COLOUR CODE - IFIC · 4. Risk prediction tools and strategies 5. Workshop: Policy design and implementation for a new paradigm Chaired by Nick Chamberlain 224 No single intervention

Draft Programme – subject to change 1

COLOUR CODE

Theme 1. Promoting the health of children and families

Theme 2. Engaging and empowering people and communities

Theme 3. Re-orienting the model of care

Theme 4. Taking measures to improve quality

Theme 5. Funding and incentives that promote health outcomes

Cross-cutting Theme: Education & Training in association with the Integrated Care Academy©

Cross-cutting Theme: Implementation

International Journal of Integrated Care

* Denotes that paper or poster has been selected for Best Paper/Best Poster Award ** Nominated by two reviewers


Wednesday, 23 November 2016

07:30

Registration, refreshments, exhibition, posters and networking

9.00 – 10.30 PARALLEL SESSION 1

1. Workshop: Developing policies to support integration of mental health services

2. Workshop: Value-based approaches to Integrated Care

3. Workshop: Improving transitional management, introducing the Special Interest Group on Intermediate Care

4. Workshop: Learning from iCOACH: implementing integrated care for older adults with complex health needs (209)

5. Redefining the role of pharmacists: the New Zealand experience

Chaired by Prof David Perkins, University of Newcastle, Australia So much planning in Australian mental health, so little change: towards an implementation toolkit (200) (Roberts, Russell James et al) A Whole of System Mental Health and Addiction Integration Transformation Agenda in Counties Manukau (226) Tess Ahern, General Manager, Mental Health and Addictions and Wendy Brown, Service Development Manager, Mental Health and Addictions, Counties Manukau Health Mental Health Integration Past, Present and Future: National

Chaired by Valentijn, Pim Peter Value-based integrated care: Exploring strategies to enhance the uptake of integrated care (145)

Chaired by Prof Anne Hendry A tale of two hemispheres - introducing the Intermediate Care Special Interest Group (Anne Hendry, IFIC Scotland, Lucy Fergus, Hawkes’s Bay DHB) Identifying communities at high risk of re-admission in Singapore and understanding their needs during transition of care from hospital to home (157) (Chan, Darren Yak Leong et al) Assessment tool for early prediction of patients in an acute hospital requiring long term institutional placement (151) Melissa Chew, Principal Medical Social Worker, Tan Tock Seng Hospital

Chaired by Walter Wodchis This session will review the policy context and research approach exposed through policy, organizational and provider level interview approaches and key findings in the iCoach project. Presenters: Walter Wodchis on policy context and overall research program goals and approach Mylaine Breton on organizational level approach and findings to date Tim Kenealy on understanding the provider’s role and outcomes from participating in integrated care programs Patient and carer perspective: Frank and Rhene Hanson

Chaired by Karen Evison, Ministry of Health NZ Supporting Medicines Adherence (165) (Hannon, Robbie) Better than an iPad app, a Clinical Pharmacist in your practice (168) (Duck, Brendan James et al) 178 Reshaping the Existing Landscape: a collaborative approach to managing diabetes in General Practice Sandy Bhawan, Programme Development Manager, Te Awakairangi Health Network 38 A Service Evaluation of the impact of a Pharmacist Prescriber managing patients with diabetes in primary care


Survey into Mental Health Integration in England (212) Emad Lilo, Integrated Care Demonstrator Site Project Manager, Social Care Professional Lead, Quality Innovation Centre, (QiC)

Towards Integration: Dispatches from the Front Line (218) (Pert, Harry et al) Can we predict who we will see in hospital next year? (192) (Navin-Cristina, Tina)

Discussion and Q&A Kerry Anne Muller, Pharmacist Prescriber in primary care, Te Awakairangi Health Network, Lower Hutt, NZ 42 Nurse practitioners and pharmacist prescribers in primary health care: A realist evaluation of the New Zealand experience Tara Officer, PhD Candidate, Health Services Research Centre, School of Government, Victoria University of Wellington *

6. Crosscutting Education - Integrated Care Academy © Part 1

Chaired by Viktoria Stein, Robin Miller and Jacquie Cummings - What is Integrated Care?

Overview of concepts, models and tools. (Viktoria)

- What is the international evidence about impact and key success factors including culture and values (Robin)

- Implementing integrated care in the NZ context: policy, data, impact and challenges (Jackie)

Group discussions throughout


10.30 – 11.00

Refreshments, exhibition, posters and networking

11.00 – 12.30

PARALLEL SESSIONS 2

1. Promoting a healthy life through education and activation

2. Workshop: Case studies highlighting integrated mental health services

3. Workshop: Whanau Ora and Te Tiriti

4. Risk prediction tools and strategies

5. Workshop: Policy design and implementation for a new paradigm

Chaired by Nick Chamberlain 224 No single intervention will solve the obesity epidemic – RACP physicians and paediatricians exploring points in the life cycle to prevent and manage obesity for children and families Professor Chris Bullen, The Royal College of Physicians, New Zealand 177 Health 4 Life. Improving Maternal Physical Activity and Nutrition Tanya Radford, Health Promotion Team Leader, Te Awakairangi Health Network and Tricia Keelan, General Manager | Māori and Population Health, Compass Health 134 Supporting Weight Management in Primary Care - ABO Programme – Brief Opportunistic Intervention &

Chaired by Prof David Perkins, University of Newcastle, Australia Clinical Video Telehealth for Mental Health Care: Operations, Engagement and Outcomes (160) (Naseem, Ahsan) The decentralization and integration of Norwegian psychiatric services and possible implications for coercive practices (115 + 149) (Wynn, Rolf and Myklebust, Lars Henrik) CDHB/ Police Watch-house Nurse Initiative (95) (Howie, Stephen James) Implementing new models of integrated mental health care: what impacts effective performance? (126 + 130) (Ehrlich, Carolyn)

Chaired by Keelan, Tricia, Compass Health Searching for Te Tiriti in Primary Care (203)

Chaired by Tracy Johnson, Denver Health Optimising Resource Use in General Practice with Predictive Risk Modelling (180) Damien Hannah, Product Manager, Clinical & Change Management, ProCARE Stratification of patients by risk of acute hospitalisation – algorithm development and implementation (163) John Grant, Director of Business Intelligence and Martin Hefford, CEO, Compass Health 137 Identifying and Selecting Patients for Integrated Care Interventions in NSW: Unpacking Risk Stratification Erin Lilley, Integrated Care Program Manager, NSW Ministry of Health A Real-time Frequent Hospital Admitter Risk Stratification

Chaired by Chai Chuah and Prof Anne Hendry Population base integrated care in Poland- policy process (221) (Koziel, Anna et al) The Five Eyes of Innovation (198) (Yap, Jason) Evolving Integrated Care: Moving Towards a Population Health Approach (129) G. Ross Baker, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto Transformation lab – to sustainability and beyond Chai Chuah and Prof Anne Hendry


Ongoing Management (Jones, Philippa Mary)

Call To Action Through Sport (Sweeney, Dave) (91+92)*

Model (FAM-FACE-SG score) to predict “Familiar Faces in Singapore” (11) Dr. Low Lian Leng, Singapore Health Services Integrated Care for Emergency Medical Patients - Irish Acute Medicine Programme (93) Dr Orlaith O Reilly, National Clinical Advisor and Programme Lead, Health & Wellbeing, Health Service Executive – South (SE), Ireland


6. Crosscutting Education - Integrated Care Academy © Part 2

Chaired by Viktoria Stein, Robin Miller and Jacquie Cummings - Introduction of the Project

Integrate Evaluation Framework (Viktoria)

- Discussion and reflection in small groups on where we stand with implementation: in our organisation, profession, local context

- 'And now what?' - how can academics, practice and policy work together: discussion and sharing of examples

- Wrap-up: building a learning environment

12.30 – 14.00

Buffet Lunch, exhibition, posters and networking

13.00 – 14.00

Lunchtime Workshops

1. Oral Poster Session: Engaging children, families and communities

2. Workshop: Whanau Tahi

3. Workshop: Quality Expeditions for GP Federations (13)

4. Workshop: IBM Watson Health - Cognitive care management improves integrated care in Harrow (119)

Chaired by Dr Andrew Wilson


Perceptions about Perinatal Deaths in the Mountainous Villages of Nepal: Fatalism and Acceptance Contributing to Poor Perinatal Survival (171) (Paudel, Mohan) An integrated model of care for children at risk of developing chronic respiratory disease (64) (Aish, Harley et al) 56 Where Youth Health and Youth Justice Intersect Robyn Sharp, MN, Team Leader Health Services, Rotovegas Youth Health @ Te Maioha O Parekarangi Youth Justice Residence and Christine Betchetti, Team Leader Clinical Practice, Te Maioha O Parekarangi, Youth Justice Residence, Child, Youth and Family Professionals mastering identity ambiguity to improve participation in a small-scale nursing home (161) (Koster, Luz Angela) engAGE – Local Integrated Multidisciplinary Teams for Older People (197) Dr Lucy Fergus, Geriatrician

Chair, NHS South Cheshire CCG & AQuA Fellow in Leadership for Quality 2016

Social care accounts for as much as 40% of a typical London Borough’s budget and could soon exceed all other council spending. IBM Watson Health and the London Borough of Harrow are taking an integrated approach to health and social care programmes and to improve individual choice in UK health and social services through the facilitation of personal health budgets, the use of cognitive technology, and care management best practices. Councillor Anne Whitehead, Harrow Council Martin Duggan, Director of Strategy and Market Development, Social Programs, IBM Watson Health


Older Persons Health, Rehabilitation and Allied Health Sevices, Hawkes Bay Hospital 3 Tweets are not always supportive of patients with mental disorders (Wynn, Rolf et al.) *

14.00 – 16:00

PARALLEL SESSIONS 3

1. Co-designing care – empowering people

2. Improving patient journeys through integrated care pathways

3. Creating networks to provide holistic care for vulnerable populations

4. Measuring integrated care to improve quality

5. Implementation: Using data to improve service design

Chaired by Vince Barry, 22 Respiratory Patients Breathing Life into the Canterbury Integrated Respiratory Service Louise Weatherall, Community Respiratory Nurse, Canterbury Clinical Network 223 Using co-design process to develop care options for people with chronic and complex care needs across four community health services in the Southern Melbourne Primary Care Partnership, Debra Starr, Central Bayside Community Health Services Parkdale, Victoria Australia

155 Integrated management pathways for alcohol and drug clients into treatment (impact) service reduces emergency department visits (Demirkol, Apo et al) 217 A randomized controlled trial measuring the effectiveness of a biopsychosocial integrated care model, care pathway and enhanced patient navigation for the management of patients with Chronic Obstruction Pulmonary Disease (COPD) in the community (Kannusamy, Premarani)

The Inner Sydney Urban Partnership for Health and Wellbeing (146 + 190) (McGeorge, Peter et al) Equally Well: together we are making a difference (85) (Lockett, Helen) * Re-orienting models of care: the creation of integrated physical and mental services (143) James Baker, Simon Besley and Allison White, North Sydney Local Health District Mental Health & Drug and Alcohol * Assessment and Management of Self Harm in Emergency

Chaired by Les Toop 36 GPVu: Your Practice Insight (Allen, Gary) 127 Integrated care for participants attending general practice: a record linkage study based on the 45 and Up population cohort study Julie McDonald, SEaRCH South Eastern Sydney Research Collaboration Hub, University of New South Wales 75 Patient Reported Measures: Delivering Outcomes and Experiences that matter to patients in NSW (Tinsley, Melissa)

Chaired by Gregor Coster 81 Transforming child health through the delivery of an integrated health information programme Bronwen Warren, Service Manager Child and Youth Health, Pinnacle Midlands Health Network ** 54 Precision Driven Health: A New Zealand Research Partnership (Dobbie, Gillian) 187 The development story of creating a whole of system cloud-based platform for supporting quality improvement for integrated care (Carswell, Peter)


Linda Betts, Linda Betts & Associates, Essendon, Victoria Australia 158 Empowering Community-Driven Change: Leadership in Southcentral Foundation’s Nuka System of Care (Gottlieb, Katherine) Developing an improvement leaders fellowship programme and the evaluation of the integration of patient fellows (114) (Myron, Rowan Rachel et al.) 213 The Unmet Needs of Patients and Carers within Community Based Primary Health Care Kerry Kuluski, Scientist, Sinai Health System and Assistant Professor, Institute of Health Policy, Management and Evaluation, University of Toronto

179 Better Journeys for People with Dementia in Northern Sydney (Olivetti, Lyn et al.) * 193 Integrating care planning for cancer patients: A scoping review (Khan, Anum Irfan; et al) Standardising care for heart attack (STEMI) patients, Ireland (199) Dr. Siobhan Jennings, Consultant Public Health Medicine, Department of Public Health, Dr. Steevens's Hospital 19 Developing a culture of health through a prevention pathway in a French Mediterranean region (Reuzeau, Jean-Claude et al)

Departments in Ireland: The National Clinical Programme (204) (Wrigley, Margo) Relationships count – person centered wellbeing support in general practice (80) Dr Sue Copas, Community Participation Manager, Auckland District Health Board

188 Development and testing of the Provider and Staff Perceptions of Integrated Care (PSPIC) Survey: Provisional results Sarah Derrett, Associate Professor in Public Health (Health Systems & Public Policy) and Director – Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago* 28 A marketing approach to innovation in chronic care: new value for patients in Lombardia region Dr. Elena Bellio, Department of Marketing and CERMES Centre for Research on Marketing and Services, Bocconi University, Italy 62 A Systematic Review of Indicators to Measure Population Health Professor Julian Thumboo, Director, Health Services Research & Evaluation, SingHealth Regional Health System, Singapore Health Services*

Using Front Line Networks to Develop and Implement Data Driven Policy (67) Richard Lewanczuk, Alberta Health Services, Canada Preliminary report of unmet needs in persons living with physical deficiencies in Quebec, Canada: a target for service integration (154) Michel Raîche, PhD Associate Researcher, Research Centre on Aging, CIUSSS-Estrie CHUS


6. Workshop: The Pegasus Health Small Group Education Programme (12)

Led by Dr Caroline Christie, Pegasus Health

16:00 – 16.30


16.30 – 18.00

PLENARY 1 – Taking measures to improve quality

Chaired by Dr Janice Wilson, Chief Executive, Health Quality & Safety Commission (HQSC) Using frameworks to measure and promote quality and integrated care: lessons from USA Dr Richard Antonelli, Medical Director of Integrated Care, Medical Director of Physician Relations and Outreach, Boston Children’s Hospital/ Harvard Medical School Getting the measure of integration: lessons from New Zealand (185) Richard Hamblin, Director, Measurement and Evaluation, Health Quality & Safety Commission Real-life data analysis and evaluation at the Clalit Research Institute: Data-driven policy in action for improving quality Dr Maya Leventer-Roberts, Director Translational Policy, Clait Research Questions and discussion

18.00

Welcome Drinks

19.30 (TBC)

Stakeholder Dinner (Invitation only)


Thursday, 24 November 2016

Main Theatre

8.30 – 9.15 Powhiri

9.15 – 9.30 Official Opening Hon Dr Jonathan Coleman, Minister of Health and Minister for Sport and Recreation, Ministry of Health

9.30 – 11.00

PLENARY 2 – Promoting the health of children and families/whanau

Chaired by Professor Alan Merry, Chair, Health Quality & Safety Commission (HQSC) Developing integrated care models for children and their families

Fionnagh Dougan, Health Service Chief Executive and Frank Tracey Executive Director, Community, Mental Health and Statewide Services,

Children’s Health Queensland Caring for Country Kids: Improving the Health and Wellbeing of Children in Rural and Remote Areas Lindsay Cane, CEO, Royal Far West ‘Caring for Country Kids’, Sydney, New South Wales, Australia

Next Generation Study Dr Judith Sligo/Assoc Prof Bob Hancox, Otago University

11.00 – 11.30

Refreshments


11.30 – 13.00

PARALLEL SESSIONS 4

1. Healthy children: whanau ora around the world

2. Technology-supported care 3. Towards health care homes (medical homes) in local neighbourhoods

4. What influences policies? Analysing the past to influence the future

5. Implementation: QI frameworks to support change

Chaired by Frank Tracey Ha ngawiri (Breathe Easy) (141) Katie Inker, Nurse Practitioner and Marlene Whaanga Dean, Community Health worker, WHAIORA (Maori Health Organisation working to promote health and wellness in the Wairarapa) Mana Tu Diabetes (201) (Jansen, Rawiri) Improving Integrated Management of Newborn and Childhood Illnesses in Northern Uganda (58) (Chitashvili, Tamar) ** Kids GPS Integrated Care - Leaving the Ivory Tower (49) (Altman, Lisa) 69 Paediatric Optometry Alignment Project: towards interprofessionality between paediatric eye care providers Dr Dana Newcomb, GP Liaison, Children’s Health Queensland

Chaired by Fiona Thomson, GPNZ 106 Promoting Patient Empowerment and Engagement in Care: The U.S. Veterans Health Administration (VHA) Home Telehealth Program Mary Walker, DNP (Doctor of Nursing Practice), Veterans Affairs (VA) Veterans Integrated Service Network 23 Telehealth Program Manager, Veterans Health Administration 215 Chronic Heart Failure Care Model for Home Monitoring of Patients Dr Rajiv Jayasena, Business Relationship Manager & Victorian Lead, eHealth Research Program, CSIRO Health & Biosecurity Business

Unit and Iain Edwards, Director

of Integrated Care & Dental, Peninsula Health 2 Patient centred care - Green Cross Health's approach to managed disruption (Simon, Jonathan Edward)

Chaired by Jeff Lowe 5 Preliminary Experiences with the Integration of a Patient-centered Medical Home into Ambulatory Healthcare Services Centers in Abu Dhabi (Baynouna Al Ketbi, Latifa Mohammad et al) 100 Weaving many strands: Northland Neighbourhood Healthcare Home Development Liane Penney and Jenni Moore, Northland DHB 72 Integrated Healthcare Homes & Neighbourhoods: governance, clinical, managerial & evaluation matters Prof Siaw-Teng Liaw, UNSW Medicine Australia** 26 The Western Sydney Integrated Care Program: Qualitative Evaluation Dr Steven Trankle, Research Fellow, School of Medicine, Western Sydney University

Critical Success Factors for Regional Health Systems - An International and Local Comparison of What Makes Regional Health Systems Tick (207) (Yap, Jason) Integrated Care: Better and Cheaper (7) Prof Guus Schrijvers, Chair, International Foundation for Integrated Care (IFIC) Inter jurisdictional governance for a health system – is it possible? (111) Nicholson, Caroline, Honorary Senior Lecturer, Discipline of General Practice, School of Medicine, University of Queensland 97 Reform but no change: The case of aging at home policy in Ontario, Canada (Peckham, Allie et al) Predictive risk modeling: Policy applications and considerations. Tracy Johnson, Denver Health

Chaired by Ros Rowarth 107 South Island Well Child Tamariki Ora Quality Improvement Project Anna Foaese, South Island Well Child and Tamariki Ora, Quality Improvement Project Manager, South Island Alliance Programme Office and Michael McIlhone, Director of Nursing, Pegasus Health 142 Sharing coordination of Health Services on Flinders Island using an applied continuous quality improvement approach Dr Sarah Ahmed, Clinical Epidemiologist, Primary Health Tasmania and Angela Smith, Nurse Unit Manager, Flinders Island Multipurpose Centre * 169 Planned Proactive Care – a quality improvement framework for Primary Care Dr Tim Hou, GP Clinical Lead Planned Proactive Care and


and GP, Mater Refugee Complex Care Clinic Hannah Johnson, Project Officer, Queensland Children’s Eye Health Strategy, Children’s Health Queensland

174 Owning My Gout – Engaging people with Gout in a Pharmacist-Led Collaborative Gout Management Service (Rolland, Ta-Mera Cherina)

Lucy Hall, Programme Manager - Integrated Care Team, Counties Manukau Health

6. Implementation: Engaging the workforce to lead change

1 Relationship Centred Practise (Phillips, Andrew John) 176 Integration between general practitioners and other health care providers in New Zealand in 2015 (Townsend, Frances et al) 39 Engaging Clinicians to lead improvement of care integration Sharyn White, Director of System and Service Integration – Northern NSW, North Coast Primary Health Network 128 Implementing peer support workers in clinically oriented sub-acute mental healthcare teams: New approaches - new challenges (Ehrlich, Carolyn et al)


13.00 – 14.30

Buffet lunch, exhibition, posters, networking and lunchtime workshops

13.30 – 14.30

Lunchtime Workshops

1. Workshop: Curricula Development for Integrated Care

2. Oral Poster Session: Using technologies to improve services

3. Workshop: Implementation – the experience with medical homes in Australia and North America

4. IJIC: Meet the Editors

Chaired by Christopher Kewley Confronting the paradigm of discipline specific expert knowledge: Is professional integration the Holy Grail for sustainable and authentic models of co-production and integrated care? (125) (Kewley, Christopher) Integrating Our Knowledge of Integrated Care – A Framework for Knowing, Understanding, Improving and Sharing What We Know (208) (Yap, Jason CH)

Chaired by Albert Alonso 66 Electronic alert on diagnosing an HIV indicator condition in Primary Care (Cayuelas, Laia et al) 136 The usability, usefulness and use of a national collaborative IT platform for the purpose of continuity of care Chelsea Ah, Senior Manager, Clinical Transformation Services Information Services Division, MOH Holdings Pte Ltd 71 eHealth and Integrated Primary Health Care Centres (Liaw, Siaw-Teng et al) 59 Seeking to Understand the Patient Experience & Co-Design a Self-Management App (Charles, Jocelyn Elizabeth)

Chaired by Rahbar, Safa Majidi et al 205 Discussion on the Implementation of the Patient Centred Medical Home model - Experiences from Australia 182 Health Care Home - what is it? (Parker, Helen) + Prof Claire Jackson and Dr Richard Antonelli


21 Retrospective Analysis of Telemonitoring (RATE) Veronica Gonzalez-Arce Research & Evaluation Officer | Integrated Health Care, South Western Sydney Local Health District 18 Admission 2 Discharge Together (A2D) – improving the hospital journey for people with intellectual disability Lif O’Connor, Clinical Nurse Consultant, The Metro-Regional-Intellectual-Disability Network, South Eastern Sydney Local Health District 184 Practice Population Profiling – Using PMS data for patient and practice benefit Dr Hwell Lloyd, Director of Health Informatics and Chris Churcher, General Manager, Health Informatics, BPAC Clinical Solutions LP Diane Taylor, Team Leader, Planning and Performance and Paul Abernethy, General Manager, Programmes and Practice Development, Te Awakairangi Health Network


Main Theatre

14.30 – 16.00

PLENARY 3 – Reorienting the model of care

Chair Dr Jeff Lowe, Chair, General Practice New Zealand (GPNZ) Integrated Care in Action: The Counties Manukau Experience (105) Benedict Hefford, Director of Primary Health and Community Services, Counties Manukau Health Moving towards Integrated Care Organisations (ICOs): Lessons from the Basque Representative from O+berri / Basque Foundation for Health Innovation A vision for general practice and a sustainable health care system: lessons from Australia Dr Steve Hambleton, Chair, Queensland Clinical Senate Questions and discussion

16.00 – 16.30


16.30 – 18.15

PARALLEL SESSION 5

1. Improving access to services and information for hard to reach populations

2. Empowerment through self-management

3. Key enablers for multi-disciplinary and inter-sectoral collaboration in primary care

4. Integrated care measurement frameworks

5. Better value for money

Chaired by Ron Durham 30 Dilly Wanderer initiatives – Wollondilly Health Alliance Paige Brown, Project Manager, Wollondilly Health Alliance, Ally Dench, Executive Director

Chaired by Campbell Brebner 51 Introduction of the DESMOND Programme for Type Two Diabetes to WellSouth Primary Health Network Rebecca Grant, Long Term

Chaired by Larry Jordan 210 Co-location of multi-disciplinary professionals within Primary Care Centres in Italy: how do they collaborate? An insight on three cases studies

144 Validating the Rainbow Model of Integrated Care Measurement Tool: results from three pilot studies in The Netherlands, Singapore and Australia

Chaired by Michael Howard 24 Integrated categories for integrated care - the importance of patient centred categories (Hoyle, Philip)


Community Services & Corporate Support Wollondilly Shire Council 20 A community cultural literacy programme becomes the trojan horse. (Te Karu, Leanne) 110 A model connecting practice, research and policy to improve refugee health outcomes (Combined with 109) Caroline Nicholson, Director, Mater UQ Centre for Integrated Care & Innovation 98 Caring for Caregivers: Establishing Resilience through Social Capital Allie Peckham, Postdoctoral Fellow, University of Toronto, Institute of Health Policy, Management and Evaluation* 118 Transfer of the idea of the Managed Clinical Network into less advanced settings Tarry Asoka, Consultant in Health Policy, Planning and Management, Care-Net Ltd (Nigeria)

Conditions Community Nurse, WellSouth 164 Manawanui whai ora kaitiaki: empowering self-management through a partnership approach (Webber, Lindsey Ann) 27 Transforming patient engagement to take charge of their health and wellbeing Diana Dowdle, Delivery Manager, Ko Awatea 186 Creating self-management teamlets in a primary care clinic; the successes of a clinical-peer team Leona Didsbury, Health Psychologist, Self-management Trainer and Gary Sutcliffe, Starcare Centre * 113 Are patient and carer experiences mirrored in the Practice Reviews of Self-Management Support (PRISMS) provider taxonomy? Dr Nicolette Sheridan, Associate Dean Equity, Faculty of Medical & Health Sciences, Associate Professor, School of Nursing, University of Auckland

from Tuscany Region through Social Network Analysis Manila Bonciani, PhD Research Fellow, Sant'Anna School of Advanced Studies, Pisa (Italy) Institute of Management, Laboratory of Management and Health 68 "To be followed up in general practice" - developing and implementing a shared care model for prostate cancer. (Bro, Flemming et al) 83 How are co-located primary health care centres integrating care for people with chronic conditions? Julie McDonald, SEaRCH South Eastern Sydney Research Collaboration Hub, University of New South Wales 25 GPs- You Can Make Time in Your Day - You can regain Control (Edwards, Jan et al) *

(Valentijn, Pim Peter et al) 90 Whole of system measurement for integrated care: The Counties Manukau experience and creation of aspirational goals (Gauld, Robin et al) 183 We know what to do, but how do we do it? A metanarrative review of implementation frameworks to guide the iCOACH project (McKillop, Ann et al) 123 and 153 Evaluating the 'Health Links": A Case Study using the Organizational Context and Capabilities for Integrating Care in Ontario, Canada Agnes Grudniewicz, Assistant Professor, Telfer School of Management, University of Ottawa, Ontario, Canada

195 HealthLinks: Incentivising better value chronic care in Victoria (Ferrier, Denise et al.) 135 The value based Logan Wellbeing Program successfully diverts inpatient funding, improving patient and economic outcomes (Crompton, David et al.) * 222 Outcomes Based Commissioning - can the care really follow the patient? An Australian perspective (Sheather-Reid, Rachel) * 104 Flexible funding for effective, individualised, integrated care Dr Jennifer Smith-Merry and Associate Professor James Gillespie, University of Sydney


6. Education & Training: Changing attitudes: enabling health workforce to provide holistic care

Using action research for workforce development and planning in integrated care (150) (Akehurst, Beverley JOY) 133 How do health professionals work in a recovery-oriented way? (Ehrlich, Carolyn) Combined with: 132 Uncovering the work involved with personally supportive recovery-oriented practice (Chester, Polly et al.)

189 Integration of Respiratory

Services in Hawke's Bay Trish Freer, Health Programmes

Manager PHO, Health Hawke’s

Bay – Te Oranga Hawke’s Bay 14 An investigation into the barriers and facilitators of acceptance, and use of Bay Navigator Pathways by general practitioners in the Western Bay of Plenty Dr. Anel Reyneke, Department of General Practice and


Friday, 25 November 2016

Main Theatre

8.30 – 10.30

PLENARY 4 – Engaging people and communities

Chaired by Dr Viktoria Stein, Head of the Integrated Care Academy ©, International Foundation for Integrated Care (IFIC) From cooperation to partnership and patient leadership: reflections from the English NHS Jocelyn Cornwell, CEO, The Point of Care Foundation WHO efforts in measuring people and community engagement in healthcare Dr Hernan Montenegro, Coordinator, Services Organization and Clinical Interventions Unit, Service Delivery and Safety Department, World Health Organization (WHO) xxx Awerangi Tamihere, Director Strategy and Design Thinking for Outcomes, Te Whānau O Waipareira Questions and discussion

10.30 – 11.00 Refreshments

Rural Health, University of Otago and GP in Papamoa, New Zealand

20.00

Congress Dinner


11.00 – 12.45 PARALLEL SESSIONS 6

1. Asking people what they want

2. Putting people first – changing regional health systems

3. Measuring what matters: incorporating values as outcome measures

4. Incentivising integration of services – innovative funding models

5. Implementation: Integrated care in AsiaPacific

Chaired by Shelley Frost 194 Pacific peoples’ perspectives of Integrated Care services Dr Debbie Ryan, Principal, pacific perspectives 82 Self-determination: what do people who experience severe mental illness want from public mental health services? (Mattner, Sandra) 99 Frail older people’s use and experience of the Irish healthcare system: a mixed methods study to inform the design of integrated models of care (Roe, Lorna Dorothy et al) 220 Networks for care: Improving quality of hospital care for rural communities Dr Carol Atmore, University of Otago, New Zealand

Chaired by Helen Rodenburg 61 'Doing Better Together': Developing a cross-agency regional child health and wellbeing plan (Shaw, Miranda Jane) 55 Delivering an integrated system of care in Western New South Wales, Australia (McLachlan, Scott et al.) 63 Mixing it up: private, public, federal, state, seeking health outcomes in an integrated primary care centre – the Oran Park Family Health experience! (Duggan, Justin et al) 29 An Integrated Health Collaboration – A Localized Solution (Pennock, Rene et al)

Chaired by Awerangi Tamihere

33 An Evaluation of Payment Incentives for Community-Based Psychiatric Care in Ontario, Canada (Rudoler, David) 34 Paying for primary care: The relationship between payment for primary care physicians and selection of patients based on case-mix (Rudoler, David Michael et al.) (one presentation) 94 Irish Integrated Care Programme for Chronic Disease - Supporting General Practice Dr. Orlaith O Reilly, National Clinical Advisor and Programme Lead, Health & Wellbeing, Health Service Executive – South (SE) Public Health 211 Innovative funding models to incentivise integrated care (Prior, Emily) 16 Local Resource Based Community Care Development as Asset for the Silver Economy of the Region (TSARTSARA, Stella I.)

Chaired by Jason Yap 76 The challenge of making health services people-centred: how are policy-makers in Asia approaching it? (Tan, Clive) 121 Integrated care in China, challenges and opportunities Dr HAO CAI, Postdoctoral Researcher, Department of Health Science and Technology, Aalborg University 167 Developing of social and community prescription model as the third system for sustainable community-based integrated health care system Toshiro KUMAKAWA, Senior Researcher, Department of Health and Welfare Services National Institute of Public Health, Japan 60 Implementing an Integrated Care Framework in Singapore: The Experience of the


152 Effects of provider incentives mechanism in integrated healthcare delivery system reform: a quasi-experiment on patients with chronic diseases in rural China Dr Wenxi (Kammy) Tang, Assistant Professor in School of International Pharmaceutical Business, China Pharmaceutical University

SingHealth Regional Health System Professor Julian Thumboo, Director, Health Services Research & Evaluation, SingHealth Regional Health System, Singapore Health Services 156 A Model of Care for a Regional Health System Dr Ng Yeuk Fan, Deputy Director (Special Projects), Khoo Teck Puat Hospital, Alexandra Health System

6. Implementation: Changing organisations and management to change service provision

7. Workshop: Introducing the Special Interest Group on Managing Complexity

147 GOODBYE COMAND & CONTROL – HELLO CIRCLES! (Saberi, Vahid) 120 & 131 Leadership and Professional Engagement in the Implementation of Integrated Care: Lessons from 9 Cases in the iCOACH Project, Ross Baker + Jay Shaw, Women's College Hospital

Chaired by Prof Anne Hendry 209 Learning from iCOACH: implementing integrated care for older adults with complex health needs (Wodchis, Walter P et al) 78 What does one learn from the implementation of a mandated integrated network for older adults across three different settings in Quebec (Breton, Mylaine et al)


122 Can complexity dynamics be harnessed to improve integration of care? The implementation of the Health Links in Ontario, Canada Agnes Grudniewicz, Assistant Professor, Telfer School of Management, University of Ottawa, Ontario, Canada 166 Tima’i mo se taeao fou - new beginnings for a new tomorrow Le’aupepe Elisapeta Karalus, Chief Executive Officer, K’aute Pasifika Trust and Kim Holt, General Manager, K’aute Pasifika Trust

138 The Future of Chronic Conditions Management in NSW: Integrated Care for People with Chronic Conditions Erin Lilley, Integrated Care Program Manager, NSW Ministry of Health and Adam Jogee, Manager - Australia, Francis Group International (FGI) 196 Anticipatory Care Planning in Scotland (Cumming, Stuart)

12.45– 14.00 Buffet lunch, exhibition, posters, networking and lunchtime workshops

13.00 – 14.00

Lunchtime Workshops

1. Oral Poster Session: Workforce redesign - the future workforce

2. Oral Poster Session: Measuring integrated care outcomes – improving access

57 Promoting the delivery of integrated care to citizens through the area managers (de Matos, Rosa Valente) 52 Building better systems on strong relationships: A co-

15 Cost effectiveness of integrated care in patients with acquired brain injury Dr Aine Carroll, National Director for Clinical Strategy and Programmes, Health Service Executive, Ireland


design case study of a local initiative Dr Paul Cooper, Clinical Director Acute Care Team, Central PHO 53 Non-medical prescribing in New Zealand: Is it achieving its aims? (Smith, Alesha) 101 Quality Enhancement Program: A Delirium-caring Culture Nurturing Program in Acute Geriatric Setting- 2-years Review (Tang, Lap Nin) 87 Turning the patient promise into reality Jane Cullen, Quality Improvement Advisor, Health Quality & Safety Commission 6 Remodelling care for low back pain: tripartite partnership among general practitioners, physiotherapists and hospital specialist’s Dr Jasper W.K. TONG, Deputy Group Director, Group Allied Health, Singapore Health Services 228 Different organizational and financial outcomes in middle sized primary care practise in Poland after basic care

41 Evaluating integrated social care by utilizing regional resources in Japan Masaaki Otaga, Researcher, National Institute of Public Health, Japan 170 Integrated Care Management in Patients with Atrial Fibrillation Dr Jeroen Hendriks, Derek Frewin Lecturer, Centre for Heart Rhythm Disorders, University of Adelaide 65 Integrated psychological care in Inflammatory Bowel Disease outpatients: Early data from a new initiative Taryn Lores, Psychologist / Health Psychology Registrar, IBD Service, Royal Adelaide Hospital, Adelaide SA Australia 175 Understanding the audience: Improving the impact of public performance reporting on quality of care. (Kelaher, Margaret et al) 148 ICD (Integrated Cardiac Device) Care through PACED (Patient-centred and Cardiac Nursing Engaged Device)


coordination model implementation. (Prusarczyk A)

Services in a Hospital in Hong Kong (Leung, Yuen Wa et al.)

14.00 – 15.30

PLENARY 5 – Funding and incentives that promote health outcomes

Chaired by Dr Nick Goodwin, CEO, International Foundation for Integrated Care (IFIC) Keynote address: xxxxx Hon Bill English, Deputy Prime Minister, Minister of Finance and the Minister Responsible for Housing New Zealand Corporation Funding and incentives to promote health outcomes considering you experience of alliance contracting in Canterbury Carolyn Gullery, General Manager - Planning & Funding, Canterbury DHB & West Coast DHB XXXXXX Gabriel Makhlouf, Secretary and Chief Executive, The Treasury A funding model of shared savings on a regional meso-level – possible for countries with sickness funds or state owned health systems: The OptiMedis-model of Gesundes Kinzigtal in Germany Helmut Hildebrandt, CEO, OptiMedis and Gesundes Kinzigtal Questions and discussion

TBC

CLOSING CEREMONY

Poster Display Only (no oral presentation time allowed)

1. 31 SNOMED Browser and Web Services: Enhancing Primary Care & Emergency Services in New Zealand, Dr Ahmed Javad, President Technical Services, Valentia Technologies Limited, Ireland


2. 84 Cardiovascular disease risk and management in people who experience serious mental illness (Lockett, Helen et al)

3. 9 Clinical advisory pharmacists within general practice Dr Linda Bryant, Chair Clinical Advisory Pharmacists Association and colleagues

4. 70 Analyze and improve the patient flow in hospital environments, with improved layout different sectors: A case study of Shahid Beheshti hospital, Iran (Sadeghi

et al)

5. 140 HIV – PEP(Post-Exposure Prophylaxis) ACCESS PROJECT Sid Kaladharan, Project Officer- HIV & Sexual Health, HIV FOUNDATION QUEENSLAND

6. 44 Organ transplant in India (OTII): Progress and challenges through net working system (Barik, Mayadhar et al)

7. 23 What do patients' want? Time to innovate medicine information leaflets Amber Young, PhD Candidate, Associate Professor June Tordoff, Project supervisor,

and Dr Alesha Smith, Project supervisor, School of Pharmacy, University of Otago

8. 45 Integration of cure and care motivated by the hospital budget (Szynkiewicz, Piotr Rafal et al.)

9. 214 A comparison of the policy and institutional environment relevant to community-based primary health care in Ontario, Quebec and New Zealand

(Tenbensel, Timothy Gerard et al.)

10. 79 Client-service engagement in social service provision as co-creation of value (Nicholas, Graeme)

11. 4 Health professionals’ reactions to patients’ social media posts about treatment (Wynn, Rolf et al.) 12. 173 A Lifespan of Care – Connecting the Dots a National Intestinal Failure Service Approach Briar McLeod, Clinical Nurse Specialist, NZ National Intestinal Failure

Service

13. 48 Antiepileptic drug exposure in pregnancy and pregnancy outcome from national drug usage data (Richards, Noni)

14. 112 Geographic and Perceived Healthcare Access Equity among Patients with Acute Cardiovascular Event in China Xiaoguang Ma, Associate professor, Zhejiang

University

15. 88 What Impact Does Behavior of Doctors and Patients on Service Integration of Multi-institutional Readmission cross Township—county Hospitals in Rural China

(Zhang, Yan et al)

16. 181 The New Zealand health care system: Digital disruption, innovation and the opportunity for new approaches to integrating care (Marmoush, Ahmed et al)

17. 227 Spiritual Care Advance Directive (SCAD) ®: A guide for a spiritual counselor to provide therapeutic and creative interventions at End-of-Life care

James H. Kim, Board Certified Chaplain, Certified in Thanatology, Spiritual Care, Torrance Memorial Medical Center, Torrance, CA USA

For further information, contact:

Fiona Lyne, Director of Communications, International Foundation for Integrated Care [email protected]

mailto:[email protected]

Documents

COLOUR CODE - IFIC · 4. Risk prediction tools and strategies 5. Workshop: Policy design and implementation for a new paradigm Chaired by Nick Chamberlain 224 No single intervention