Northland Integration

1. Northland Integration Dr Nick Chamberlain July 2014

2. Kotepaetata, whakamaua, kiatīnā Kotepaetāwhiti, whaia, kiatata This whakataukī, provided by Professor Sir Mason Durie, might be interpreted as “secure the horizons that are close to hand and pursue the more distant horizons so that they may become close”, or he suggests it can be put even more simply as “manage today and shape tomorrow”.

3. New Zealanders enjoy good health outcomes ... • Amenable mortality (PPYL) rates are around the OECD average • Acute care quality. Hospital fatality rates for heart attacks are among the best in the OECD

6. So, Everything is going well!

7. Northland Health Services Plan (NHSP) Drivers • Growth in acute services, ED • Growth in GP services • Ageing population • Long term conditions • (esp diabetes) • No extra funding • 170 extra beds • $70m in the red annually • If we carry on as before, in 15 years:

8. Getting the balance right = The Triple Aim • Population • health • Improving health status overall and reducing inequities • All decisions should be made by balancing three factors... • Simultaneously • Value & • sustainability • How wisely we use our resources; value for money • Patient experience • How the system deals with people; quality and safety

9. ... there are some areas for concern. • Marked income and ethnic disparities, suggesting barriers to access for some • Primary care performance appears mixed • e.g. Admission rates for asthma and COPD are relatively high

11. We have highquality General Practice but still: • Inequities - funding (Our VLCA issue), Access, and health Outcomes • Fragmentation and Multiplication - feedback • Unco-ordinated, Unconnected Care • No clear focus on high risk population • Acute demand….

12. Population Changes • Key Points: • 3% increase overall in Northland population since 2006 - but de-population especially in economically deprived areas • 29.6% of Northlanders identify as Māori • Māori represent 48.3% of the <5yr population; overall the <15 year population is declining

13. Key Points: • A net loss of more than 5600 people in the 30-50 year age group in Northland since 2006 (14% decline). • 1065 were Māori; of these 774 were from FNDC • Ageing: >50 years, growth in all age bands…

14. Explaining Inequities in Health • Differential access to health determinants or “exposures”, leading to differences in disease incidence • Differential access to health care, and • Differences in the quality of care received. Camara Jones (2001)

15. Drinking and smoking • Small decline in hazardous drinking • Decline in regular smoking (2006-2013 Census data) – but rate of decline lower for Māori (16%) than for Non-Māori (28%)

16. Obesity –NZHS 2013 data • Just under half of Northland Maori surveyed (48.9%) had a BMI indicating obesity • Increasing obesity was seen for Northland Maori women (from 44% to 54%) • and non-Maori women in Northland (from 23% to 27%)

17. Differential access to health care in Te Tai Tokerau • National and local evidence for differential access e.g. rates of GP utilisation, NZHS data re cost and other barriers, etc • Large inequities in Ambulatory Sensitive Hospitalisation (ASH) rates in Te Tai Tokerau across age groups and conditions

18. Unmet need in primary care

19. Prescriptions unfilled due to cost

20. Visited dentist only for pain, or never visited

24. Case Study: ASH Respiratory Admissions in Children <15yrs • Te Tai Tokerau (2010/11 – 2012/13) • Overall decline in ASH respiratory admissions in <15yrs olds • Represents ~100 fewer children admitted/year in 2013 compared with 2011 • Healthy Housing insulation programme and better asthma management in Primary Care are likely contributors to this improvement • But inequity remains (Māori rate double non Māori)

29. General Practice • “A marvel to get through the morning without any mistakes but a miracle to get through the afternoon as well” • Don’t know error rates, but likely to be as high as 20% • Adverse drug events are the fourth largest cause of admissions to ED in USA

31. Workforce Slide from NZ Doctor

32. Workforce Slide from NZ Doctor

33. Now • 2 PHO CEOs on DHB ELT – Everything shared • NPHOs • Four IFHC projects – little integration so far • 100% E-referrals for 2 years. Specialist E-advice significant reduction in FSAs. Multiple Integration IT pilots. • Maori Provider nursing, District Nursing, Aged Care Nursing, HBSS, Physios, OTs, Social Workers, Dieticians, Pharmacists, Ambulance – plenty of resources, multiple organisations disconnected with General Practice

34. What you’re saying about Hospital Care- GP Survey • Response rate: • Only 1/3 of GPs have responded. A higher response from TTT • This compares with 80% in BOP survey. • A high level of appreciation for service responsiveness   • Areas of concern • Three services stand out in terms of concern: Pain management, Orthopaedics, Dermatology. • Timeliness and content of discharge summaries • Other themes: • Need for better communication, integration and more joined up services, • eReferrals work well but could be further developed • Doctor etiquette

37. England, 4 case studies • GP based integration • 3 & 4. Virtual wards in Torbay and Devon • Care planning and MDT for frail older people and those with diabetes. Working in clusters of 30k-50k geographic localities • GP practices participating in care planning. Monthly mdt to review complex patients. Risk stratification. • Whole system governance, shared IT system • Target: avoid 1 admission per month per GP • Early evaluation shows that it is working to reduce ARC and acute hospital admissions. • Disease management • ‘My integration is your fragmentation” • 1. Integrated CHD/stroke service • Disease management carve out. lead provider is specialty hospital. Commissioned for outcomes. Eg 85% of eligible people complete cardiac rehab • 2. Pennines musculoskeletal partnership - GP triage and management of MSK referrals. • 7

38. Greenwich Integrated health and social care Single point of access for referrals and immediate response to prevent admission Joint emergency team – provides care at home within two hours. Stays with patient for a max of 5 days. Runs 13 hours a day. 24 staff in team. Nurses, swk, physio. Covers population of 270k Five collocated cluster teams – FTE numbers needs based core team: social worker, care coordinators, DNs, podiatry, physio. In future also mental health Three re-enablement teams – 6 weeks rehab plus ongoing care - mainly health care assistants directed by physio, OT Risk stratification approach - targeting hi risk, hi need individuals. • 8

39. Tower Hamlets on the Isle of Dogs Federation (network) of localities with 4-5 GP practices per locality - about 30k pop Achieving better outcomes and managing acute demand. Winning tenders for further services incrementally,e.g. cardiac rehab, mental health, etc Incentives - in the order of $8mfor 35 practices. 280k pop Tele health - Hurley group is aiming for 80% consults outside the building. Using structured e-consults, symptom checkers and pt initiated risk stratification • 9

40. Zorggroep, Almere, Netherlands • Living at home as long as possible in a supportive environment. Admission as short as possible • Locations in the neighbourhood Strong infrastructure of primary carein a healing environment • One philosophy - Planetree • GP surrounded by pharmacist, midwife, nurse, dietician, social worker, mother and child care, physio, dentist • 3 X 15,000 population practices to form 40,000 population nodes Built around the patient rather than the GP. Around them is informal caregivers, then primary Health care, then intramural hospital care

41. Don Berwick Keynote

42. “manage today (and together) let’s shape tomorrow”

43. Leadership "Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has."  Margaret Mead

44. Leadership http://www.youtube.com/watch?v=t3DDjeVeJu4&feature=related