At Risk Individuals ProgrameA Model of Care

August 2016

Date: Created by:

Values Vision Process

Principles• Model of Care• Planned, Proactive Care• Enhanced Primary Healthcare home• Integration

Enhanced PHC Home

Dr-Pt

PHC Team

GP Nurse

Registrar ICHO

Nurse Pract. CHW

HCA

HHC NASC

VHIULocalityCoordinator

WhanauOra

Mental Health

Social Services

Enhanced PHC Team

PHO Services:Secondary CareServices

Emergency Dept

Locality/Cluster Services:MDT:

SMO'sMental Health

Social ServicesWhanau Ora

PHO'sLocality Coord.

Self ManagementCoordinationChild & Youth

Hub:Locally based

Social servicescoordinationWhanau ora

Self ManagementSupport

LocalityCoordinator

VHIU

NGO's

Advisory & Education

E-Referals & Secure MessagingDynamic Pathways

POAC

ARI - A Model of Care

AlliedHealth

Pharmacy Midwife

Change ManagementData

Practice Relationships

Generalist team

s assoc with localities

Child & Youth Services

Palliative Care

Values Vision Process

Principles• Model of Care• Planned, Proactive Care• Enhanced Primary Healthcare home• Integration

Integrated Care Framework Integrated Care

Com

mun

ity H

ealth

Inte

grat

ion

Pla

nned

, pro

activ

e ca

re

Com

mun

ity H

ubs

Urg

ent &

unp

lann

ed c

are

Enh

ance

d P

rimar

y C

are

Integrated Care Framework

• Planned, Proactive Care– ARI– Modified DCIP & Diabetes– Community Health Integration– Self Management Support– Integrated MH & Addictions– Others……

• Urgent & Unplanned Care

At Risk Individual: Tools• Partners In Health• PHQ2 (In development)• eShared care plans• Named care coordinator in existing PHC home• eHealth summary• Access to multidisciplinary teams (MDT)• Flexible Funding

– Interventions– Quality improvement

• Combined risk score (In development)

Patient story - K• 27 yo PI woman • 5 children ages 2-9 yo• Housing NZ home• Dx acute rheumatic fever 2013• Discharged with antibiotics and follow up apts• Allergic to antibiotics & DNAs followed

The New Normal

• Medical complexity– Multiple dx– Multiple meds

• Mental health• Psychosocial complexity

– Financial– Family/Relationship

Values Vision Process

Principles• Model of Care• Planned, Proactive Care• Enhanced Primary Healthcare home• Integration

12

Proactive Planned Care

Risk stratification e-tool under development, clinical

criteria agreed in the meantime

Risk stratification2

Shared protocols & pathways3

Care delivery and coordination

5

GP Enrolled Population

1Care planning

4

Case conference6

Community pharmacist

Practice nurse

Allied Health

Districtnurse

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

14

Proactive Planned Care Risk stratification e-tool

under development, clinical criteria agreed in the

meantime

Risk stratification2

Shared protocols & pathways3

Care delivery and coordination

5

GP Enrolled Population

1Care planning

4

Case conference6

Community pharmacist

Practice nurse

Allied Health

Districtnurse

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

eShared Care Plan

16

E-SH

ARED

CAR

E VI

EWS

eSummary Record

“As we scrolled through her e-shared care plan we came to the box where her goals and aspirations had

been carefully noted. They were simple, humbling, and yet so powerful. The room fell silent. It brought the

patient into the room with us. The human being was what we discussed as we kept these goals in mind.”Gillian Aspin, Diabetes Clinical Nurse Specialist

“Patient’s plan

brings room to silence”

18

Proactive Planned Care Risk stratification e-tool

under development, clinical criteria agreed in the

meantime

Risk stratification2

Shared protocols & pathways3

Care delivery and coordination

5

GP Enrolled Population

1Care planning

4

Case conference6

Community pharmacist

Practice nurse

Allied Health

Districtnurse

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

“It’s great, now when I visit the doctor or nurse, I know they have talked about my care with those looking after me. They know me and my story and I no longer have to keep telling it.”

Karl Farell, ARI patient(photographed with his wife Ruci and CM Health Occupational Therapist Krishna Narayan)

“I feel like I’m getting my life back”

20

Proactive Planned Care Risk stratification e-tool

under development, clinical criteria agreed in the

meantime

Risk stratification2

Shared protocols & pathways3

Care delivery and coordination

5

GP Enrolled Population

1Care planning

4

Case conference6

Community pharmacist

Practice nurse

Allied Health

Districtnurse

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

Patient story – K cont. • MDT presentation

– VHIU nurse & manager– Practice nurse known to ‘K’– Local pharmacist– SMO– Mental Health– Allied Health– GPs

At Risk Individual (ARI) dashboard

For further information www.countiesmanukau.health.nz/integrated-care

Supporting patients with long term conditions to live well through more planned and proactive care and improved self management.

At Risk Current Snapshot Key numbers & stats about our current programme:

4.3

3.7

4.5

5.4

Manukau

Eastern

Mangere/Otara

Franklin

4.9

26.5

17.5

37.8

17.5

Other

Pacific

Maori

European

Asian

PATIENTS BENEFITING FROM ARI PROGRAMME Patients with long term conditions are receiving more planned, proactive care with care co-ordination and goal based care plans.

20,119

What does success look like?

MDTs are occurring within general practice cluster networks to support care planning for complex patients.

General practice clusters have broad networks of healthcare professionals supporting them.

Improved self-management means patients feel more in control and understand their health condition.

People living with long term conditions in CM will receive self-management support BY JULY 2016

Patients per year enrolled in ARI programme BY JULY 2017

60,000

SHARED CARE PLANS

PATIENTS WITH A LONG TERM CONDITION IN COUNTIES MANUKAU

20,618

427 Patients have been supported through a formal programme to help them better manage their long term condition.

Patients with a shared care plan BY JULY 2016

SELF MANAGEMENT REFERRALS

MORE THAN

30,000

50,000

30,000

PERCENTAGE OF ENROLLED POPULATION

ARI ETHNICITY

20,119 20,119

20,119

Patients with a shared care plan BY JULY 2016

Patients per year enrolled in ARI programme BY JULY 2017

People living with long term conditions in CM will receive self-management support BY DECEMBER 2016

Patients with a goal based care plan that is electronically shared with the care team members.

As at 31 May 2016

ARI: Tools – Flexible Funding• Interventions funding:

– 50% ARI budget

• Quality Improvement funding:– 10% ARI budget– Patient Engagement for 2016

• Patient Activation• Interventions to increase activation

Informed, Activated PATIENT

Prepared, Proactive

Practice TEAM

Productive Interactions

Functional and Clinical Outcomes

Community Resources and Policies

Self Management Support

-Advocacy -Resources -Skills Training -Role adaptation

Delivery System Design

-Providers -Roles Clear -Communication & Follow-up system

Decision Support

-Guidelines -Provider Education -Specialty support -Feedback

Clinical Information Systems

-Registries -Reminders -Measurement -Feedback

Health System Organization of Health Care

Overview of the Chronic Care ModelRobert Wood Johnson Foundation/Sandy MacColl Institute

STEPPED CARE SELF CARE SMS PROGRAMMES

ACTIVATED PATIENT PROACTIVE PRACTICE TEAM

Complex cases with comorbidities 3-5% all cases

Higher risk cases 15-20% LTC

70-80% LTC

LTC

COMMUNITY AT RISK

End of lifeDHB Maori & Pacific teamsFront doorLocality coordinatorVHIU

PHO:SIA $$

eShared CarePrimary Health CareHomeCCM Depression, CHSI

ARI

NGO’s“Activated Community”Community Partnerse.g. alcohol strategy

LocalitiesPHO’s

Community based models: - church - gyms- NGO’s - green Rx

Group models: Practice based

Virtual: text, internet, social media, apps ….

DCIP

Modified DCIPFrailty, fallsIntegrated mental health

1:1 PHC based Health coachingPeer support

LEVEL 1Supported Self Care

LEVEL 2Shared Care

LEVEL 3Intense Professional Care (case management)

(High tech)

ARI patients who have had 3 episodes or more in the 12 months before enrolment in ARI have reduced ED attendance rate and reduced IP episodes following enrolment in the programme.

Improved patient outcomes –diabetics had 6% shift from poor to good control when enrolled in ARI

Compared with 2% shift for non-ARI.

Improved self ratings across 8/10 of the PiH dimensionsAve change in score 4.27% (statistically sig.)

“I was down in the dumps. I had no oomph. This is the first time anyone has taken the time to explain things and work with us. They taught us how to eat better. My cholesterol has more than halved, I’m back to gardening and have just finished off building a deck!”

Stu Bogun, Patient, Greenstone Family Clinic

“The flexibility of funding has meant we can spend more time with patients.

As a result they are more engaged in

managing their own health. We’ve seen incredible results.”

Devika DayalNurse Leader

Greenstone Family Clinic