Innovation in commissioning and provisioning of community healthcare - Counties Manukau Health, New Zealand

The Art of the Possible –Integrated Community Care through

Locality Clinical Partnerships

The Counties Manukau Health Experience

Benedict Hefford, Director Primary & Community ServicesJuly 2014

2

This presentation will cover:

1. Why we’re integrating community care through Locality Clinical Partnerships: Our challenges, approach, and goals

2. The clinical approach: Commissioning proactive care of ‘At Risk Individuals’, supported by e-shared care and care pathways

3. Unlocking community teams’ capacity and saving hospital/care home bed days through collaborative improvement & re-design

And finally some early quantitative results and critical success factors (and battle scars!)

1. Why integration: CM Health Challenges

Rapidly aging and growing, but still younger than overall NZ population

Multi-ethnic, high proportion living in areas of high socioeconomic deprivation, especially Pacific peoples, Maaori and children

Overall life expectancy increasing (81.9 years) but gap for Maaoriis 10 years+

0 20 40 60 80 100

Unable to express needsPoor attendance at clinics

No EnglishNo family / friend support

Living alonePsychological issues

HousingRisk at Home

Poor health literacyPoor GP access

Dependent with ADLsMental health diagnosis

Substance misuseLiving with dependent

No support servicesDollars as health barrierPoor compliance - meds

Progression of diseaseNot mobile

Multiple co-morbiditiesPolypharmacy (>8)

Assessed Health Needs:

If LCPs are the solution, what’s the problem? More acute beds… or better community care

350

400

450

500

550

600

650

2010 2011 2012 2013 2014 2015 2016 2017

Nu

mb

er o

f m

ed/s

urg

/AO

U/M

SSU

bed

s

Year

Projections of bed demand against planned beds for medical and surgical services in Middlemore Hospital

Existing & planned beds

Existing & planned beds (subjected toapproval)

Projected demographic and non-demographic growth (high growth)

What’s the problem? A Patient Journey…

X = GP visit

∆ = After hours attendance

∆ = A&E Attendance

∆ = District Nursing

∆ = Inpatient Admission

● = Residential Care

● = Social Care assessment

= Homecare

Locality Based Integration

Integrated Locality Services

Alliancing to improve care & services

10

διαιτήμασί τε χρήσομαι ἐπ' ὠφελείῃ καμνόντων κατὰ δύναμιν καὶ

κρίσιν ἐμήν, ἐπὶ δηλήσει δὲ καὶ ἀδικίῃ εἴρξειν.

I will prescribe regimens for the good of my patients according to

my ability and my judgment and never do harm to anyone.

1. Why we’re integrating community care through Locality Clinical Partnerships: Our challenges, approach, and goals

2. The clinical approach: Commissioning proactive care of ‘At Risk Individuals’, supported by e-shared care and care pathways

3. Unlocking community teams’ capacity and saving hospital/care home bed days through collaborative improvement & re-design

This presentation will cover:

Low Risk

Moderate Risk

High Risk

Very

Hig

h

Risk

Planned, Proactive & Coordinated Care for At-Risk Individuals

80+% of population = health promotion plansPrimary care identifies people with lifestyle risks (eg. smoking, high blood pressure)Brief interventions to screen, give advice & refer or sign post:- Smoking cessation assistance- Exercise options-Depression / anxiety (referral to IAPT)-Social isolation (referral to 3rd sector support) -Housing related support

20% of population = self care plans

Primary care identifies people with LTCs, disability, or social needs

Proportionate assessment to create a co-produced, goal led care plan, for

example:

-Referral to Expert Patient Programme /peer educators /health trainers

-LTC pathways eg., diabetes, dementia

-Assistive technology / telecare

5% of population = integrated health and social care plan

GP, Registered Nurse, Social Worker or health professional facilitated to

include for eg:

-Rehabilitation, recovery, reablement

-Telehealth

-Medication review

0.5% of population = comprehensive assessment & care plan

GP, Registered Nurse, Social Worker or Health professional facilitated to

include for eg:

-End of Life care

-Hospital at home nursing

-Specialised therapies (eg stoma care)

-Continence careVery

High

Risk

High Risk

Moderate Risk

Low Risk

1

3

At Risk Individuals – Care Process

Risk stratification e-tool

under development, clinical

criteria agreed in the

meantime

Risk stratification2

Shared protocols & pathways3

Care delivery and

coordination

5

GP Enrolled

Population

1Care planning

4

Case conference5a

Community

pharmacist

Practice nurse

Allied Health

District

nurse

SMO

Whanau

Support

Community

Mental Health

Case conferences to be used

from time to time for very

complex patients who need

MDT input to their care planAll ‘at risk’ patients should have a plan that is proportionate to their

clinical and social needs, risks and ability to benefit: Logged on e-

shared care

Day-to-day

Non-exhaustive examples

GP

Care pathways and agreed clinical protocols are used to inform

assessment, care planning, & coordination

SME

Coordinator

Next specific action

- Current phase of

care (initial

presentation,

therapy, follow up)

- History, examination

and investigations

- Previous treatment

and outcome

- Actions taken by

other providers

- Resources available

(localised)

- Judgement of

provider

Shared Protocols & Care Pathways

Disclaimer: The software and its development are confidential to Pathway Navigator Ltd. (c) 2012

Health Partners Scale & Outcome Indicators

E-Shared Care: Overview Screen

To deliver outstanding shared services that enable healthcare

This presentation will cover:

1. Why we’re integrating community care thru Locality Clinical Partnerships: Our challenges, approach, and goals

2. The clinical approach: Commissioning proactive care of ‘At Risk Individuals’, supported by e-shared care and care pathways

3. Unlocking community teams’ capacity and saving hospital/care home bed days through collaborative improvement & re-design

Single Point Entry Single Point Entry Single Point Entry

District

Nursing

Mental

Health

What’s the problem? Integrated Community Healthcare…

Community/clinic based NHS & Social Care Services

Social Care

Allied Health

Collaborative Improvement – ‘Ground up’ Innovation

Deliver – This step focuses

on ‘what will be’

Recommendation and

implementation of

the model of care

This informs the way we

move forward

Dream – After identifying

the current situation the next

step focuses on ‘what might

be’

How does a locality

look like in the future

2-3 years from now?

Discover- the first step in the

AI Cycle. This will focus on

identifying the ‘What is’?

Discover the current

situation at the

locality

Design - We will have

discovered ‘what is’ and

what might be, now we look

‘how can it be’

Best way to do this

By who, by when

Discover

Dream

Design

Deliver

The team’s ideas for change…

Community Care Re-Design – Releasing Capacity

Primary Care Re-design: Better, Sooner & More Convenient

This presentation will cover:

1. Why we’re integrating community care through Locality Clinical Partnerships: Our challenges, approach, and goals

2. The clinical approach: Commissioning proactive care of ‘At Risk Individuals’, supported by e-shared care and care pathways

3. Unlocking community teams’ capacity and saving hospital/care home bed days thru collaborative improvement & re-design

And finally some early quantitative results and critical success factors (and battle scars!)

Actual vs Predicted Bed Days

140,000

142,000

144,000

146,000

148,000

150,000

152,000

154,000

156,000

158,000

160,000

162,000

164,000

166,000

168,000

Jun

-11

Jul-

11

Au

g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

To

tal

Be

d d

ay

uti

lisa

tio

n o

ve

r a

ro

llin

g 1

2 m

on

th p

eri

od

Actual bedday cumulative total Predicted bedday cumulative total

Some promising early results…

Average Length of Stay

UCL

CL

LCL

3.40

3.60

3.80

4.00

4.20

4.40

4.60

4.80

5.00

Jul 2009

Oct 2009

Jan 2

010

Apr

2010

Jul 2010

Oct 2010

Jan 2

011

Apr

2011

Jul 2011

Oct 2011

Jan 2

012

Apr

2012

Jul 2012

Oct 2012

Jan 2

013

Apr

2013

Jul 2013

AL

OS

Critical Success Factors

Clarify your goals

• Create a vision, set achievable goals and timeframes, take your stakeholders with you.

Start now, start small and then grow, spread, and improve

• Endless analysis and planning are proxies for cowardice!

Integrate your integration projects!

• Align commissioning, metrics and IT enablers in each initiative

Clinical Leadership

• This is a clinical transformation project not an IT project.

Put the patient at the center

• Patient stories and journeys are compelling: theories and concepts aren’t

(see number 2)

Soft changes are as important as structures, processes and $

• Co-ordination, care planning, patient activation, and communication are mostly about shared beliefs, goals, and values

Stay awake!

• Keep things on track by being a telescope, a mirror, and a magnifying glass

Thank you and any questions?

Email:[email protected]