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Mr Hamish FranklinExecutive
Integrated Care
Green Cross Health
University of Auckland
9:20 - 9:45 Reducing Demand and Improving Outcomes Through
Continuous Care
CHANGE IN PRIMARY CARE FUNDING
MANAGING DEMAND: SIMPLY
• The problem: the situation in general practice is consistently challenging
–Work is frantic: a constant stream of 15 min sessions, often shorter if there is an urgent care queue
–The paper work; clearing the red dots and inbox and happens from 5.30pm onwards
• Capitation makes General Practice a stakeholder in risk managing the population, yet in many cases practice capitation is nearly exhausted by demand
• The opportunity presented by managing demand: for practices to survive the current funding pressure, and for the workforce to have a lifestyle that is sustainable
WHERE DOES THE DEMAND ORIGINATE?
• Lets look at the demand through a lens that aligns with funding
$(500.00)
$(400.00)
$(300.00)
$(200.00)
$(100.00)
$-
$100.00
$200.00$
Number of patient visits (utilisation)
Retained earnings per patient per visit
Total Revenue Total Costs Retained capitation
0 1 2 3 4 5
CAPITATION: GENERAL PRACTICE AS A RISK-HOLDER
No. of visits
PRACTICE POPULATION SEGMENTED BY RETAINED CAPITATION
Higher cost
Higher value
Avg. 1.0 visits
Avg. 6 visits
39%visits
61%visits
Funding > utilisation
Funding < utilisation
78%pts
22%pts
19Kpts
39Kvisits
Avg. 2.0 visits
PRACTICE POPULATION SEGMENTATION
GP SEGMENTATION
GREEN CROSS COLLABORATIVE CARE
A further look into higher utilising patients, with high clinical need
Age Group Count of Pts Total Visits Avg Visits 0 to 12 48 226 4.71 13 to 17 8 25 3.13 18 to 24 18 84 4.67 25 to 44 95 424 4.46 45 to 64 81 480 5.93
65 and over 19 188 9.89 Total 269 1427 5.30
WHAT CAN BE DONE SIMPLY?
• Proactive repeat medicines management
–Patients prompted to ask GP to review (and renew) medicines prior to script expiry
–Highlight to GP pre-booked appointments, outstanding recalls if any, and potential opportunities for synchronising medicines
• Using entirely existing workflows & tools
• 45% response rate from patients
TARGETED INTERVENTION STRATEGIES
NHH Model: Migrate these people using phone and email to significantly reduce utilisation
Improve self manage and drive to remote models of continuous care
Many of these people are ill, or pre-ill, and in need of illness prevention interventions
RISK STRATIFICATION
• How do we effectively risk manage the population
–A lot of effort has gone into predicting hospitalisations
–But General Practice is incentivised to maintain the health of it’s population (not just keep them out of hospital)
–So lets help people maintain and improve their health – by intervening with those most at risk of health decline. How?
–By understanding illness severity, and illness trajectory – and target those whose health is in the most serious decline
RISK STRATIFICATION APPROACH TO SELF MANAGEMENT
•We use risk stratification to identify those at some risk of health deterioration
•We prioritise those at most risk of illness decline (based on the trajectory of their illness decline)
Acute presentations
(patients visiting frequently)
People who are for the most part
in good health
People at high risk for illness/health decline
People at moderate risk for illness/health decline
RISK STRATIFICATION
Illness Trajectory Factors ‘Valence’
Measure Description Reduce Increase
BP Sys Systolic blood pressure +ve -ve
LDL Low density lipoprotein +ve -ve
HDL High density lipoprotein -ve +ve
TC Total Cholesterol +ve -ve
eGFR Glomerular filtration rate -ve +ve
TG Triglycerides +ve -ve
BMI Body Mass Index +ve -ve
CVD risk Cardiovascular disease risk +ve -ve
HbA1c Haemoglobin A1c +ve -ve
ACR Albumin creatine ratio +ve -ve
Weight Kg +ve -ve
RISK STRATIFICATION REPORTS ID PATIENTS FOR SELF-MANAGEMENT SUPPORT
RISK STRATIFICATION APPROACH TO POPULATION HEALTH
Acute presentations
Package 1:High intensity, MDT led care
Package 2: Nurse led, Health Coach
managed (3 months intense support)
Package 3: Health Coach led, self mgmnt focus
(2 months intense self-mgmnt support)
•Within the at-risk group, we have three tiers of support, depending upon the person’s clinical needs
• The MDT assigns patients into each package of care
People at moderate risk for illness/health decline
OUR APPROACH
•We use risk stratification to identify the next tier of people with declining health status, particularly those most disengaged with their GP
•We collaboratively (with Pharmacy) engage these people in low cost self-management programs to proactively improve their health behaviours
Acute presentations
(patients visiting frequently)
People who are for the most part
in good health
People at high risk for illness/health decline
People at moderate risk for illness/health decline
HEALTH COACHINGIMMEDIATE IMPACT AND SUSTAINED BEHAVIOUR & OUTCOME CHANGE
Control Blood Pressure Target Achievement
Sys BP 140 (baseline 165)
Coaching plus collaborative care platform
Coaching without collaborative care platform
Traditional GP care
HEALTH COACHINGEVIDENCE OF EFFECTIVENESS
Blood Pressure
Target Achievement
<140/90
Office Visit Reduction
Total Cost of BP Care
(per patient per year)
COACHING & SELF-
MANAGEMENT
56%
NOT PUBLISHED
$2,693
100PATIENTS
COACHING + CARE
PLATFORM
85%
66%
$1,498
250-500PATIENTS
STANDARD VISIT-
BASED CARE
30%
NONE
$2,130
N/APatients Per Coach
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