Integration Networks Pathways - MidCentral District Health Board

Addiction & Mental Health District Group
Alistair Watson
7 May 2013
The burden of long term conditions
• Almost one in three of the population (and half of those over
60) have a long term condition.
• This group accounts for two thirds of the health spend.
• The number of people with comorbidities is expected to rise
by a third in the next ten years.
• Common mental health problems affect about one in seven of
the adult population, with severe mental health problems
affecting one in a hundred.
• These conditions fall more heavily on the poorest in society
Source: Dept. of Health, England (2012)
Local Maori Health Statistics
Health Needs Assessment 2005
Cancer death rate 40% higher
Respiratory death rate 80% higher
More likely to smoke
Make up 15.2% MDHB’s pop
– Poorer health yet 14.2% admissions
• Three times more likely to not attend
•Higher diabetes discharge rates compared
to MidCentral overall
•18% more than expected COPD hospital
discharges compared to MidCentral overall
•19% higher than expected neoplasm
(cancer) deaths compared to MidCentral
overall (age adjusted).
•Children aged 5 showed poorer dental health
than children from Manawatu
•The highest proportion of smokers among
MidCentral territorial authorities (24.6%)
•20% higher than expected number of deaths
compared to MidCentral overall
•Lowest % of households with access to a car
Statistics New Zealand, March 2006
Contracted Providers of Health and
Disability Services in MDHB Region
General Practice
Aged Residential Care facilities
Community Pharmacies
Mental Health
Personal health
Primary Care
Secondary care
OECD Admission rates 2009: COPD
The Way Services Are Organised &
Utilised Does Matter
• Despite standardised approaches to management of common
conditions there are major differences in way the care is
delivered both nationally & locally
• Current way services are utilised is based on the way they are
structured & provided
• Limited effectiveness due to fragmented planning & organisation
and opportunity for improvement exists at every stage of the
Changing models of care
Moving to care models that
shift expenditure / activity
away from hospital care,
effectively to improve health
Ref: Dr Helen Bevan, NHS Institute
Patients with Complex Needs
(Integration: A Report from the NHS Future Forum)
• Intensive users of services, repeatedly crossing
traditional organisational and sector boundaries.
• Gaps, duplications or poor reliability of care
multiplied as their journeys progress
• More difficulty in understanding their or
understanding their often tortuous care journeys
making it more difficult to exercise choice or
control, or manage their own care
• Needs may include education, social care,
housing & justice
Patients with Complex Needs
(Integration: A Report from the NHS Future Forum)
• Groups most likely to benefit from integrated
care include
– Children and adults with complex needs
– People with enduring mental heath problems
– Homeless people
– Frail older people and their carers
– People at the end of their lives receiving palliative
Expectations for patients with complex
or long-term needs
(Integration: A Report from the NHS Future Forum)
• To receive care as close to home as possible
• To be informed about the options available to
• The opportunity to discuss their options with a
professional skilled in shared decision making
• Easy access to a named care coordinator who
knows them and is able to provide a tailored level
of support to navigate their care journey and
make choices at appropriate junctures
• To know what to expect at each step of planned
care journeys
Expectations for patients with complex
or long-term needs
(Integration: A Report from the NHS Future Forum)
• To have an integrated care plan and where
appropriate be offered an integrated budget
• Every provider involved in the individual’s care to
have access to their care record
• Transitions between professionals, teams and
organisations to be safe, smooth and efficient
• To understand clearly and simply what care and
support they are eligible for and how they might
pay for it if they are not eligible for state funding
• To be confident that appropriate information,
training and support are available for carers
Definition of Integration
“the act of making a whole out of parts, the
coordination of different activities to ensure
harmonious functioning”
Clinical Integration
• Many approaches with different terminology:
shared care, transmural care, intermediate care,
seamless care, disease management, case
management, continuous care, integrated care
pathways, integrated delivery networks
• Patient centric view and needs of complex
patients with chronic illness are considered
• Scope varies but requires some form of seamless
care or multiprofessional approach that values
the role of all health professionals
• Aim to improve coordination and integration of
• Types of integration (e.g., organisational,
professional, clinical, functional)
• Breadth of integration (e.g., vertical, horizontal, virtual)
• Degree of integration (i.e., across the
continuum: linkage, co-ordination to full
• Processes of integration (i.e., cultural and
social as well as structural and systemic)
Clinical Integration
• Different models of care: consultative, collaborative,
coordinated, multidisciplinary, interdisciplinary,
• A continuum from informal to formal arrangements
with an increasing intensity of governance in the
relationship between the providers
• More fully integrated systems coordinate more
information, activities and resources and consolidate
organisational structures
• Unlikely one model appropriate for all organisations or
Principles of Clinical Integration
(Valentijn PP. Int J Integr Care 2013)
• Coordination of person focused care in a single process
across time, place and discipline
• Requires a person-focused perspective to improve
someone’s overall well-being and not focus solely on a
particular condition
• Patient as a co-creator in the care process; with shared
responsibility between the professional and the person
to find a common ground on clinical management
• Emphasis should be placed on a person’s needs, with
people coordinating their own care whenever possible
Requirements For Change In
The essential requirements for success are:
• Broad-based clinical leadership
• District-wide service planning & organisation
• Avoiding the fragmentation induced by existing
service structures
(Bate P, Mendel P, Robert G: Organizing for Quality. Oxford: Radcliffe Publishing;
MidCentral DHB Journey to date
MidCentral DHB Journey to date
Community Participation
Coordination of Services
Development; increasing
sector capacity
• Integration between
primary and secondary
• Quality
MidCentral DHB Priority Plans
Oral Health
Additional Clinical Services
• Locally based primary
chronic care teams :
smoking cessation,
physical activity, clinical
• Locally based integrated
“disease state” & cancer
nurses and respiratory
• Psychological support
• Community pharmacy
• Community specialist
cardiology clinics, heart
failure service & tests
• Community GP sleep
apnea, pulmonary
rehabilitation &
• Extended palliative care,
Liverpool Care of the
Dying pathway, psychooncology
Other Developments
• Multidisciplinary Disease Management advisory
• Primary Care Health Development Team
– Professional development Knowledge and skills frame
works, Nurse practitioners
– Developing new models of care; “Long term
conditions” nursing
• Compass Health
– Provide managed service operations: community
Better Sooner More Convenient
Business Case 2010
District wide response
to providing the best
possible patient
experience whilst
building a clinically and
financially sustainable
BSMC Programmes of Activity
Acute Demand Management
Older person’s services
Integrated family health centres
Whanau Ora
Systems levers
Acute Demand Management
Self management support
Chronic care management
Case management
Walk in clinics
Enhancing intermediary care/Recovery at
• Single point of access to after hours care
Older Person’s Services
• Inter RAI
• Interdisciplinary older person’s teams
• Care planning and management tools
Systems Levers
Clinical networks
Clinical pathways
Organisation design, leadership & governance
Workforce development
Information management
Organisation design, leadership &
• DHB Clinical Leadership Council
• Combined ALT/CPHO Governance and
• DHB Quality Improvement Framework
• Contracted Providers Network (proposed)
• DHB Clinical Networks
• Collaborative Clinical Pathway Programme
• Health Care Development Team
Workforce development
• Transformational leadership programme
• Interdisciplinary Knowledge and Skills
Framework including LTC and case
• Career path for nursing from novice to expert
leading to Nurse Practitioners
• GP training scheme
Information management
Traffic Light system
“Realtime” GP performance data
Shared Care Record (with proposed patient access)
Map of Medicine integrated with MedTech (and
Clinical Portal (“Concerto”)
Best Practice
Web based Apps
Patient access centre
Medicines management programme
Devolution of radiology
Youth one stop shop
Urgent community care paramedic pilot (UCC)
MidCentral DHB Network
Network: an interconnected group or
Clinical Network: is a social-professional structure made up of
doctors, nurses and allied health staff tied through interdependencies such as collegiality, friendship, referrals,
function or common interest
Braithwaite 2010
New Zealand Networks
• National
– Cardiothoracic
– Cardiac
- Stroke
- Long Term Conditions
• Regional
– Cancer
– Midlands: maternity, elective, cardiac, renal, rural, stroke, mental
health/addictions, older people, radiology
– Central: cardiac, renal, mental health/addictions, older people, population
health, (stroke)
– Greater Auckland Integrated Health Network
• District
– Canterbury:
• aged, child & youth, collaborative care, IFHC’s, laboratory, long term conditions,medication,
pharmacy, primary care liason, rural urgent
• Healthcare pathways
– MidCentral:
• child/tamariki, mental health/addictions, cancer, elder, urgent, long term conditions,
• Collaborative clinical pathways (Map of Medicine)
Network Types
• Informational Networks
– Education, research and guidelines
• Co-ordinated Networks
– Care pathways, joint assessments, no binding contract, a ‘managed
clinical network’
• Procurement Networks
– Budget given to a lead funder or provider, to contract with a range of
organisations to deliver integrated care
• Managed Networks
– Highly managed long-term network of partners, e.g. Kaiser
Permanente delivering and co-ordinating care for a whole population
(Goodwin et al, 2006)
“Need to harness the natural
complex sociotechnical properties
of the Health System”
Braithwaite, Runciman & Merry 2009
Two Types Of Networks
• Type A: purpose-designed, funded or imposed by
authority, in structured organisational or institutional
forms [designed, mandated networks]
• Type B: those composed of the relationships amongst
clinicians, via professional interests, referrals,
supports, friendships, communications & advice
[natural networks]
Braithwaite, Runciman & Merry 2009
Socialising Network in Emergency Department.
Creswick N,Westbrooke JI & Braithwaite J. Understanding communication networks in the emergency department, BMC
Health Services Research, 2009 9 247.
Natural Networks
• For every health care problem there are hubs and
clusters made up of clinicians & others with a special
interest & expertise in that area
• Form a self selected group with a natural interest to
identify and solve ‘coal face’ clinical problems in
voluntary collaboration with others
• Clinicians with common concerns & complementary
expertise voluntarily grouped
Child Health/Tamariki:
To improve the provision of health services to children and their
families/whānau through optimised service development and delivery
Child Health/Tamariki Ora District
Group: Functions/Objectives
• Promotes sector wide inclusive approach, that
incorporates Whānau Ora
• Develops an open & supportive environment for those
working in the child health/tamariki ora community
• Improves quality, safety & effectiveness of care
• Develops & sustains collaboration & communication
with stakeholders and between related network groups
• Develops an annual plan including about 6 time limited
Child Health/Tamariki Ora District Group:
• DHB funding manager
• Consumer representative
• Intersectoral
• Child health advocate
• Maternal
• Clinicians:
• Nursing
• Allied
• Medical
Network Forum
To engage with clinicians & consumers to:
Exchange information on current network activities
Identify & prioritise current issues, &
Seek advice on strategies to address current issues
Open to all interested consumers, clinicians &
Held once per year, or more frequently according to
District Group Work Plans
• Choose about 6 time limited coal face projects
• May include
– Developing patient-centred integrated model of service
– Clinical pathways
– Developing common performance indicators
– Developing evidence-based clinical standards, guidelines &
• Requires formation of about 6 person work group &
collaboration with wider clinical community
Mental Health And Addictions
Work Plans
• Development of a robust crisis respite journey
• Alcohol and drug services targeted for young people
• Create models for change / treatment journey PHO / GP /
Psychiatrist support (to improve connectedness)
• Increase access to the shared care scheme to support
primary delivery
• Link to Whānau Ora
• Suicide minimisation across the district
• Building psychosocial models of care, brief interventions
Child Health/Tamariki Work Plans
• ‘Health Home’: Establish a single, principal data repository to
link families & whānau with service providers & facilitate
• Disability-ASD children: Increase capacity of and improve
access to secondary care child health services for children
with autism spectrum disorder
• Behavioral and Learning Referral: Consolidated entry into
services for those with behavior & learning issues
• Parental child health education: Teaching parents how to
assess & manage their child’s health care needs & issues
• Map of Medicine Child/Tamariki Ora: Further integrate 1 & 2
care services for child health
To assist MidCentral DHB create and maintain a Clinical
Network structure and in doing so ensures that clinicians
and consumers (and their family/whānau) are the core of
health service development and improvement
Transitional Steering Group: Membership
• Chief medical officer
• Director of nursing
• Chair Central PHO Clinical
• PHO clinical director
• PHO management
• Funding division
• Operations directors
• Community representative
• Manawhenua Hauora Board
• PHO director Maori Health
• Maori health representative
• Business case representative
• Chairs DMGs/Reference
• Director integrated care
To provide leadership, direction and influence to ensure
clinical quality, effectiveness and sustainability of health
services for the people/populations of the district
Central PHO Alliance Leadership Team (ALT)
•Ultimate programme governance
•Programme Sponsor
CEOs - MDHB and Central PHO
Sign-off from organisational perspective
MDHB Clinical Leadership Council
Receives all information
Monitors the programme from a clinical perspective
Reviews and advises if significant impacts to delivery of care, funding allocations or
No changes/ No
impacts identified
in pathway
Operations Director(s), MidCentral Health,
GM and Clinical Director CPHO
MidCentral Health & CPHO Clinical
Sign off the paper from a managerial perspective
Review and sign-off paper
If changes to resourcing required
If changes to clinical practice
Transitional Steering Group
Approves the final report / outcome
District Groups
Considers report/outcome and feedbacks to working group
Approves the final report / outcome
Working Groups
Managerial/ Organisational
Undertake to complete working plan of the District Group
District Groups/ Clinical Networks
Nominate pathways for development
Develop workplans
Network brand
Network newsletter 3 monthly
DHB & PHO newsletters
Press releases
Presentations at clinical & other meetings
Surveys of constituent groups
• SharePoint for district & collaborative groups
• Work undertaken as part of usual role (DHB and
other employees)
• Meetings expected to be during work hours
• Parking & travel expenses for meetings
• Use of normal DHB support functions
• 0.5 FTE administration officer
• 2.8 FTE network manager
• 0.5 FTE clinical lead
NSW Agency for Clinical Innovation - Clinical Networks Project Logic Framework
Haines et al. Implementation Science 2012, 7:16

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