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

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.
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.
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.
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.
Locality Based Integration

8.
Integrated Locality Services

9.
Alliancing to improve care & services
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.
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.
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.
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.
Health Partners Scale & Outcome Indicators

15.
E-Shared Care: Overview Screen
To deliver outstanding
shared services that

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.
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.
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.
The team’s ideas for change…

20.
Community Care Re-Design – Releasing Capacity

21.
Primary Care Re-design: Better, Sooner & More Convenient

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.
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.
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.
Thank you
and
any questions?
Email:
benedict.hefford@middlemore.co.nz