Locality clinical partnerships – principles for contracting & funding Martin Hefford 8 December 2011 Locality Clinical Partnership Objectives Deliver Better, Sooner, More Convenient Healthcare Improve patient health outcomes Reduce avoidable hospitalisations Improve clinical governance Deliver more integrated healthcare Deliver better value healthcare Locality clinical partnerships: overview Locality Clinical Partnerships to commission and review the work Locality Health Profile • To identify health priorities Models of Care • To address health priorities Enablers • To achieve models of care An opportunity to create a clinically led integrated healthcare system that bridges the divide between primary care, community health services and secondary care. Enhancing primary care to make it more accessible, comprehensive and proactive. Enrolled populations of CMDHB service localities, Q3 2011 Locality Total % of pop enrolled in CM practices Rank by size Eastern 102,590 23% 3 Franklin 45,570 10% 4 Mangere/Otara 138,230 31% 2 Manukau 156,870 35% 1 Grand Total 443,250 100% Source: PHO enrolment register Quarter 3, 2011, analysed by CMDH, December 2011 Ethnicity of the service locality enrolled populations Franklin Eastern Maaori Pacific Indian Maaori Pacific Other Asian European/ Other Other Asian European/ Other Mangere&Otara Other Asian Indian European/ Other Manukau Maaori Indian Maaori European/ Other Pacific Pacific Indian Other Asian Proportion of locality population defined as ‘High Need’ PHO funding and monitoring frameworks include proportion of enrolled population defined as ‘high need’ – Maaori, Pacific or living in area defined as high socioeconomic deprivation (NZDep, quintile 5) Locality Eastern Franklin Mangere/Otara Manukau Total % High Need 7% 26% 81% 53% 48% Within each locality, practice age structures vary Locality % of locality 0 – 14 yrs % of locality 15 – 44 yrs % of locality 45 – 64 yrs % of locality 65+ yrs Eastern 20% 40% 27% 13% Franklin 25% 37% 25% 13% 30% 46% 18% 6% Manukau 24% 42% 23% 10% CMDHB 25% 42% 23% 10% Mangere/ Otara Size of practice enrolled populations Locality 0-4,999 patients 5,000-9,999 patients 10,000+ patients Total Eastern 21 6 1 28 Franklin 1 2 2 5 12 4 5 21 Manukau 38 6 1 45 CMDHB 72 18 9 99 Mangere/ Otara How are the population distributed across practices Total hospitalisations Distribution of hospitalisations by ethnicity Crude rates acute med-surg-EC MMH by practice Note, crude rate not age standardised, EC presentations Percentage of EC presentations statistically admitted Locality Age Grp 0-14 years 15 years & over All ages Total Mangere Eastern Franklin Manukau / Otara Total CMDHB localities 42% 50% 43% 43% 43% 70% 72% 63% 65% 66% 64% 67% 57% 59% 60% Volume of specialist OP visits Contracting for Locality Clinical Partnerships INITIAL THINKING Alliance agreement mandates: • Leadership group – clinically lead, focused on service integration, better value healthcare, and quality improvement • Risk and gain sharing and $ commitment • Management support, incl analysis and reporting Agreement GPs, PNs, Pharmacy, Alliance Agreement • Locality clinical network – broad interest based membership DHB NGOs, social services Clinical Leadership Group PHO 1, 2, 3 Locality clinical network NASC, DNs, home care SMOs, allied health Management support – enablers, IS, reporting, project management GAIHN contracting guiding principles (subset) • Incentivise the achievement of outcomes not the provision of service • Build collaborative trust-based systems and processes • Keep contracting simple, collaborative and outcome focused • Have transparency in all dealings • Use a broad ‘dashboard’ of measures to prevent the manipulation of single measures Locality Clinical Partnerships - commissioning Determine current use of primary and secondary health resources by locality (shadow budgets) Allocate budget decision making rights to three streams: 1. We discuss, DHB decides (eg hospital services) 2. We discuss, LCP decides (eg community services) 3. We discuss, primary care decides (eg capitation) Move to equitable budgets, & increase LCP decision making over time Commissioning – evolution over time Decision making We discuss, DHB decides We discuss, LCP decides Time E.G. Hospital operations, IDFs. E.G. POAC, After hours, community and home based services, primary mental health, CCM, Careplus … We discuss, Primary care decides E.G. SIA, HP Capitation Acute demand costs Acute demand gain sharing - overview Net saving P&C costs planned Time Acute demand risk & gain sharing - principles Funds that would have been used for extra hospital staff/resources will be invested in primary & community settings to buy additional services. Net gains to be re-invested in extra primary / community services – locality clinical leadership groups to advise on use. Risk of poor outcome to be shared between DHB and primary care partners (say 75:25). Acute demand targets & gains to be allocated by locality. Fitting the pieces together Regional initiatives GAIHN / NHC / AH+ • • • • 20,000 bed days Risk tool Care pathways POAC Whanau ora • Evidence and collaborative support for acute demand management in localities BSM business cases REGIONAL Plan • IS - shared care, e-referrals, • Auckland clinical networks (diabetes, CVD, etc) • ISG led business case for service integration MOC and primary care development with emergent LCP. Locality clinical partnership •Alliance agreement •Locality leadership group, •Clinical network Next steps Develop locality clinical leadership groups Use 20,000 better care days as an initial programme for contracting Use Better Sooner More Convenient Business cases to develop alternative models of care & service integration plans for localities Develop shadow budgets Put in place partnership agreements Monitor performance, evaluate, and adjust over time. Discussion points for board members Do we want to share some risk with primary care? Do we agree to take the largest share of risk? Do we agree that LCPs should decide on the use of any conserved resources? Locality Clinical Partnerships could be as an alliance agreement or a formal joint venture – thoughts? Proposed that the agreement is with PCOs (or PHOs?) but the network is wider. Thoughts? Do we consider that future employment of community health staff could change?