The Mission We Chose to Accept: Achieving Integration

1. The Mission We Chose to Accept:Achieving Integration Natalie Sullivan General Manager Yarra Ranges & Angliss Hospital Chief Allied Health Officer

2. Achieving Integration • Policy – Victorian Vs Tasmanian – are they that different? Dust collectors or roadmaps for service improvement? • Implementing the policy – system wide reform, integrated area based planning, enablers-are they that important? • What does it look like from a capital development perspective? Will bricks and mortar be the answer? • What can be achieved without capital investment? Making a difference where it really counts. • Eastern Health Experience – the good, the bad and the ugly. • Mission critical – my view on the success factors for achieving service integration.

3. Why is this concept relevant? • 70% of the total burden of disease is attributable to 6 disease groups all with potential ability for community management • Chronic disease is now commonplace and continuing to affect increasing proportion of Australian population • 2/3rd of medical separations and 1/3rd procedural separations are same day in Victoria • Across RHH, LGH & NWRH in 2004-05 • 7700 separations • 30,300 beddays • Approx 83 beds across the state. Attributable to patients who potentially could have been treated in a non-inpatient setting

4. Our current health environment • Older population have increased health care needs • Demand for health services will grow quicker than the rate of population growth • Escalating costs in hospitals • Mismatch between what the community needs and what out current health service has capacity to deliver • Declining bulk billing rates • Overburdened hospital system • Barriers to increasing community based care

5. System Limitations • Fragmented primary and tertiary care sector • Lack of appropriate facilities and infrastructure • Cultural barriers to change (clinicians, bureaucrats, community, patients) • Complex funding arrangements • Workforce pressures

6. Victorian Policy – Care In Your Community • Care in your community provides a ten-year vision for a modern, integrated and patient-centred health system. It is based on area planning and focussed on the following needs • chronic disease and complex care; • episodic and urgent care • health promotion and illness prevention. • Launched in April 2006

7. Aim of the policy • Maximise access • Maintain and/or improve quality • Improve continuity of care • Improve service flexibility • Maximise opportunities for service substitution and diversion • Ensure optimal use of resources • Determine capital developments to co-locate services outside of the hospital environment

8. Getting from here to Utopia • Recognising there is more to this than goodwill and a good plan • Jumping the hurdles, removing the barriers • Enablers • Funding models • Workforce • Integration tools • Information management • Partnerships

9. Can anyone give me the directions to Utopia? • Planning • Who plans? • How do we plan? • What do we plan? • What about existing plans? • Planning burnout!

10. Integrated Area Based Planning Approach • Population Health Planning • Integration Planning • Community Based Service Configuration Planning • Regional and Statewide Planning

11. The Planning Process • Determine the needs of the local catchment population in terms of the three areas of need • Profile the existing service system on the basis of the schema • Determine how the planning principles apply to the local service system. • Conduct an assessment of the local service system based and the application of the planning principles • Develop recommended priority actions to achieve integration goals and to move towards the future service configuration

12. The Planning Schema • Modes of Care • Settings of Care • Levels of Care

13. Modes of Care The way care is provided. • Inpatient admission • Same day admission • Specialist care: care that requires specialised clinician, infrastructure or other support • Primary care • Group program: care that is organised for groups of people with like needs • Self-care: care that individuals undertake themselves or with the aid of a carer or family member

14. Settings of care Refers to the physical setting for the delivery of care and is classified into: • hospitals • community-based health care facilities • outreach (care delivered where a person lives, through a mobile facility or in some other public or private location, such as the workplace).

15. Levels of care • Level 4 • health care provided on a day admission basis that must be delivered in a hospital setting, requiring inpatient back up in order to be safely and effectively delivered, e.g. ED, radiotherapy, day surgery or procedures involving high degree of clinical risk, Outpatient services required immediately pre-and post admission • Level 3 • requires specialist resources and a large critical mass for services to be effectively and efficiently delivered, • Level 2 • requires specialist resources, but a reduced level of back up resources and / or critical back up • Level 1 • focused on delivering primary care in a minor centre

16. Integrated Area Based Planning Trials • Three trials across the state • Southern Metropolitan Region • Eastern Metropolitan Region • Gippsland Region • Why these areas? • Strong existing partnerships eg PCPs • Strong local capacity and commitment • Socio-economic demographics (high need and high incidence of ambulatory care sensitive conditions.

17. Trial of integrated area based planning Objectives • to develop partnerships between key stakeholders (building on existing partnership work); • to provide a focus for the further development of program planning parameters by individual DHS programs; and • to develop and refine the detailed area-based planning methodology for broader application.

18. The Outer East Experience Outer East Pop: 394,215 Area: 2647m2 Knox, Maroondah, Yarra Ranges

19. Key Health Organisations in OE • One Metro Health Service • Eastern Health (Outer East component -3 acute sites, 2 EDs, Home and Centre Based subacute ambulatory and Inpatient) • The Outer East PCP • 3 Stand alone Community Health Services • EACH, Knox CHS, Ranges CHS • One integrated Community Health Service • YVCHS & Maroondah & Angliss integrated CH • 3 Divisions of General Practice • Whitehorse, Knox & Eastern Ranges • RDNS

20. How we went about it……….

21. Phase1: Initiate project • Stage 1:Establish Planning Network • Senior Managers of all LGA and significant health providers • Terms of Reference (inc. project outcomes, project management responsibilities, stakeholder engagement responsibilities) • Establish Project Management Group • Clarify reporting relationship to DHS governance of three trials • Stage 2: Agree Project Methodology including consumer consultation • PRINCE2 Methodology • Community Engagement Strategy developed

22. Phase 2: Set priorities • Stage 3: Examine existing material • Organisational strategic and service plans • Eastern Health stategic plan and service plan for each site • Mental Health Service Plan • EACH • RCHS • KCHS • PCP Community Health Plans 2006-09 • Aboriginal Service plan 2006-09 • HACC Triennial Plan • Palliative Care Consortium 2005-09 plan

23. Phase 2 continued…… • Stage 4: Determine area priorities • Options: • Undertake a priority defining exercise (pure approach to planning) • Use health priorities of EH PC&PHAC (diabetes, CV health & Mental Health) • Focus on areas defined by DHS in trial guidelines (CDM-incl early intervention, community health counselling, renal services, dental services) Decision – Option 2 plus renal and dental as outlined in DHS priorities

24. Phase 3: Affirm Context • Stage 4: Analyse population characteristics data • Review of statistic data (ABS, Dept of Infrastructure projections, DHS data on Victorian ACSC, Burden of Disease estimates) • Stage 5: Consult with consumer peak bodies • Consulted with Chronic Illness Alliance, Migrant Info Centre, Yarra Valley Indigenous Service, Carers Victoria • Confirmation of appropriateness of priority areas

25. Phase 3 continued……. • Stage 6: Apply service schema • Public sector community based organisations in the region • Added further issues for description including • Site ownership and accessibility issues • DHS funding type and activity • Planned service hours • Key referring organisations • Suitability of existing location • Co-location service development opportunities

26. Phase 4: Develop Action Plans • Stage 8: Scoping Papers • Acted as information resource & initiated dialogue with stakeholders, including service providers, consumers and carers. • Stage 9: Action Planning Statements • Series of workshops were held for each priority area • Workshops formulated action planning goals • Stage 10: Formulate Action Plans • Scoping papers, consumer feedback and action planning statement synthesised in to draft action plans • Planning Network workshop considered all draft action plans and associated recommendations

27. Action Plan Structure • Description of underlying need • Description of current service delivery arrangements and partnerships • Consumer (and carer) observations on the arrangements • Specification of a preferred patient pathway • List of planning network supported actions • Assessment of the initiatives against the planning schema • A client and system impact assessment • Implementation requirements • Impact on Community • Resources • Risks • Endorsement needs • Other ideas requiring further consideration

28. Phase 5: Prepare Report • Stage 11: Draft report • Stage 12: Assess learnings • Stage 13: Finalise report

29. Trial Outcomes – the Good • Partnership and relationship • Continued partnership development • Integration and strengthening of existing health planning activities • Communication • Forums brought together key stakeholders from acute and primary settings for the first time in some priority areas • Formal inclusion of consumer and carer voice in a planning process • Methodology • Elevation of regional planning from an organisational to a service system perspective • Direction Setting • Short, medium and long term plans • Capital development

30. The Bad and the Ugly! • Partnerships and Relationships • Relationship with existing planning forums and associated resource implications • Methodology • Resource intensive • CinYC process not well aligned to Local Gov planning role • Recruitment of specialised planning skills • Time lag on progress of enabler work • Keeping action plans real and deliverable • Highlighted communication issues between region and various DHS programs • Difficulty engaging medical specialists • More work on interface with private • Direction Setting • Taking disease focus put less emphasis on health promotion and prevention • Issues relating to issues such as transport were out of scope

31. Future of the Planning Network • Currently disbanded • Have made recommendations regarding any future establishment of Planning Networks or similar planning structure including a range of principles. • Progressing low hanging fruit actions from action plans • Awaiting DHS advice on future of the planning outcomes

32. From a dream to reality...capital developments • Integrated Care centres in Victoria • No single name • Integrated Care Centres • Health Precincts • Day Hospitals • ‘Superclinics’

33. Integrated Care Centres • Cranbourne Integrated Care • Governed by Southern Health • Dialysis, AH, Counselling, Dental, RDNS, public and private consulting, Mental Health • PANCH • Provides services in partnership with, The Northern Hospital, Bundoora Extended Care Centre, Austin Health, Mercy Hospital for Women, Darebin Community Health, Dental Health Services Victoria and Darebin City Council.

34. The Super clinics • Melton, Craigieburn, Lilydale • Melton & Craigieburn • Both Greenfield sites • Similar service profile • Renal Dialysis • Chemotherapy/Day medial Procedures • Specialist Medical • Allied Health • Diagnostics • Urgent Care (but not an ED) • Other Community Health type services (paeds, antenatal etc)

35. Currently under construction Construction $13M Due to open July 2008 Small site Responsible for premature ageing and increased alcohol intake! Lilydale Super clinic – Yarra Ranges Health

36. What makes YRH different to the others? • Small and difficult site • Built next door to independent community health service • No service planning prior to capital announcement! • Political imperative to commence building prior to state election (before service profile was agreed) • Service Profile is quite different

37. Service Profile • Proposed Services • Day Surgical services • Day Chemotherapy • Palliative Care • Maternity Services • Sub-acute Ambulatory Care Services • Audiology • Mental Health • Proposals on hold • Early Referral & Response • GP Clinics (managed by Ranges Community Health)

38. Co-located health services • Independent Community Health Service • Presents challenges as well as opportunities • Governance • Funding models • Treating patients in best space • ICT compatibility • Dual workforce • Opportunity to extend community service types in to acute eg Dental Surgery • Eastern Palliative Care • RDNS • Royal Eye and Ear Hospital

39. Tips :Before you walk in my shoes • PLAN, PLAN, PLAN • Make sure all branches of DHHS are on the same page • Ensure all partners are committed to the same outcome • Manage the political agenda • Select your Community Advisory Group members carefully • Have an agreed service plan and recurrent budget before you start building!

40. From the Good, Bad and Ugly to the Excellent! The HARP Story Objectives of program • To improve patient outcomes • To provide integrated seamless care within and across hospital and community sectors • To reduce avoidable hospital admissions and Emergency Department presentations • To ensure equitable access to healthcare • Care coordination and specialty clinical services (aged, chronic disease, pharmacy, allied health & Psychosocial)

41. Current Structure HARP • Partnership between Eastern Health (5 sites), Community Health Services (6), Divisions of General Practice(4), Primary Health Care Services(2) & Primary Care Partnerships(2) • In 06-07 2432 new clients (nearly 6,500 on books) • $50M budget, over 50 multidisciplinary EFT • Funding And Service Agreements (FASAs) • Area based teams • Clinical teams

43. Drive and vision *Specialty clinical support *Voice for clinical specific issues across region Support *Assist with recruitment and give feedback for use in performance management Coordination Multidisciplinary case conferencing Relationship building with area stakeholders (E.g. ED, PCP)

44. HARP: Achievements • Consumers • Improved health outcomes • Improved capacity of self management and knowledge • Less time in hospital • More support for carers • Consumers like it! • Community engagement • Community Hospital collaboration beyond HARP • Flexible models of care developed • System impacts and reduced demand acute services

45. Some of the changes that helped us achieve our goals. • Changing from individual projects to one program (Eastern HARP) that spans all organisations • Yearly funding to recurrent funding • Changing funding from Input to Outcome funding • A Funding and Service Agreement (FASA) created and implemented Sustainability, when combined with guidelines ensures consistency and collaboration, yet allows flexibility for local arrangements.

46. Eastern HARP guidelines • Based on DHS guidelines and regional service coordination manual • Includes defined point of entry, assessment, intake and discharge criteria, care coordination role, care plan, brokerage, structures and accountability, GP notification and engagement, information management Consistency across region and a great resource for orientation of new staff

47. HARP Access • A defined point of entry • Access point for all Eastern HARP services • Central 1300 number (1300 661 141), fax number and Eastern HARP e-referral • Staffed by clinician and administration-greater satisfaction • Used regional service coordination manual (PPPS) principles • Common eligibility tool utilized, priority rated and most appropriate stream identified for care coordination Simple for referrers to navigate the system and importantly more equitable access

48. Assessment • Common assessment across all Eastern HARP services that can be shared • Specialist assessments have been created for each area • Assessments will auto populate SCTT and the Eastern HARP care plan • Also monitoring InterRai progress Greater sharing across sectors and decreased duplication

49. Care Coordination & Care plan • One and only one care coordinator across HARP at any one time • Communication by external providers occurs through one person • One care plan that is shared across all staff and shared with other providers (eg. GPs) Seamless care, greater knowledge of patient journey, and less duplication and confusion

50. IT System - Allied and Ambulatory • Eastern HARP use the same system as Eastern Health Allied Health and Ambulatory services (eg Allied Health, Post Acute Care, Sub Acute Ambulatory Care Services) • Connection of all sites both internal to EH and external partners (community health, divisions of general practice) using Citrix, aventail environment • Sharing of information-common HARP assessment, SCTT, Care plan, screening tool, diary, GP notification and engagement, unique identifier. • Ability to track patients across the continuum from an allied health and ambulatory care view point. Sharing of appropriate information across agencies, reduced duplication, improved consistency with data and improved reporting of data