Improving health and support for people with chronic conditions in Western Sydney

Improving health and support for people with chronic conditions in Western Sydney A long-term partnership approach to integrating care for western Sydney

A BETTER WEST - Healthy People Integrated health is about people, families and communities being involved in decision making about their health and wellbeing, having enabling environments, groups and services which support their needs Western Sydney stakeholders working group, 015 Western Sydney has a vision to create an environment where people can live well, stay well and manage well with support. LIVE WELL Western Sydney is a place that enables people to live healthy, happy and purposeful lives. Health and social agencies work together as one to improve health, wellbeing and safety in western Sydney. There is a regional approach to peoples health, safety and wellbeing. STAY WELL As people need access to healthcare and social services, they are supported to improve their health and to live to their full potential. Healthcare and social services are connected. MANAGE WELL Individuals requiring healthcare to improve their health supported by their family and carers as active participants in healthcare to the maximum of their ability. In this way both the individual and services have a shared responsibility for health outcomes. This vision is being delivered as part of the Integrated Health Framework for western Sydney in partnership with key health agencies (Western Sydney Local Health District, Western Sydney Primary Health Network and Sydney Children's Hospital Network), government agencies including Premier and Cabinet, Family and Community Services, Education, Justice and Police and non government social policy services, community and consumer organisations. We are committed to working in partnership to deliver Better Health Together. www.betterhealthtogether.com.au 3

014 Why integrated care for western Sydney? Western Sydney s community of more than 95,000 people is the most ethnically and culturally diverse of NSW. Further diversity across age, socio-economics, health literacy and language amplifies the challenge of meeting health care demands and community needs. The region faces concerning health trends; a growing disease footprint, an overweight population, childhood obesity, rising mental health issues, conditions associated with aging and increasing complex chronic conditions. The resulting demands place enormous pressure on health care resources and the ability to respond with sustainable, quality health care. In response to this challenge, western Sydney is taking action, developing an integrated care program to assist people with chronic conditions, their family, carer s and health care providers to better manage their care. The program applies a proactive process of enrolled, planned and monitored care, designed and delivered through an informed and engaged network of patients, carers and health professionals. Patient journey prior to Western Sydney Integrated Care Program For many people with long term chronic conditions, the health trajectory has traditionally involved frustration and uncertainty regarding the best ways to monitor and manage their condition, numerous presentations at hospital emergency departments and hospital admissions. Some patients have also experienced dis-integrated care with a disconnection of care provider services. From both the patient and provider perspective, the care process has often been reactive, with inadequate patient education and support. Western Sydney clinicians have articulated a need for improved collaboration, accountability, prevention and patient-centred care that manages patients more in the community than in acute settings. There is real potential in western Sydney to engage with the community more and work with them to improve their health literacy, self-care and capacity to navigate services to receive the right care at the right time in the right place. The aim of the Western Sydney Integrated Care Program is to improve the management of people with chronic conditions in the community, reducing unnecessary ED presentations, minimising preventable hospital admissions and shortening length of stays in hospital. The facts Health costs of dis-integrated care 48% of people speak a language other than English at home Western Sydney is a diabetes hotspot with an estimated 5% 10-0 % of the population likely to be affected by diabetes or pre-diabetes higher incidence of diabetes and respiratory issues Hospital activity has been escalating faster in western Sydney than population growth with a 4.7 17% 57% state average of the population is in the most disadvantaged decile of Socio-Economic Indexes for Areas Home to the largest urban Aboriginal & Torres Strait Islander population with most living in low socioeconomic areas than the NSW % compound annual growth rate compared to % CAGR in 011-013 Blacktown s south west has the highest number of deaths from COPD with a rate 66 % higher than the Australian average of western Sydney residents have 1 of 4 health risk factors ED presentations:...17 ($15k) Admitted episodes:...5 ($54k) Total cost:...$69k Potentially preventable cost:...$6k ED presentations Admitted episodes Potentially preventable # # Days of stay for key episodes *Size of shape indicates length of stay (days) What if things were different? 015 013 + Care Patient Facilitator 3 01 GP Patient Late 60's Chronic disease 009 Family 011 010 1 4 4 4 + HOSPITAL + HOSPITAL Western Sydney data. Reference Source Ministry of Health 015 4 www.betterhealthtogether.com.au 5

A partnership approach to integrated care The NSW Government has committed $180 million over six years to achieve innovative, locally led models of integrated care across the State to transform the NSW health care system. As part of the NSW Integrated Care Strategy, western Sydney is one of three lead demonstrator sites across NSW engaged in developing an innovative, system-wide and sustainable service model for providing coordinated and integrated care services. The Western Sydney Integrated Care Program brings together a range of existing initiatives, programs and services to provide coordinated care across the primary, community and specialist settings, with a focus on improving the health care journey of people with chronic conditions. I was referred to the integrated care program by my GP. I found it really beneficial and very helpful. It offered me a different level of care than just visiting the doctor. I was attending regular exercise classes and learnt a lot about correct breathing, which was really important for my emphysema. The nursing staff gave me a lot of advice about my condition, exercises to help me breathe and things to do to better manage. I wouldn t have got that from just going to the doctor. It definitely made me feel like I was getting a lot more information and advice. Declan Hampsey, Patient, 67, Lalor Park Western Sydney Local Health District (WSLHD), and Western Sydney Primary Health Network (Wentwest) have collaborated in a partnership approach to address the growing chronic condition epidemic in western Sydney. The partnership focusses on supporting patients with one or more of the conditions; congestive cardiac failure, coronary artery disease, chronic obstructive pulmonary disease and diabetes. The Western Sydney Integrated Care Program (WSICP) is designed to: Improve the health of patients Enhance the patient experience Reduce healthcare costs; and Better support health professionals The Western Sydney Integrated Care Program Based around the Patient-Centred Medical Home (PCMH) concept, the Western Sydney s Integrated Care Program aims to provide better care for people with chronic conditions through improved communication and connectivity between health care providers in primary care, community and hospital settings, and better access to community based services close to home. The initiative s focus is on several key objectives including; Improved identification and better targeting of services for people at risk of developing chronic conditions Engage patients from the cohort into a Patient- Centred Medical Home and actively involve them in the management of their care implementation and program outcomes Coordinated care services across the health system including health service providers and funders Team based care coordination with health professionals working more effectively together Align local health services - enabling best use of locally available services whilst following best clinical practice Support & Build Capacity In GP Services Use technology to streamline care Better targeting of services Team based care Chronic Care Patient Utilise community based care facilitators to assist in care planning, navigation, transitional care between services, and patient education and self-management. Provide rapid access to specialist care Create care pathways and shared care plans between primary, community and hospital providers for continuity of care Increased patient participation - Better supporting individuals to engage and manage their health and wellbeing Using technology to share and integrate information across primary & hospital settings Supporting and building capacity in our GP services to increase uptake into the program Targeted investment in primary care to support timely creation, maintenance and display of health summaries, care plans and clinical metrics Report on patient experience PATIENT CENTRED MEDICAL HOME MODEL Provide ongoing evaluation of implementation and program outcomes. While the initial focus is on the management of chronic conditions, the initiative will in time be scalable and transferable to a broader array of patients. Coordinated services across the health system Increased patient participation Patient Home Base Align local health services 6 www.betterhealthtogether.com.au 7

Key Components of the Western Sydney Integrated Care Program PATIENT-CENTRED MEDICAL HOME (PCMH) The PCMH model emphasises a patient having an ongoing relationship with a GP who leads a multidisciplinary practice team; and primary care that is comprehensive, coordinated and accessible, with a focus on safety and quality. The PCMH coordinates the care delivered by all members of a person s care team which may include hospital inpatient care. INTEGRATED CARE TEAM For the selected patients, the Western Sydney Integrated Care Program provides an integrated care environment consisting of the primary care team, care facilitator, specialist team and community based healthcare providers. Patients within the cohort are enrolled through primary care, community or hospital specialist teams depending on the point of first contact and are registered in a central database. Patients are managed and monitored in accordance with their care plans by their GP who is supported by other members of the primary care team and community based care facilitators. The care plans are shared with the patient and all healthcare providers and maintained by the healthcare team using LinkedEHR, an online repository for the shared care plan. The primary care goals are to maintain good health and prevent acute or chronic deterioration of the patient s condition. The patient s health status and care plans are regularly reviewed by the primary care team. CARE FACILITATOR ROLE Located in community and primary care settings, care facilitators are registered nurses who support GPs and assist clinicians to identify, enrol, manage and monitor patients using integrated care enablers such as HealthPathways and LinkedEHR. Care facilitators ensure patients have regular reviews based on preventative and continuing care needs. In conjunction with the patient s GP and specialists, care facilitators provide referrals to health coaching, self-management strategies, community and other specialist services. CAPACITY BUILDING One of the overarching principles of the Western Sydney Integrated Care Program is to support and develop the Patient Centred Medical Home approach, improving the management of chronic illness in the community. Creation of the GP Support Line, access to specialist services and case conferencing are all underpinned by extensive training across professions. GP SUPPORT LINE The GP Support Line is a telephone service that provides an avenue for general practitioners to contact the relevant specialist hospital service. GPs are referred to the appropriate specialty and hospital, Westmead or Blacktown. SPECIALIST TEAMS PROVIDING RAPID ACCESS AND STABILISATION SERVICES (RASS) RASS are specialty services that have been established at Westmead, Blacktown and Mount Druitt hospitals to reduce: Waiting times for patients as they navigate the system Unnecessary hospital admissions Avoidable presentations to emergency departments Readmission rates; and Provide a less complex and more appropriate patient journey. The Rapid Access Clinic provides fast evaluation of an acute deterioration of a patient s chronic condition. The assessment may result in avoiding a hospital admission or expediting admission. GPs directly contact the relevant integrated care specialty clinician via the GP Support Line bypassing unnecessary management delays or Emergency Department (ED) presentations. The aim is to transition these patients from the hospital environment back to their primary care team and the community setting as quickly as possible. I have several patients who are part of the integrated care program. As a GP we look at the medical side of things. We prescribe the drugs and treat the condition. The integrated care facilitator looks at a patient s health more globally. They have the time to look into what a patient really needs beyond just medical assistance. They have the time to investigate their social situation, their lifestyle and they can refer them to social workers, exercise programs, rehabilitation, things that as a GP, I might not be aware of. It does make my job easier because you know you have someone there who is looking at the patient holistically. The feedback from my patients has been really positive. They like having someone calling them up and checking in on them. It s giving them that next level of care. They ve got another person looking after them. Dr Con Paleolopos, GP, Alpha Medical Centre 8 www.betterhealthtogether.com.au 9

How integrated care works in western Sydney INTEGRATED CARE PROGRAM EXAMPLE Joseph, 65, has high blood pressure. He was diagnosed with type diabetes five years ago and is lax in checking his blood sugar levels or seeing his GP. He has been admitted to hospital twice with complications. Western Sydney GP Dr Phan runs a busy practice with four GPs. He struggles to manage people with chronic conditions because their appointments run over making it difficult to see other patients. Hearing of the integrated care program from a fellow GP, Dr Phan contacts the Western Sydney PHN support team. With his practice already ehealth enabled, Dr Phan joined the program and trained on LinkedEHR and HealthPathways. On his next visit to Dr Phan, Joseph is introduced to the integrated care program and a shared care plan is prepared for him in LinkedEHR. He meets care facilitator Jenny who refines his plan and they identify services to help him achieve his goals. Dr Phan refers Joseph to a foot specialist and other allied health services using LinkedEHR. The following week Jenny arranges Joseph to undergo a behaviour-based checklist to ascertain the barriers and challenges to his care and to help self-manage his blood sugar. A few weeks later Joseph becomes breathless and dizzy and is assessed by his GP. Dr Phan uses the GP Support Line to discuss Joseph s case with an integrated care cardiologist and they agree to refer Joseph to the RASS clinic where he can see a specialist without going to the ED. After treatment to control his heart failure, the specialist messages Dr Phan about any changes in Joseph s management. Mary, the clinical nurse coordinator, sends the updated action plan to Dr Phan and arranges Joseph to be seen by his GP. At that review, Dr Phan updates Joseph s LinkedEHR record, revises his medication and arranges his practice team and Jenny the care facilitator to revise the shared care plan and set up regular reviews at Dr Phan s surgery. With the online HealthPathways decision support tool, Dr Phan can obtain best practice, evidenced-based information about managing people in his care. Dr Phan is also supported by specialists through a GP Support Line, case conferencing and the Rapid Access and Stabilisation Services at the local hospitals. Care Plan Example Joseph * is a 65yr old man. Joseph has diabetes and is enrolled in the Western Sydney Integrated Care Program. *Joseph is a fictional patient used to demonstrate how the care plan could work My team will help with... Education in lifestyle choices to improve my condition. Enrol me in an upcoming diabetes workshop. Lifestyle Goals Take a 30min walk 3 times per week. Stand up more during the day. Diet Goals Personal Goals Improve my health so I can visit my son in QLD and spend time with my grand children. Continue in my part-time working role for another years. Monitoring Support Network Joseph lives with his wife Prisha, daughter Riya and mother Saanvi in their family home. Self Help Goals Research diabetes online to improve my understanding. Attend a healthy eating workshop. Health Info Goals View my Care Plan online. Access my health information via linkedehr.com.au. Medications Stop eating at the work canteen and instead bring healthy meals from home. Research affordable and healthy ways of eating. Meet with my Care Facilitator on a monthly basis to ensure everything is progressing well. Record my activity so I can monitor my fitness progress. Take my prescribed medicines consistently. Get pharmacist to set up a Webster Pack for my regular prescribed medications. HOSPITAL SPECIALIST TEAMS Working as a care facilitator is extremely HOSPITAL ADMISSION Rapid Access Specialist Service Stabilisation Clinics Patient Support CARE FACILITATORS CDMP HealthOne Closing the Gap Community Health PRIMARY CARE PATIENT-CENTRED MEDICAL HOME rewarding. You are not only enabling better and timely access to healthcare services for clients, you are an educator, an advocate, a leader and an innovator. The role of a care facilitator is full of challenges but what I most enjoy is having the ability to empower clients and carers to make Building Capacity in Primary Care informed choices. Our goal is always to prevent deterioration and improve a client s quality of life. WESTERN SYDNEY INTEGRATED CARE PROGRAM - MODEL OF CARE (RASS) WESTERN SYDNEY INTEGRATED CARE PROGRAM Heena Puri, care facilitator 10 www.betterhealthtogether.com.au 11

Western Sydney Integrated Care Program - Addressing System Reform PARTNERSHIPS By working in partnership with our community, consumers and their families, we are creating an environment and way of working together that enables an improvement in health service delivery. The resulting social benefits contribute to achieving optimal outcomes within an integrated whole of system approach. Western Sydney has a robust partnership with key health agencies comprising the WSLHD, WSPHN and SCHN. In addition, we are continuing to develop strong alliances and build on the existing partnerships with other government and social policy agencies including NSW Department of Premier and Cabinet, Department of Family and Community Services, Juvenile Justice, NSW Department of Education, and the NSW Police. These partnerships work in collaboration to address the key determinants for health, well-being and safety in the community. CONSUMER AND COMMUNITY ENGAGEMENT WSICP has an established Consumer and Community Advisory Group which has been increasingly engaged in the program planning processes to achieve healthcare integration, communications and feedback processes to inform and refine the integrated model of care. A best practice, evidence-based approach is favoured with consumers recently accepting a proposal to work with clinicians and The George Institute on a translational research project involving an SMS intervention program for people with diabetes and cardiovascular conditions. WSICP is uniquely positioned to leverage opportunities to become truly innovative in building a consumer-centered health care system. Future transformative change involving new ways of thinking about the role of consumers will lead to innovative ideas such as partnering to deliver consumer health leadership development programs and fund health literacy programs to assist the multicultural diverse western Sydney population with self-management of their chronic conditions. SHARED GOVERNANCE Strong governance has been one of the key success factors for the WSICP, the hallmark of which is collaboration between executives and senior clinicians. The WSICP s shared governance structure between WSLHD and the WSPHN reports through an Executive Steering Committee and the Integrated Chronic Care Management Program Advisory Committee (ICCMPC). The WSICP is an innovative model trialing shared governance between WSLHD and the WSPHN, including service design, priority setting, funding and performance monitoring. This is reflected in the collaborative program of works undertaken including change management, consumer engagement and HealthPathways. CHANGE MANAGEMENT AND SERVICE REDESIGN An evidence-based approach has been taken in implementing a long-term, collaborative change management program underpinned by behavioural and social change theories designed to create collaborative impact through partnerships around collective work. This work has resulted in a collective, shared vision for integrated health in western Sydney. An Integrated Health Framework, representative of our partnerships is being progressed and overseen by the Health Partnership Advisory Council. The significance of the framework will be evidenced in strengthened shared governance, operationalised steering groups and collaborative action in the continued pursuit of healthcare integration. CLINICAL LEADERSHIP Clinical leadership has been a catalyst for developing a model of care and disseminating a shared focus and interest in integrated care initiatives, and importantly, establishing the fundamental linkage to social and behavioural change. Supporting the western Sydney journey towards implementing integrated care has seen a WSICPinitiated tailored Clinical Leadership Academy conducted by McKinsey, Kaiser Permanente, Hurley Group and the NHS England with the objectives of sharing best practice ideas with clinicians and stimulation of thinking about future models of healthcare integration. Health sector-partnering workshops targeted to diabetes, respiratory and heart failure models of care are being led by senior clinicians. There is an ongoing investment in GP and Specialist Clinical leads in both the primary and secondary care settings to provide the senior leadership and influence necessary for successful healthcare integration. CAPACITY BUILDING WSICP is invested in capacity-building opportunities and activities in primary care. In partnership with the WSPHN (WentWest), GP and nurse education, case conferencing and a number of interactive sessions are being delivered with specialists for diabetes, respiratory and heart failure and tailored COPD training to community practice nurses. A range of capacity building and ongoing activities continue to be implemented to deliver integrated care strategies and support to general practices across western Sydney. HEALTHPATHWAYS The HealthPathways program, a collaborative initiative between WSLHD, WentWest (Western Sydney PHN) and Sydney Children s Hospitals Network in Western Sydney, a key enabler of integrated health has been aimed at systematically improving the quality and appropriateness of care between general practice and its hospitals at a local level. Built and maintained on evidence-based, locally agreed information including red flags, assessment and management of clinical conditions it functions as both an online decision-support tool and a health service referral directory. It plays an important role in delivering safe, appropriate and efficient care and services for over 50+ pathways, including the suite of WSICP Integrated Care protocols for chronic conditions - heart failure, coronary artery disease, COPD and diabetes. In combination with other integrated health strategies HealthPathways impacts Emergency Department avoidance, unplanned admissions and can contribute to decreased length of stay by facilitating the right patients to receive the right care in the right place and timeframes. At a system level this has the effect of reducing unwarranted variation in identifying and defining the care and services people should expect to be offered or receive for their clinical condition regardless of where they are treated across Western Sydney. westernsydney.healthpathways.org.au ehealth/it The WSICP has worked closely and in combination with e-health NSW, WSLHD and external IT providers to deliver a range of e-health enablers to support both GP s and hospital clinicians to manage patients with chronic conditions across the health continuum. A significant IT break-through includes access to the shared care repository (LinkedEHR) through GP s clinical information systems in the primary care setting and via the Cerner system in the secondary setting for treating Specialists. This now means that clinicians, whether primary care, community or hospital-based can collectively view and work from a shared care plan for their patients with chronic conditions. There are further opportunities to implement a fully-functional shared care planning process. An e-referral solution is expected to be delivered towards the end of 016. We are continuing to work with e-health NSW to deliver further IT solutions within Clinical Data Architecture Standards. FUNDING REFORM The WSICP is at the forefront in implementing the Patient Centred Medical Home (Health Care Home). Funding Reform at State and Commonwealth level is critical to the success of integrated care. Future reform in this area will further support integration and the learnings from the WSICP will assist to inform future policy and funding reform. The WSICP have been working with western Sydney GPs exploring alternative funding arrangements that better align with the PCMH approaches; for example, a multimodal system comprising payments based on fee-for-service (FFS), patient complexity, performance, and capability and capacity building. Such a payment system would improve health outcomes and the financial sustainability of general practice. With funding reform shifting away from fee for service (FFS) payments towards block funding, providers could be delivered a more consistent funding stream that reflects the complexity of care provided. EVALUATION Evaluation of the WSICP is multipronged. WSICP are undertaking a quantitative analysis assessing the impact on hospital length of stay, Emergency Department presentation frequency and monitoring specific clinical metrics for each of the chronic conditions heart failure, coronary artery disease, COPD and diabetes. There is a further independent qualitative analysis being conducted by Western Sydney University of patient experience and satisfaction as well as health care provider satisfaction with the changes delivered by health care integration strategies. The results and findings from each component are designed to support proof of concept and inform future model of care design. 1 www.betterhealthtogether.com.au 13

Looking forward for western Sydney Integrated Care is a high priority for WSLHD and the WSPHN. Together we are building an overarching integrated healthcare framework partnering with the Sydney Children s Hospital Network, social policy agencies including Family and Community Services, Education, Justice, Police and consumer organisations. WSLHD is moving towards a healthcare business that utilises its hospital services more appropriately, increasing its focus on keeping people healthy and well, and enabling high performance through workforce and technology improvements. It has commenced a process of strategic realignment, moving from a hospital to a healthcare business. Services and programs have been aligned to better meet the needs of patients, an integrated health framework and strategic directions of the LHD. These programs include the new Integrated Chronic Care Management Program (previously Connecting Care); HealthOne; HealthPathways; the Diabetes Initiative; along with several IT enablers. The Western Sydney Integrated Care Program is gaining traction. Strong foundations for an integrated care platform have been built on the achievements to date. Time is needed to consolidate system changes. The next phase will involve: Further work to support the Primary Care in better management of long term chronic conditions. Refining the role of the care facilitators to determine how to better support coordination of care. Consolidating in the community and monitoring services to ensure closer links with primary care. Lobbying and advocating for system changes; funding models, IT and sharing of data to support integrated care for patients. A comprehensive communications campaign to promote the WSICP to integrated care stakeholders, primary care and consumers. Continue to partner with consumers to improve self management and health literacy in the community. The Western Sydney Integrated Care Program aims to improve the care experience for patients, carers and families; advance the health of the population; achieve better use of health resources; and improve the work life of healthcare providers. We believe the work of the Western Sydney Integrated Care Program is providing a robust foundation necessary for system reform. As we continue to consolidate the learnings from this program of work, we build a stronger platform to adapt and develop services which better meet the needs of people in western Sydney and the NSW Health system. Danny O Connor Chief Executive Officer Western Sydney Local Health District Walter Kmet Chief Executive Western Sydney Primary Health Network I have been having treatment for diabetes for months, dealing with my head doctor, two nurses and a social worker. Often in the healthcare system, you feel like you have so many different people saying different things to you. Integrated care works because everyone is on the same page. All the health professionals talk to each other and they re all working together to give you the best care possible. I feel like I ve been getting quality care because everyone is across my case. I don t have to keep explaining it to different people, everything is integrated. It s given me confidence in the system and taken a lot of the fear away. You know everyone is working together. For a patient, that level and type of care is very comforting. How to get involved... You are invited to work with us, partnering in the development of a sustainable, highly functional integrated care program for the people of western Sydney. For general program information call Ph. 1800 113 644 GP Practices should contact WentWest Practice Support Team on... Ph. 8811 7117 Find out more about the program at www.betterhealthtogether.com.au Gail Smith, patient, 61, Seven Hills 14 www.betterhealthtogether.com.au 15

Contact Western Sydney Integrated Care Program Level 3, Administration and Education Building, Blacktown Hospital Telephone (0) 9881 7770 Facsimile (0) 9881 7606 Email wslhd-integratedcareexecutive@health.nsw.gov.au www.betterhealthtogether.com.au Western Sydney Primary Health Network PO Box 5, Blacktown Post Shop NSW 148 Telephone (0) 8811 7100 Facsimile (0) 96 3448 www.wentwest.com.au A long-term partnership approach to integrating care for western Sydney