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

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

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Benedict Hefford is Director of Primary and Community Services at Counties Manukau Health, where he is also the executive lead for integrated care:
http://www.countiesmanukau.health.nz/AchievingBalance/System-Integration/system-integration-home.htm. As Director, Benedict is responsible for both operational delivery and commissioning of health and social care services in South Auckland – a culturally diverse and economically deprived area of New Zealand with over 500,000 residents.

Benedict has 20 years healthcare experience encompassing senior management, commissioning, and strategic roles in both New Zealand and the UK. Prior to joining CM Health, he was Director of Commissioning (Social Care and Health) in central London. Benedict’s previous experience also includes re-designing community care services at Hammersmith and Fulham PCT and Capital Coast Health, as well as developing national health strategies as a Senior Policy Analyst with the NZ Ministry of Health. Benedict holds an MSc in Public Services Policy & Management from King’s College London; a Postgraduate Diploma in Health Services Management; and a BSW (Hons).

Benedict Hefford is Director of Primary and Community Services at Counties Manukau Health, where he is also the executive lead for integrated care:
http://www.countiesmanukau.health.nz/AchievingBalance/System-Integration/system-integration-home.htm. As Director, Benedict is responsible for both operational delivery and commissioning of health and social care services in South Auckland – a culturally diverse and economically deprived area of New Zealand with over 500,000 residents.

Benedict has 20 years healthcare experience encompassing senior management, commissioning, and strategic roles in both New Zealand and the UK. Prior to joining CM Health, he was Director of Commissioning (Social Care and Health) in central London. Benedict’s previous experience also includes re-designing community care services at Hammersmith and Fulham PCT and Capital Coast Health, as well as developing national health strategies as a Senior Policy Analyst with the NZ Ministry of Health. Benedict holds an MSc in Public Services Policy & Management from King’s College London; a Postgraduate Diploma in Health Services Management; and a BSW (Hons).

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

  1. 1. The Art of the Possible – Integrated Community Care through Locality Clinical Partnerships The Counties Manukau Health Experience Benedict Hefford, Director Primary & Community Services July 2014
  2. 2. 2
  3. 3. 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!)
  4. 4. 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 Maaori is 10 years+ 0 20 40 60 80 100 Unable to express needs Poor attendance at clinics No English No family / friend support Living alone Psychological issues Housing Risk at Home Poor health literacy Poor GP access Dependent with ADLs Mental health diagnosis Substance misuse Living with dependent No support services Dollars as health barrier Poor compliance - meds Progression of disease Not mobile Multiple co-morbidities Polypharmacy (>8) Assessed Health Needs:
  5. 5. 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 Numberofmed/surg/AOU/MSSUbeds Year Projections of bed demand against planned beds for medical and surgical services in Middlemore Hospital Existing & planned beds Existing & planned beds (subjected to approval) Projected demographic and non- demographic growth (high growth)
  6. 6. 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
  7. 7. Locality Based Integration
  8. 8. Integrated Locality Services
  9. 9. Alliancing to improve care & services 10
  10. 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:
  11. 11. Low Risk Moderate Risk High Risk Very Hig h Risk Planned, Proactive & Coordinated Care for At-Risk Individuals 80+% of population = health promotion plans Primary 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
  12. 12. 1 At Risk Individuals – Care Process Risk stratification e-tool under development, clinical criteria agreed in the meantime Risk stratification 2 Shared protocols & pathways 3 Care delivery and coordination 5 GP Enrolled Population 1 Care planning 4 Case conference 5a 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 plan All ‘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
  13. 13. 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
  14. 14. Health Partners Scale & Outcome Indicators
  15. 15. E-Shared Care: Overview Screen To deliver outstanding shared services that
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. The team’s ideas for change…
  20. 20. Community Care Re-Design – Releasing Capacity
  21. 21. Primary Care Re-design: Better, Sooner & More Convenient
  22. 22. 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!)
  23. 23. 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 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 TotalBeddayutilisationoverarolling12monthperiod 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 Jul2009 Oct2009 Jan2010 Apr2010 Jul2010 Oct2010 Jan2011 Apr2011 Jul2011 Oct2011 Jan2012 Apr2012 Jul2012 Oct2012 Jan2013 Apr2013 Jul2013 ALOS
  24. 24. 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
  25. 25. Thank you and any questions? Email: benedict.hefford@middlemore.co.nz

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