Takehome messages from WCIC4
It is now more than a month since the 4th World Congress on Integrated Care (WCIC4) was held in Wellington. Over 600 delegates from the USA, Europe, Asia, Australia and of course the host nation, New Zealand attended the 3 day event taking advantage of the high quality of plenary discussions, parallel sessions and workshops.
My focus as a new fellow of IFIC was in regards to the learning and networking opportunities that I could develop at the conference. I was focused on the patient centered medical home (PCMH) and integrated care (IC) for chronic complex medical conditions from the corporate perspective which I could adapt to an Australian setting. So, the first sessions I attended were the Integrated Care Academy, Parts 1 and 2, which were presented by Robin Miller, Viktoria Stein and Jackie Cumming.
The initial proposed questions of what is Integrated Care? Followed by – How does it take shape ? And then – What is your burning question regarding integrated care for today? –were focus points for the groups who attended those integrated care academy sessions. The discussions reinforced my increasing understanding of integrated care. I could see the commonality in the responses to the requirement of communication with a focus on the patient and the family as well as seamless transitions between providers, organizations and teams who lead development and relate this to quality and improvement.
The negative effects that work on integrated care were discussed and have a universality that is reflected in the Australian system. We talked about leadership failing because of a lack of ownership of patient chronic complex needs and sometimes the lack of involvement of the patient and/or the health care provider through poor communication between the professionals. I found this easy to identify with. I am transitioning a system of corporatized medicine where episodic care has been the dominant component and encouraged via a fee for service system. To counter this there has now been recruited into the Fairfield Medical Centre, two chronic care co-ordinators, who are registered nurses. Their charter is to identify via a records data search, patients who have chronic care conditions, and for them to develop GP management plans and team care co-ordination plans. This process will be evaluated using a modified version of Richard Antonelli’s – Care Coordination Functions and Outcomes in the Medical Home Care Coordination Measurement Tool (CCMT.
One of the key learnings I took from the Integrated Care Academy© was an outline of the transformational change required in the implementation of Integrated Care. This framework provided me with a tool to review the steps I am taking in my project (ref to previous blog). I am currently reviewing my change management process by assessing my projects journey against the framework presented at the sessions mirroring the steps we have taken with those described in the session (ref):
• needs assessment
• situation analysis
• value case development –
• vision and mission statement
• strategic plan
• establishing mutual gain
• implementation and institutionalisation
• monitoring and evaluation.
This process can be enhanced by – establishing a guiding coalition, building support for change and developing collaborative capacity. Utilising a team based approach, components of the stepwise framework can be delegated amongst the team members making the collaboration more efficient and effective.
In some aspects I have been fortunate to have been supported within my medical centre by having recruited numerous allied health providers and specialist services, with a system that did not require a financial contribution from the patients in order for patients to access those services. This has simplified the interconnectivity between the Health Care Practitioners, as we share the patient record system and can in realtime access information. It also allows the team members to be personally familiar with one another , extend clinical relationships through the team members networks as well as be aware of the clinical competencies and limitations of the members.
Some of the models discussed in IC highlighted for me the difficulty the Australian system has due to the multiple funding arrangements currently implemented for clinical care. There is a failure in cooperation in the funding of the provision of services often reflected in cost shifting activities occurring within those organizations. Care is often limited due to the budget priorities. This occurs at all levels, national, state and local.
Primary Health Care LTD (Aus) has funded the care co-ordination trial at the Fairfield Medical Centre as well as a number of alternative trials with private health groups. There is also a medical benefits review as well as care trials commencing this year through the Federal Government MBS Review Taskforce. Hopefully the issues of addressing the lack of financial support for IC will be at least partly addressed.
In contrast Viktoria gave the example of the German system where the government had passed Federal laws enacting the requirement for IC. This is not a model available to Australia due to legal constitutional restrictions. It is likely that a voluntary opt in system will be presented to the health care professionals after the current trials have completed.
The implementation process was noted to be both a bottom up as well as top down process with the bottom up process often initiated by physicians dissatisfied with the system. Should an opt in system of involvement materialize within the Australian system, then that will be equivalent of a top down incentiviser. PHC is using its resources to test a number of financial models that allow those incentives to be utilized to fund the cost of establishing and developing teams and programs, commencing with rewarding team leadership within our centres.
Another concept revisited throughout the meeting was that the bulk of care is self care, being 70-80% of those with chronic conditions. This is unpaid care provided often by family or friends, which is represented within the Kaiser Triangle. At its apex, are the case management patients, who are the highly complex patients, with at the next lower level of the pyramid the disease management group, who are high risk patients, followed on the lowest tier, the supported self-care patients who as a proportion were 70-80% of people with chronic conditions. This self-care group contributes significantly in care without significant cost to the Health Care System
Australia is implementing the National Disability Insurance Scheme and the Kaiser Triangle concept has real relevance in its roll out. Patients with disability’s are allocated a budget for their care including its coordination and contract with the Government in planning with patient centred goals for their management. with poor support during the implementation phase causing anxiety in the very people the system is meant to focus upon.
From attending the whole conference, I have been able to compare the different models consider not only the clinical PCMH perspective but consider and act to modify the social determinants of poor health as well. These models highlight the difficulties which the Australian system has with regards to the multiple funding and government level interactions in supporting medical management
In my accepting the significance of social determinants of health I intend to include onto the local PHN committees, non-medical social welfare representatives who can support the development of programs that will look at the health effects of disadvantage in those local communities that the PHN represents.
Improving Health Outcomes for Children through development of an Integrated Wellness Model.
Healthcare in New Zealand faces the same challenges as most first world countries; we are experiencing a rapid growth in the prevalence of non-communicable disease. The misdistribution of this reflects inequalities in modern society and has a direct link to deprivation. Healthcare providers are seeing more patients requiring repeat episodes of acute and long-term hospital care. For society, these health inequalities lead to premature death and people living restricted or dependent lives. Current health systems and models of care do not have the resource to meet future needs unless our approaches change. The challenge for governments and healthcare providers is how to address this inequity, flatten the growth curve and reduce the associated human and financial costs. It is now generally acknowledged that social factors are the fundamental determinants of health, equity and wellness, and it is these which policy must address to improve the quality of health for our populations.
The Scottish government recognised a number of years ago that focusing on our children to offer them the best possible start in life would lead to long-term health gains. Their Early Years Collaborative is founded on an underlying philosophy that children deserve an equal opportunity to thrive, learn and succeed. As Chief Medical Officer of the Lakes region I am acutely aware that our population has some of the worst levels of social deprivation and inequity in the country. This impacts many of our children and with the disparities widening these greater inequities are ultimately driving the growing burden on health services. To create a local solution for integrated care in the style of the Scottish collaborative will require currently siloed agencies to reach into communities, families and whanau and consider and address multiple issues from education, welfare and health.
Legislatively District Health Boards are responsible for the health of its geographic population, moving forward it must play a fundamentally different role within local community. Our DHB is currently building a new community based children’s centre and this offers the ideal nexus for driving integration at all levels. This will require a systems approach, engaging a wide group of stakeholders to develop networks that span organisational boundaries. These partnerships need to utilise expertise from across the whole systems, but key to success will be a sense of shared responsibility and accountability.
The aim of this Fellowship is to leverage off the development of the Children’s Centre and create a focus on improving health and wellbeing outcomes for the children of Rotorua. To achieve this requires a number of pieces of work that will be based on reviewing some high performing international examples. Specifically this Fellowship will be aiming to:
1. Create a plan to improve children’s health and wellness in the Lakes region. Critical to success is to create a shared vision, strategy and governance structure to oversee implementation and continued monitoring of any models. Currently there is no governance system or explicit strategy to support an integrated approach to improving child health and wellness at the macro level. I will be researching the best international examples and how are they transferable to a New Zealand model.
2. Review international outcome measures for children’s wellbeing. Measuring and determining appropriate outcomes is challenging and any new approach needs to ensure it supports children and their families in ways that are person centred and effective. I will look to identify what is adaptable for enhancing social and health integration at the local context.
3. Identify what models of commissioning have been successful in relation to child health and wellness and what a local solution might look like. Specifically I will be researching how this can be accomplished across different sectors with a focus on wellness not illness.
4. Identify areas of excellence that can support the evolution of models of care for the Children’s Centre.
5. Identify opportunities for the models to be transferred to other populations within Lakes DHB such as the elderly or patients mental health issues.
A major challenge for this work is that implementation of any new model will require greater collaboration amongst organisations with differing cultures and legislative requirements. The demographic make up and size of our population should theoretically enable and support the requisite relationship development. I am confident that adoption and adaptation of some of the excellent examples internationally where these challenges have been addressed will enable us to achieve our goal.
Chief Medical Officer
Lakes District Health Board