progress of all PHOs in their regions. They all reported that PHOs in their areas were at different stages of organising and delivering Care Plus, and were doing so under various service models and with different levels of success. They explained that the majority had fallen below targets, with few exceeding them. Commonly, participants observed that many organisations who were implementing the philosophy of Care Plus as a system of care delivery were requiring more time to embed it into general practice. Description of service delivery models Payment structures and service models PHOs differed in the way they were administering Care Plus funds to practices. Patient copayments ranged from no charge to $20 per visit, and some practices charged less than the possible maximum fees agreed with PHOs. They pay $14. We are Interim funded, so that is really good. Not all practices and PHOs were willing to provide details of Care Plus co-payments and/or the precise amounts paid to practices with respect to the payment structure. Some PHOs simply stated that the fees were within the Ministry specifications and patient co-payments were not above $20 per visit. The two tables below outline the different payment models. Table 2 outlines the payment structures in order of complexity, along with the stated rationale for the system. Table 3 relates the models to the size of the PHO, alignment with any CCM system, degree of teamwork, and level of financial risk to the PHO. Evaluation of the roll out of Care Plus p 17

Table 2: Care Plus Payment structures Simple models Payment structure Rationale for use Equal fee-forservice payments P Up-front loaded; two payments per annum E Up-front loaded; fee-for-service payments P Practices are paid equal amounts for each visit. Payments made on a quarterly basis are based on one initial invoice detailing enrolment. Practices are paid a large initial payment ($150) to enrol patients and complete the first visit based on one initial invoice detailing enrolment. They then receive one further payment to cover follow-up visits. Practices are paid a large initial payment to enrol patients ($80) and complete the first visit. Smaller subsequent quarterly payments are paid on submission of invoices for each visit. The model was selected to reduce the amount of paperwork for practices and to simplify the administration from the PHO s perspective. The model was used exclusively by very small PHOs to reduce the administration workload. Staff perceived that the larger first payment would encourage nursing input into the initial stages of Care Plus. Staff perceived that this model had encouraged nursing input into the initial stages of Care Plus. More complex models One up-front capitation payment for practices Care Plus quota ($30 per patient); four equal feefor-service payments P visit. Mixed fee-forservice and capitation model E Up-front loaded; mixed fee-forservice CCM and Care Plus payment E and P Up-front loaded; uncapped fee for-service model for Care Plus patients without other subsidies Flexible funding for extra services Practices receive an up-front capitation payment, based on their allocated Care Plus quota and on signing a memorandum of understanding to undertake the programme. Subsequently, practices are paid equal amounts for each visit on submission of invoices for each Practices receive a quarterly fee for Care Plus. The PHO also provides them with a capitation top-up to give HUHC capitation for all Care Plus patients. Practices receive a large initial payment to enrol patients in CCM and/or Care Plus and complete the first visit and CCM templates. Smaller subsequent quarterly payments are paid on receipt of an invoice. Practices are paid a larger initial payment ($45) to enrol patients and complete the first visit. Smaller subsequent quarterly payments ($20) are paid on submission of invoices for each visit. Practices receive extra monies ($15) per visit for Care Plus patients without other subsidies. At any stage in the Care Plus process, practices can claim extra service The model was perceived to be uncomplicated for the practices who forward a monthly invoice for Care Plus. The initial capitation payment was seen to cover a practice s fixed overheads and encourage the employment of any extra staff. The alignment of this payment to a signed memorandum of understanding was advocated as a way to formally obtain a practice s buy in to complete the programme. This is a model used by larger organisations that have merged Care Plus and HUHC funds to give practices capitation payments. In this way, they ensure that practices can earn exactly the same amount for Care Plus as they would for HUHC. This model was selected to encourage practitioners to enrol CCM patients onto Care Plus (there is a higher payment for dual enrolment, as opposed to Care Plus only). Care Plus funding forms the basis of the CCM system funding. This model was used by larger organisations that have merged Care Plus and HUHC funds to give practices capitation payments. In this way, they ensure that practices can earn exactly the same amount for Care Plus as they would for HUHC. The model also ensures that all patient copayments are the same as those for Community Services Card holders. It also provides for the involvement of other professionals and services in Care Plus, through the flexible funding of extra services. Evaluation of the roll out of Care Plus p 18

payments of $80 per patient to purchase extra services. E Practices could elect to group the extra service payments for all Care Plus patients. Notes: E = electronic-based claiming system; P = paper-based claiming system. Table 3 shows that the more complex payment structures were devised by the larger PHOs, who have commonly aligned Care Plus with an existing or new CCM system. However, some smaller PHOs are involved in more complex payment structures because of Care Plus/CCM alignment, while some of the larger organisations have opted for simple payment structures with the aim of reducing the administration burden. Table 3: Features of payment structures Model PHO size* CCM system: yes/no Equal fee-for-service payments Level of teamwork Small and large No Low High Level of financial risk held by PHO Up-front loaded, two payments per annum. Up-front loaded; fee-forservice payments More complex models One up-front capitation; equal fee-for-service payments Mixed fee-for-service and capitation model Small No Low but evidence of nurse involvement Small and medium No Low but evidence of nurse involvement High Medium Medium Yes High High Large Yes High High Up-front loaded; mixed fee-for-service CCM and Care Plus Small, medium, and large Yes Low Medium Up-front loaded; uncapped fee-for-service model and flexible funding Large Yes High High * Based on the number of practices: small: 1 2; medium: 2 19; large: 20 plus. All the payment models contained some financial risks for the PHOs. Models at either end of the complexity spectrum appeared to carry the highest risk, for different reasons. The less complex models pay practices based on an invoice system, often in the absence of an effective means of tracking actual activity. If the practice does not complete the PMS records properly, HealthPac will not subsequently reimburse the PHO for those patients in the next quarter. Evaluation of the roll out of Care Plus p 19

It s a funding nightmare. If they do not fill out the form correctly to HealthPac, we lose out. The practice has already been paid. Those at the other end of the spectrum, employing reasonably complex capitation/fee-forservice models, recognised that these funding schemes did not fit well with the Ministry payments. Representatives explained that managing cash flow has proved to be a real issue because of the popularity of the schemes for A3 7, 25 64-year-old patients. Managers believed there were two drivers of the situation: (a) the payment schemes provide some financial benefits for this patient group; and (b) there is a perception among practitioners that Care Plus is a chance for early intervention for younger patients with chronic conditions. A3 patients, 25 64-year-olds: there is a financial advantage to the patient, not the doctors, if you put them on Care Plus. PHOs that had given practices larger up-front or initial payments thought this had encouraged nursing input into Care Plus. However, payment of equal amounts for each visit was thought to have led to some GPs viewing Care Plus as a funding stream for reduced-cost routine GP consultations. The equal funding means funding for cheaper GP visits. Some won t involve the nurses at all. There were some risks associated with up-front payments in that it takes a few Ministry payments before PHOs break even. Most had been able to cover deficits from the initial 50 percent up-front funding reserves. The Care Plus/CCM payment scheme was described as cumbersome because patients must be divided into those who are part of CCM and Care Plus, Care Plus only or CCM only. It s been a nightmare. We get information from the DHB on those in CCM. We get invoices from the practices and now a copy of every enrolment which we enter into a spreadsheet. Impact of funding changes All but two of the PHOs reported they had had to reduce Care Plus funding for at least one calendar quarter. The majority reported they had been able to use the 50 percent up-front funding reserves to cover any cash flow deficits. However, all noted that those funds were depleting rapidly, and if targets were not attained subsequent financial penalties could threaten the viability of the programme. We are bordering on real financial risk now because we have tried to maintain the integrity and philosophy of it all. It s a real risk for us now. 7 A3 is used to refer to an unsubsidised adult patient Evaluation of the roll out of Care Plus p 20