Enabling people to manage their long

Report
Te Whiringa Ora
Ray Wihapi
14 November 2013
© HHL Group March 2013
Te Whiringa Ora/Care Connections
1. Background
2. The model
3. The results
1
© HHL Group March 2013
Why we developed Te Whiringa Ora
2
© HHL Group March 2013
Why (continued...)
•
Chronic health conditions are increasing globally.
New Zealand has followed this trend, with an
estimated 80% of all deaths resulting from a chronic
condition (National Advisory Committee on Health
and Disability, 2007).
•
Need for a more proactive and responsive approach.
•
Current reactive models of health care are failing to
meet the needs of some individuals
Te Whiringa Ora
© HHL Group March 2013
3
Our people
•
•
•
•
•
Eastern Bay of Plenty
Population of 50,000
48% identifying as Māori (national average is
14%).
The area has high levels of long-term conditions
which are higher than the national average
Clients are those who have been admitted to
hospital two or more times over the past 12
months and/or have had six primary care visits in
the past 12 months (including ED visits)
Te Whiringa Ora
© HHL Group March 2013
4
Te Whiringa Ora approach
•
•
•
•
•
•
•
Underpinned by the principles of Whānau Ora
Innovative and evidenced-based approach to
addressing long term conditions
The client and their whānau in the driver’s seat
Facilitating interdisciplinary care
Complex health needs and high users of hospital
services
Provide a ‘web of care’ to connect what exists already
Time-limited support phase of three to six months
Te Whiringa Ora
© HHL Group March 2013
5
What we do
• Home visits – CM and KTT
• Engage, relate and build trust
• Holistic assessment at intake and discharge
Te Whiringa Ora
© HHL Group March 2013
6
What we do (continued)
•
•
•
•
•
Shared support plan
Client prioritised goals
Interventions associated with goals
Linking to the right service at the right time
Enabling people to better understand and
manage their condition - health literacy
• Provide information and support
• Tele-monitoring
Te Whiringa Ora
© HHL Group March 2013
7
Linking people to the right service at
the right time
Te Whiringa Ora
© HHL Group March 2013
8
Key objectives
•
•
•
•
•
•
Improve access to primary, secondary and community
health care to achieve better health outcomes for
clients and whānau
Provide seamless access to quality health services
that meet clinical, social and cultural needs
Reduce disparities in health outcomes
Contribute to improving primary care management of
chronic and long-term conditions
Improve client self-management of long-term
conditions
Support the health outcome priorities for Eastern Bay
of Plenty
Te Whiringa Ora
© HHL Group March 2013
9
Key objectives (continued)
•
•
•
•
•
Reduce preventable hospital admissions and hospital
length of stay
Increase proactive intervention to prevent or delay
deterioration which results in increasing levels of care
and acute admissions
Provide a holistic client-centred and whānau ora
approach to care
Educate service users and their whānau in selfmanagement of chronic care and lifestyle changes
Increase sustainability of future health services by
increased use of the unregulated workforce
Te Whiringa Ora
© HHL Group March 2013
10
Results - Synergia evaluation
• SF12 scores - quality of life
• Analysis of baseline and follow-up SF-12 data
• Physical composite score: bodily pain,
physical functioning, role-limitation physical
and general health
• Mental composite score: mental health,
energy/vitality, role limitation - emotional
and social functioning
Te Whiringa Ora
© HHL Group March 2013
11
Results - Synergia evaluation
• Whose health improved?
 Māori and non-Māori (approach applies cross
culturally)
 Males and females
 All age groups
• All showed a clinically significant increase in
their SF-12 scores
Te Whiringa Ora
© HHL Group March 2013
12
So what does this mean?
• TWO assists in the improvement of clients’
quality of life
• Deterioration is typical for clients with
multiple long-term conditions
• SF-12 struggles to monitor change in smaller
samples
• Many evaluations of other models have found
no change in these outcomes
Te Whiringa Ora
© HHL Group March 2013
13
Use of inpatient services
Time in hospital:
• A 10% reduction in bed days for TWO clients
• A 47% increase in bed days for the control group
Hospital admissions:
• A reduction in the use of inpatient services for TWO
clients. No change for the control group
• TWO clients were spending more time at home and
using inpatient services less frequently
Te Whiringa Ora
© HHL Group March 2013
14
Use of outpatient services
TWO clients usage of outpatient services decreased in
frequency or stabilised:
• Decreased for COPD
• Stabilised for diabetes
• Decreased for heart disease
Control groups’ use of outpatient services:
• Increased for COPD
• Increased for diabetes
• Remained the same for heart disease patients
Te Whiringa Ora
© HHL Group March 2013
15
Emergency Department presentations
• ED presentations occurred less frequently for
most TWO clients - especially COPD and
diabetes clients.
Te Whiringa Ora
© HHL Group March 2013
16
TWO potential savings (per client)
Te Whiringa Ora
© HHL Group March 2013
17
Evaluation summary
• TWO evaluation findings are very positive
• Evidence provides support for TWO and the
model underpinning it
TWO supports:
• Improvements in service coordination and
access
• Improvements in self-management
• Improvements in clients’ quality of life
• Reductions in clients’ use of hospital services
Te Whiringa Ora
© HHL Group March 2013
18
“ People don’t care how
much you know until they
know how much you care”
Te Whiringa Ora
© HHL Group March 2013
19

similar documents