GAIHN Business Case Executive Summary FINAL

8/3/2019 GAIHN Business Case Executive Summary FINAL

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ExEcutivEsumm

ary


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BUSINESS CASE TO DELIVER BETTER,

SOONER,MORE CONVENIENT HEALTH CARE

GREATER AUCKLAND INTEGRATED HEALTH NETWORK (GAIHN)

Summary Paper

1 March 2010


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1 | P a g e G A I H N B u s i n e s s C a s e S u m m a r y

THROUGH GAIHN...

Patients will experience

Care that focuses on your whole family/whnau Better access to after-hours care Clinicians know more about you less duplication of tests and questions Better management and support for chronic disease Phone help and navigation support so you can access the right services Faster access to radiology services Better care for the elderly where they live More health promotion from your GP, especially for children More services available locally through Enhanced General Practice and Community Health

Hubs

Better care outside the hospital when you are acutely ill

Clinicians will experience

More time spent caring for patients, less time spent filling out forms More direct access to diagnostic tests when you need them More services available to treat your patients in the community Phone help so you can access the right services Electronically shared care plans to support multidisciplinary care teams Evidence-based clinical care pathways to support high quality care Networks of clinicians across clinical disciplines and organisations Active involvement in determining where health resources are used


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At a Glance

Through a network of 1050 general practitioners working in primary care teams, 11 PHOsand 3 DHBs, we will deliver Better, Sooner, More Convenient health care to 1.25 million

Aucklanders.

The Greater Auckland Integrated Health Network (GAIHN) is a commitment by DHBs andPHOs in the region to share the risk and responsibility to deliver: Better health outcomes

Better patient experience and Better use of money.

GAIHN will sustainably achieve zero increase in hospital acute demand in three yearsthrough more effective community-based health services. GAIHN will also deliver on

measurable goals for reducing inequalities, chronic conditions, elective services and

prevention. GAIHN will do this within the current funding environment.

GAIHNs goals can only be achieved by impacting on decisions made by thousands ofclinicians every minute of every hour of every day. GAIHN will be empowering clinicians

with new skills, community networks and access to clinical resources to meet the needs ofMori, Pacific and high needs communities.

Clinicians have advised that the best ways of achieving the goals are to: improve the patient journey through consistent best practice models of care for all

GAIHN partners, focusing on long term conditions, acute care and prevention

give clinicians tools to work together and make better decisions, including accessto diagnostics, IT and training

build a new locality focus by establishing six Local Health Networks (incollaboration with PHOs), and new multiservice Community Health Hubs that will

support the shift of services from hospitals into the community. Three major

Community Health Hubs will be developed during 2010/11, with others to follow.

GAIHN will also support a market-led response to general practice amalgamationand co-location of services to deliver Better, Sooner, More Convenient care.

To deliver these outcomes, GAIHN will simplify and transform the health environment, withjoined-up organisational and clinical leadership, and an aligned and simplified funding and

contracting environment. GAIHNs new infrastructure will support multidisciplinary teams

and new opportunities for efficient use of the workforce.

Preliminary financial analysis has shown that there are substantial savings to be made byimproving the impact of community services on hospital demand. More detailed financial

analysis is required.

GAIHN believes that the new clinical and management structures will lead to significantefficiencies and direct cost savings. GAIHN acknowledges the need to continue to evaluate

management structures, to ensure that form follows function, and that the environment it

has put in place will rationalise structures over time. The GAIHN partners agree to

achieving organisational efficiencies, including consolidation, over the next two years.

GAIHN will remove barriers and implement changes by improving regional coordinationand building from the strengths of the GAIHN partners.

GAIHN will systematically implement its plans over three years, with regional and localclinical leadership.


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The GAIHN business case story1. Make health Better, Sooner and More Convenient

for patients and clinicians

Faster access toradiology services

Better access to afterhours care

More healthpromotion at your

GP

Better support forpeople with chronic

disease

Phone help so you

can access the rightservices

Better care for theelderly

Greater range ofservices available

locally throughCommunity Health

Hubs

Better access to careoutside the hospital

when you are acutelyill

Care models thatfocus on your whole

whanau

Clinicians know aboutyou less duplicationof tests and questions

Whats better forpatients in GAIHN -

2010/11

Access to your ownmedical records foryou and people you

trust

Education designed tosupport you to take

control of decisionsabout your health

GAIHN will deliver real, visible changes that deliver Better, Sooner, More Convenient health care

for patients. It will also make the heath environment one where clinicians are empowered todeliver high quality care for their patients. Improvements will start in mid 2010 and will continue to

expand in scale and scope over the three years of the business case. GAIHN will improve personal

health and population health.


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4|P a g e G A I H N B u s i n e s s C a s e S u m m a r y

GAIHN recognises, trusts and values all clinicians by redesigning our

health system to increase clinical leadership and empower clinicians to

have more access to resources in caring for patients. These changes

carry with them an increased responsibility for clinicians to ensure the

health system works well for all Aucklanders, including those not

specifically cared for by their services. Our new health system is based

on cooperation, networks and alliances across the sector. It moves

away from them and us towards together we; looking to break down

barriers between clinicians and management, primary and secondary,

clinicians and communities and across health disciplines.

2. Set ourselves real measurable goalsfor the whole health system

The core business case proposition for GAIHN is that it will sustainably

reduce hospital acute demand through high performing community-based services. By leveraging the efficiencies of community-based

services, GAIHN will deliver improved whole system outcomes at a

lower cost. Improvements will be achieved through better use of

existing resources and predicted future funding streams.

GAIHN believes that in order to achieve a sustainable high quality health service within the

economic constraints of the New Zealand environment, GAIHN must focus on the parallel

achievement of: Better health outcomes, Better patient experience and Better use of money.

Improved services for the

whole family across age groups

and levels of ability. Skilled

experienced health

professionals, applying

contemporary evidence

informed practice, using

innovative models of care that

are patient and family centred

rather than health professional

centred.

Opportunity for patients and

families to have their say about

their own health care with the

provision of all relevant

information.

The quotes in these boxes are

from the on-line survey of front-

line clinicians GAIHNcommissioned to inform the

Business Case development


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GAIHN is committed to reducing inequalities and aims to halve the current measurable inequalities

over the next three years, wherever it intervenes in the health system.

GAIHN is driven by four measurable goals that align with the New Zealand Health Targets.

GAIHNs Outcomes and Goals will lead to a voluntary alignment of strategic approaches across the

GAIHN partners, including incorporation of the features of the GAIHN Regional Annual Plan in DHB

District Annual Plans and in PHO contracts. GAIHNs progress towards its goals will be measuredthrough a set of whole system performance indicators.


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3. GAIHN is committed to new solutions for reducinginequalities

GAIHN provides new opportunities for addressing the issue of health inequalities. GAIHNS statesits commitment to:

An unequivocal priority for reducing health inequalities Measurement of existing inequalities and of the impact of interventions Incorporating reducing inequalities as an important element of all initiatives at all levels

GAIHN will focus on reducing inequalities through four strategic planks:

1. Targeting the clinician-patient interaction: Real change to inequalities happens at thehundreds of thousands of interactions every day at the front line. GAIHN believes that

reducing inequalities is best addressed by providing front line health professionals with the

motivation, tools, resources and skills to provide services that better meets the needs of

Mori, Pacific and other high needs groups.

2. Aligning regional effort to reduce inequalities across the whole system: GAIHN willembed new regionally-consistent best-practice models of care that will emphasise

inequalities and whnau focused care.

3. Achieving new whnau and localities focus(partnerships with communities):GAIHN will develop

new locality-based health infrastructure through Local

Health Networks and Community Health Hubs. The

locality infrastructure will better meet the needs of local

communities. The new infrastructure includes Whnau

Ora Centres and Networks.

4. Support service innovations and rapid diffusion ofgood ideas that work:Many excellent services already exist that support high needs

individuals and communities. GAIHN will rapidly spread good ideas to reduce inequalitiesacross the network. GAIHN will work constructively with the Alliance Health+ and Mori

PHO Coalition to support new models of care, such as Whnau Ora.

Holistic care of the family unit, not just

an individual within that unit. Ability to

address a need when it is recognised.

Health professionals considering the

family/whnau's own resources,

strengths, commitments, health beliefs

and practices.


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4. Simplifying and transforming the healthenvironment

GAIHN proposes a new, simpler health environment, (shown above) in which PHO, DHB and Iwi

partners link with clinical leaders to produce a GAIHN Regional Annual Plan. This plan will inform a

new resourcing environment:

New aligned DHB funding, planning and contracting for community-based services acrossGreater Auckland.

New focus on locality-based resourcing through aligned Local Health Networks, led byPHOs.

New - scope for general practice to commission services on behalf of their patients.Clinical initiatives, focused on the GAIHN goals, will be implemented in a coordinated fashion

across Greater Auckland. Implementation will be supported by clarity of direction and performance

expectations, outlined in the annual regional plan, but accompanied by local flexibility on how to

deliver improvements.

GAIHN expects impacts to include better strategic decisions, more responsive local services,

greater operational efficiency and faster change through reducing both clinical and organisational

bureaucratic log jams. GAIHN aims to lift whole system performance across its three outcome

areas of Better Health outcomes, Better patient experience and Better use of money.


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5. Improving clinical practice across the patientjourney

GAIHN realises that it will only achieve its goals by influencing the many decisions that thousands

of clinicians make every minute, of every hour of every day. Change at the periphery will not

suffice.

In developing this business plan, GAIHNs clinical leaders have spent considerable time looking at

how the new joined-up approach can deliver the biggest benefit for front line clinical practice and

patients.

The core clinical focus for the next three years is to achieve more consistent best practice clinical

decisions in priority areas. GAIHN will focus on achieving best practice models of care across

prevention (with a focus on whnau health), long term conditions (including frail elderly and end of

life care) and acute care (including adults and child/youth).

Long term conditions (including frail elderly)

GAIHN will develop and implement a comprehensive, proactively planned approach to long termcondition management across the network.

The LTC model of care will be progressively implemented by identification and transfer of existing

best practice models. This approach will maximise effort on implementation, not invention. The

aim is improved prevention and community based management of disease and of complications.

This will include management of the frail elderly and end of life care.

The 2010/11 work plan will focus on developing and piloting a regionally consistent long term

conditions programme incorporating:

Self management programmes Developing an annual interdisciplinary review Standardised and consistent pulmonary and cardiac rehabilitation Services that can be accessed according to patient and

family/whnau need

Establishing Health Navigators (Patient and Practice).

Acute care (Adults and child/youth)

GAIHN will implement initiatives across the network that targetthe drivers of acute demand (ED presentations and acute hospitaladmissions). The 2010/11 work plan will focus on:

Extending and strengthening the Primary Options forAcute Care programme regionally

Developing a regional quality pre-contact telephone triage service Developing regionally consistent Integrated Care Pathways Improving accident and medical and after hours care via:

oco-ordination across all providers of acute care

o walk-in nurse assessment clinics.

I would like to see Primary Care teams

focus on how can we make the patient

less dependent on the healthcare system

by enhancing the role of the expert,

empowered patient who can safely and

effectively self-manage their acute and

chronic health conditions.


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Prevention (focus on whnau)

GAIHN will implement best practice preventive health that encompasses health promotion and

primary prevention. The initiative will improve health promotion and self management of chronic

conditions, with a focus on family-centred interventions. It will also improve capability to deliver

child and youth health, immunisation, screening and smoking cessation interventions. The

2010/11 work plan will focus on:

Implementing the Health Promoting Practices Quality Framework across at least 10% ofpractices

Optimising general practice systems for immunisation, screening, counselling and support.

6. Improving tools and enablers for quality clinicalpractice

Community-based clinicians need better access to clinical tools and information if they are to take

on greater responsibility for managing patients with complex conditions.

Access to diagnostics

GAIHN will introduce direct access to diagnostics for GPs, based on agreed clinical pathways. GPs

will be able to directly order diagnostic tests, including CT, MRI, Ultrasound, Plain X-Ray, according

to guidelines, without the need for the current specialist review and authorisation.

This process will provide earlier diagnosis, faster access for patients and more appropriate use of

specialist time. General practice will order diagnostic tests within a framework in which they arefully aware of the cost and of their responsibility to work within a constrained resource

environment. The methods used here are expected to expand or scale to cover direct access to

many other services in the future.

Health Information technology

There is an existing regional information systems strategic

plan (RIS10-20) for Greater Auckland that outlines a pathway

for information systems technology development. GAIHN

supports this plan and aims to work through the plan to

ensure that the IT needs for the specific GAIHN initiatives are

prioritised, including:

Knowledge Management:Making sure that relevant information is available to providersand patients when required. This includes non patient-centric data such as referral

processes, care pathways and general health information for patient care.

Population Health Information:Structured clinical information about the population,gathered from different areas but stored in a single repository and available for both

anonymised research and reporting and to drive behaviour change at the point of care.

Shared clinical information:Rather than exchanging information between providers whomay need access to it, a Regional Health Management Information System is established,

and all providers and patients can access that resource using appropriate security and

privacy mechanisms. Starting with shared electronic care plans in year 1.

Ability to order ultrasounds and x-rays

and mammograms and CT's through the

community (publically funded), without

having to refer to a specialist, without

actually having to budget-hold.


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Resource Management:Information systems support frontline clinician decision makingand provide timely and accurate information to health funders and planners to determine

the quality and quantity of health resources being utilised.

7. Developing new locality-based infrastructure andaccountabilities for health

A fundamental step for providing Better, Sooner, More Convenient services for patients is the

development of new locality-based health infrastructure. GAIHN believes this is the key to

achieving the full potential of the NZ Primary Healthcare Strategy.

Locality-based infrastructure will be more responsive to local needs, improve coordination of care

for patients, increase access to support services, provide integration between health and social

services, ensure efficiency within community-based services and to enable the shift of hospitalservices into the community.

Local Health Networks

GAIHN will develop six new Local Health Networks (LHNs). The LHN is a locality-based network of

clinical professionals, health organisations and social services. PHOs will establish and support he

networks.

LHNs are a new concept for New Zealand, therefore GAIHN is

proposing pilots in the first year that are based around a variety

of dimensions e.g. size, population need, scope, and are

supported by a learning framework so success factors are

identified to inform future development. It is likely the pilots will

involve scale differences, from LHNs responsible for 100,000

down to 10,000 people.

Enhanced general practice

GAIHN will support the amalgamation and development of

general practice to support a greater range of health services. This process will occur by the clearly

describing incentives and benefits for Enhanced General Practice. GAIHN will support an

entrepreneurial, market-led response by general practice and accident and medical clinics.

Community Health Hubs

In order to support the shift of services from hospital to community, scale is necessary for many

services. Community Health Hubs are larger centres for health support services and social

services. Community Health Hubs will help general practice, as the patients medical home, to

better manage patient care outside the hospital. They will support Better, Sooner, More

Convenient access to health services.

Community Health Hubs are likely to service populations of about 100,000 people. DHB planning is

essential for an orderly and safe shift of services into the new hubs. GAIHN will establish at least

three new hubs in 2010/11, one in each DHB district.

I do not believe that you can sustain

long term devolution of services unless

there are better primary care delivery

units. Patients are not virtual they need

to be physically seen and larger medical

centres will provide efficiencies of service

and economy.


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Whnau Ora Centres

Two GAIHN PHO partners, Te Kupenga o Hoturoa Charitable Trust and Tamaki Healthcare Ltd, are

also members of the National Mori PHO Coalition. Both PHOs have indicated that they wish to

develop a number ofWhnau Ora Centres. GAIHN is supportive of this approach.

Initial models for Whnau Ora Centres have been developed and include:

Mori owned and governed Enabling families to improve their wellbeing Holistic approach to promoting wellness and addressing causes of ill-health, not only

providing clinical services

Targeting Mori and high need populations, but open to all Engaging with other providers to improve health outcomes for Mori and high need

populations

The Whnau Ora Centres will be developed to have a synergy with the GAIHN Community HealthHubs. The first graphic below shows the relationships between a Local Health Network, a

Community Health Hub and other health services. The second shows a Whnau Ora Centre and its

potential relationship with a Community Health Hub.1

1Acknowledge Tamaki Healthcare, Te Kupenga o Hoturoa Charitable Trust and Francis Group for the Whnau

Ora plans


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GeneralPractice is

Medical

Home

Healthconsumers

Hospital andDHB

communityservices

Self referral walk in andafter hours

General Practice

registered patient

Examples of GP referrals

Diagnostics

Chronic conditions

support team

Acute episode support/observation

After hours care

Devolved secondarycare services

Community support

services

Discharge care

Local Health Networksupports GPs from any

PHO

Appropriate direct GP

relationship with hospital,

clinicians and privatespecialist services

Supports GP manage patient needs in

the community

Appropriate care and interventions

in collaboration with GP

Real time medical notes

Training and developmentopportunities for general practice

staff

Provide scale to enable

shift of services

Integrated care

Devolved secondaryservices

Devolved

community services

Private medicalspecialist services

Appropriate

referrals

DHB strategichealth programmes

Credentialed services andnetwork of clinicians fromhub, hospital, community

and local general practice

Other socialagencies

Reduces ED

admissions and acute

demand on hospitals

Improves mgt of

acutes, electivesand discharge

Improvedlocal access

to serivces

CommunityHealth Hub

Patients remainregistered with theirfamily medical

practice

Multidisciplinary,multiservice centre

Local HealthNetwork supports

care integration

A&M services

Improved

care and

continuityfor patients

Improved clinical management ofacutes, electives, discharge and

long term conditions

LocalH

ealth

Netwo

rk

and

Comm

unity

HealthH

ub

Whnau Ora Centre

Primary Services

GPs, Nurses, Others

Secondary Services

Mm, Pp& Tamariki,

LTC, Others

GAIHN CHH(Othercomplementary

localities)

DHB

Services

Shared

Services

GP Practices

Other

Services

After

HoursMarae

Rnanga

Mori Health

Providers

Social

Services

Economic & Social

Development

Clinical

Networks

Tertiary

Education(incl. School of

Population Health)


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Examples of impact on acute demand management from GAIHN actions 2010/11

GAIHN actions

2010/11

Speed outflow from

hospital and reduce

readmission

Reduce inflow to

hospital (short term

- 1 minute to 1

week)

Reduce inflow to

hospital (medium

term - 1 week to 1

year)

Reduce inflow to

hospital long term

(long term - 1 year

to a lifetime)

Models of care

Long term conditions Health Navigators

Self Management

Education

Pulmonary & Cardiac

Rehabilitation

End of Life Care

Health Navigators

Clinical Care

Pathways

End of Life Care

Health Navigators

Multidisciplinary

Annual Review for

Complex Patients

Self Management

Education

Clinical Care

Pathways

Health Navigators

Multidisciplinary

Annual Review for

Complex Patients

Self Management

Education

Acute Care Enhanced Primary

Options

Improved After

Hours CoordinationTelephone Triage

Walk In Clinics

Prevention Smoking Cessation

CVD Risk

Assessment

Immunisation

Health Promoting

Practices

Clinical enablers

Access to diagnostics Direct Access to X-

Ray, CT, MRI &

Ultrasound

Direct Access to X-

Ray, CT, MRI &

Ultrasound

Direct Access to X-

Ray, CT, MRI &

Ultrasound

IT Shared ElectronicCare Plans

Shared ElectronicCare Plans



Population Health

Tools

Locality-based infrastructure

Local health

networks

Improved

Communication

Improved

Communication

Improved

Communication

Improved

Communication

Enhanced General

Practice

Walk In Clinics

After hours

Multidisciplinary

Teams

Multidisciplinary

Teams

Community Health

Hubs

Community Based

Beds

Specialist Advice

After hours

Specialist Clinics

Whnau ora centres Links to social

services

Outreach services Multidisciplinary

Teams

Multidisciplinary

Teams


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8. Improving the capability and productivity of ourworkforce

GAIHN understands that workforce is both a key constraint and enabler of sector performance. Ourworkforce is also mobile and GAIHN sees a huge opportunity in developing a strategic response

across Greater Auckland.

New locality infrastructure of Local Health Networks, Enhanced General Practice and Community

Health Hubs and Whnau Ora Centres establish multidisciplinary ways of working and new

responsibilities across teams and across the hospital/community divide.

There is also greater opportunity for professionals to learn

together and break down barriers that currently inhibit the

delegation of tasks whether from specialist to GP or from GP

to nurses. GAIHN not only provides opportunities for new

models of care, but to prove that those models are scalable.

GAIHN will identify workforce models and skills that are

required to provide whnau-centric care and develop these at

a scale required to make a real difference to reducing

inequalities.

GAIHN will increase the rate of learning in the health system

as this is the key to continuous quality improvement. The

Active Clinical Network will lead clinical learning, based on data and improved information about

what is working across the GAIHN network. The Active Clinical Network will link to the Local

Clinical Networks to support local level and regional learning.

9. Creating regional leadership that bringsorganisations and clinicians together

In signing this business case the GAIHN partners agree to:

Participate in a formal network Support the charter and principles (e.g. information sharing) Participate in developing a Regional Annual Plan (including outcomes/performance

measures)

Commit to implementing the plan which may require resource reorientation DHBs will incorporate the Regional Plan in their DAPS PHOs will incorporate the Regional Plan in contracting.

GAIHN is a network; it does not supplant the governance of any of the partner organisations. It

improves collective leadership for community based health services.

Professionals working together as a

team and not doing their own thing. We

need to agree that we all can togetherimprove the health outcomes of our

patients. Better sharing of information,

resources and the acceptance by all

parties that we should be working

together would improve the care to our

patients.


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GAIHN will be developing two key leadership structures for Greater Auckland, the GAIHN Partner

Group and the GAIHN Active Clinical Network.

The Partner Group will build from the current GAIHN Steering Group. The Partner Group

represents the collective interests of GAIHN and is a leadership forum charged with developing theGAIHN Regional Annual Plan and supporting its implementation and measurement of GAIHN-wide

performance. GAIHN will not develop new bureaucratic layers it is an integrator.

The Active Clinical Network will include leading clinicians from across the GAIHN partners and from

key professions. The ACN will provide leadership across clinical priorities, programmes and

infrastructure and will link to the emerging Local Health Networks.

It is expected that once the Partner Group and ACN are established a number of existing

bureaucratic and clinical committees will be disestablished, leading to a more streamlined

leadership process.

10. An efficient and practical approach to resourcingand contracting across health

GAIHN plans to simplify the whole approach to health planning,

funding and contracting in primary care.

Resourcing decisions will be guided by the GAIHN Regional

Plan. GAIHN believes that having one plan for community-

based health that all partners agree to will lead to a large

reduction in process complexity and bureaucracy, with much

clearer understanding of roles and goals.

GAIHN will pilot innovative new contracting approaches that

provide incentives for organisations to work together. This

alliancing approach is being developed by the Ministry of

Health and GAIHN sees opportunities in new contracting

mechanisms to drive service integration and service level

alliances across organisations.

Develop explicit inter disciplinary

approaches that promote recognition of

the core knowledge and skills of the

disciplines working in the community.

Recognise where there are overlaps and

focus teams on best possible outcomes

for individuals with difficulties achieving

optimal independence and quality of life

with most efficient use of resources.


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PHOs will be aligning their many funding streams to create Flexible Funding Pools, which improve

responsiveness and targeting of resources for Mori, Pacific and other high needs groups.

The locality approach will lead to PHOs developing consortia to support locality-based networks. As

these networks mature, GAIHN believes there is opportunity for new and innovative locality-based

resourcing, to reflect local needs and capabilities.

General practice will take on a greater role in commissioning clinical resources directly for patients.

11. Achieving efficiencies in bureaucracy, infrastructureand clinical practice

The 11 PHO GAIHN partners, along with the three Auckland DHBs are committed to working

together to create efficiencies. These include eliminating the need for duplication of process andcontracting that is present under the historic structures. Functioning at a regional level also offers

fewer border-driven constraints to efficiencies and

consolidation.

GAIHN will achieve efficiencies across:

clinical infrastructure organisational efficiencies investment efficiencies

Examples include regionally consistent care pathways, oneplan (not 3 flowing into 14), and alliancing meaning fewer contracts, better coordination, and

leveraging rare skills and capabilities across the whole network.

GAIHN acknowledges the need to continue evaluating PHO structures in terms of form following

function, and believes that the environment it has put in place will lead to a rationalisation of PHO

structures over time. GAIHN will work towards achieving organisational efficiencies over the next

two years.

GAIHN is aware that all but one of its PHOs serves an enrolled population above the median PHO

size in NZ. GAIHN will support further work to identify the optimal size of a PHO and to ensure that

consolidation processes are based on a clear logic around outcomes.

GAIHN notes that PHOs and DHBs retain valuable skill sets and relationships and that any

efficiency and transformation processes should be seeking to retain and leverage that capability

within new structures.

Create provision of alternatives to

hospital admission. Respite services.

Often people don't require admission to

hospital but do so as there are not

enough services in the community to

enable safety and reduction of risk.


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12. Creating financial systems that improve productiveinvestment

GAIHN resources

GAIHN has identified a series of existing funding streams and other resources it expects to utilise

to deliver BSMC as outlined in this business case. These include:

Flexible funding pools from existing PHO contracts comprising health promotion, servicesto improve access, care plus and management fee streams and valued at $40.6m per

annum

Other DHB / PHO existing contracts that provide resources in the areas relevant toachieving GAINs objectives are currently valued at $21.2m per annum

NGO contracts with DHBs to provide services in support of objectives aligned with GAIHN DHB owned services which contribute to achieving objectives aligned with GAIHN.

GAIHN will align the goals and objectives of the matrix of existing resources and does not intend

significant redistribution of resources. Instead, GAIHN partners have committed to utilising the

resources they currently have in support of common goals and objectives as laid out in the GAIHN

Regional Plan.

Efficiencies and improvements

GAIHN has identified areas where significant cost savings could be achieved whilst simultaneously

improving the quality of health care. GAIHN has not been able to undertake financial modelling

around all these opportunities. However, two are outlined below as examples.

These are aligned with the year one priorities of GAIHN:

Long Term Condition Management where Ambulatory Sensitive Hospitalisation (ASH)rates are our main chosen indicator. ASH accounts for around $112m of healthcare

expenditure per annum in the GAIHN region. In theory all of these events are avoidable,

however based on the assumption that 15% of these are actually avoided over the first

three years we could estimate a net saving after the costs of alternative programmes in

primary care of around $20m.

Reducing Acute Demand Of the approximately $500m per annum spent on triage anddirect hospitalisation costs following ED attendances, approximately $100m is spent on

patients triaged as being categories 4 or 5. Conservative estimates suggest that around

76,000 attendances at ED, which cost around $25m per annum, are amenable to

management in primary care. Using an uptake curve of 25% in year one, 50% in year 2

and 70% in year three of these 77,000 potentially primary care managed cases, we

estimate that after costs we would produce a net cost saving of around $10m over the first

three year period.


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Implementation of GAIHN business case

The GAIHN business case sets out high level priorities for changes to our health system and also

provides some analysis of the size of the opportunities and the broadly anticipated costs. Despite

this, there remains a requirement for much more detailed costing analyses as each of the priority

areas is worked into implementable projects and programmes.

In order for the GAIHN partners to have confidence to progress together, GAIHN has adopted a

stage-gate approach through which concepts develop into proposals and projects (discussed

under the risk section). As the stages progress so more detailed financial information is required.

GAIHN believes the financial components of these projects needs to include:

Whole of system perspective, especially looking at the incentives for different stakeholdersto take different actions and also looking at the risks of unintended consequences causing

cost overruns elsewhere in the system

Accurate and detailed costing of the proposed new services, including projections ofnumbers of patients that could be affected, proposed uptake modelling and transition costs

Projections of the future if the status quo was preserved Analysis of the strength of the evidence that supports the size of the projected

improvement in health outcomes or cost efficiencies, including analysis of the relevance of

the evidence to our specific environment

Explicit understanding of the risks associated with changes and exactly who is responsiblefor managing them and how they plan to undertake that management.

Looking forward whole system financial thinking

In the current resourcing system, funding for community interventions and for hospital servicesare delinked savings made in hospitals through improved community services are not reinvested

in the community. Also, where community services create increased pressure on acute demand

they are not held accountable. GAIHN believes that key to a sustainable health system is a much

improved whole system resourcing and incentive frameworks.


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Community-based

intervention

Assess theresultantimpact onhospitaldemand

If loss or ineffective modify or stop.

GAIHN makes decision will freed up resourcego to efficiency bottomline or for re-investment

If benefit - define

efficiency and extractfreed up resource

Saving

New system and culture requirements

Improvedlinkage of community

activity and ED/outpatientstrends etc

Improvedimpact

measures

Develop ability to extractfreed up resource

Enable informed decisionmaking about best use of

sector resource

GAIHN defines bestinvestment areas

The graphic describes a new type of system in which there is an explicit attempt to understand the

impact of community services, extract efficiency gains in real dollars and make a clear

prioritisation decision about reinvestment. Achieving this approach will require a new thinking, new

financial support systems and a new culture.

13. Remove barriers and build from strengths toimplement change fast

Year 1 Year 2 Year 3

Clinical infrastructure: Establish andpilot LHNs, EGP and CHHs

Clinical Enablers: Establish regionalenablers to support quality clinicalpractice access to diagnostics, POAC,HPP, Optimising general practice,telephone triage etc

Models of care: Develop consistentregional models of care for LTC,prevention and acute. Acute /COPD focus in year 1 expand to cover new conditions and greater % of practices

Expand scope of services and coverage across Greater Auckland

Focusforserviceand

infrastructureimprovements

Expand scope of enablers and % of practices

High needs innovations: Begin togrow innovative models e.g.whanaucentred models and whare orangainitiatives

Phasing of change

Resourcing environment: Establishnew resourcing and contractingenvironment pilot alliancingapproaches

Evolutionary transition from old to new resourcing environment

Evaluate and expand successful models

Impa

cton

health

outco

mes

,patien

texp

erienc

ean

dus

eof

money

Approx10 - 30% impact

Approx 20 70%impact

Approx 60-90%impact


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The graphic above identifies the key action domains for GAIHN over the next three years. The aim

is that by year three, the cumulative impact across the programmes is such that it achieves the

goal of sustainably reducing hospital acute demand to zero.

The implementation challenge is substantial in terms of technical,

process and relationship complexity. GAIHN sees the key to this is

to build from the strengths of existing organisations, encourage

entrepreneurial market-led solutions and empower clinical

leadership.

Through its regional plan, GAIHN will set out high-level outcomes

and directions. GAIHN will also identify key indicators and

performance measures, including some elements of consistent

infrastructure and clinical protocols, but it strongly supports

existing organisations to flexibly deliver the changes, and for DHBs

to retain the rights of lead planners across their districts.

GAIHN expects that partner organisations will take the lead on

various projects for the whole network, thus reducing duplication.

PHOs/LHNs and DHBs will be encouraged to stagger the

implementation of the GAIHN initiatives in a manner that best

meets the needs of their localities, for example a focus on children

versus a focus on frail elderly.

GAIHN believes the new structures will reduce significant bureaucratic logjams and create a point

of dialogue around significant issues impacting on implementation.

Clinical communications and leadership are at the core of the implementation approach.

14. Build efficient risk management into ourimplementation process

GAIHN understands the business case involves risks and that many of the initiatives require more

work before they can be agreed all partners. However, there is a need to embrace both prudent

risk management and change at a faster pace.

GAIHN believes the solution is to introduce an explicit stage-gate process for all major projects.

The stage-gate approach is used in managing inherently complex and risky projects. The stage-

gate aims to enable rapid development and implementation of projects, and to do so in an

environment where risk is constantly managed.

The concept is to clearly identify a pathway for development and critical decision points in advance

of a project progressing. The criterion for decision at the stage-gates is clearly defined in advance

to meet the project objectives and risk management concerns associated with the project.

For GAIHN, it is intended to use the stage-gate approach for the major initiatives. This forces a

process whereby the GAIHN partners outline their objectives and risk requirements early in the

process and agree to development pathways, timelines and stop/go criteria for projects.

If projects do not meet the stop/go criteria they do not proceed, or are reworked until they meet

the criteria. GAIHN will be developing stage-gate criteria during the implementation phase.

Im all in favour of new models of

care, and of clinical networks, but

Id like to know that it was going to

work before throwing too many

eggs in this basket. Im

unconvinced that there is sufficient

untapped clinical leadership (with

time available) in primary or

secondary care, project expertise

or the money required, to makethe IHCF work in totality, certainly

in the next few years happy to be

convinced otherwise.


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15. Next steps to build our business planFollowing submission of this business case, GAIHN will establish its Partner Group and Active

Clinical Network and continue to develop the details of the business case, whilst working on the

Regional Annual Plan for 2010/11.

GAIHN

Busin

essCase

ongoin

gdetailed

develo

pment

GAIHN

Regio

nalPlan

develo

pment

Busine

ssCase

Boardsignoff

1 March 2010 30 June 2010

Challenge in GAIHN shortterm work plan

Time

GAIHNw

orkplanand

stageofre

adiness

As the graphic above shows, the aim is to have more details to support the fundamental business

case and a signed off GAIHN regional plan for 2010/11 by 30 June 2010.

Key outcomes for 30 June 2010 include:

Functional governance structures partners signed up with Charter Further Business Case details agreed and signed off Regional Annual Plan developed and agreed Ownership across stakeholders Accountabilities clear Engaged sector Ministry of Health sign off.

The new GAIHN structures will build from the existing GAIHN organisational and clinical leadership.

Workstreams will continue to develop the detailed clinical, organisation and financial requirements

for implementation.


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The process outcomes for the implementation stage include:

Clinical ownership Informed sector Informed debate around the hard issues

Informed decision making Keep partnership together Improved community and consumer input into process Greater understanding across DHB clinical and support workforce Public communications accurate information and expectations.


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16. GAIHN response to MOH criteriaBusiness case

assessment criteriaGAIHN response

1 The nature and expected magnitude of benefits that will flow fr om the proposed service improvement initiatives, including how theproposal expects to:

1.1 Support the delivery of theGovernments key health

targets;

GAIHN is committed to achieving the Governments health targets (see GAIHN outcomes and measurable goals)

The primary focus is on acute demand management (sustainable zero absolute acute demand growth), designedin such a manner as to support the Government health targets of:- shorter stays in Emergency Departments (and improved access to after hours)- shorter waits for cancer treatment- reduction in tobacco consumption through more help for smokers to quit- integrated multidisciplinary diabetes and cardiovascular services- increasing immunisation

GAIHN is focusing on acute demand management strategies in 2010/11 and will address elective services from2012/13. This pathway was chosen to create a more manageable set of initiatives for 2010 and to create relieffor hospitals from acute demand pressures.

GAIHN is addressing the health targets directly through its models of care, clinical enablers and localityinfrastructure initiatives. GAIHN aims to systematically implement the initiatives over three years.

GAIHN is aiming for broad influence across all clinicians as well as niched programmes for high needscommunities. The magnitude of impact will be across more than 1000 GPs and associated primary healthteams. Approximately 300,000 health consumers will be impacted by the establishment of six Local HealthNetwork and three Community Health Hubs from 2010/11.

These initiatives, including Enhanced General Practice and Whanau ora centres will continue roll out across theregional over the three years of the business case. The aim is to have coverage of the whole GAIHN catchmentby 2013/14


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1.2 Contribute to health sectorproductivity and qualityimprovement;

GAIHN will improve productivity and quality:

Regionally consistent best practice models of care and integration pathways

Change based on rapid transfer of existing best practice across the network proven quality/low risk Regional clinical leadership through the Active Clinical Network to inform clinical quality, performance indicators

and a learning/ quality framework.

Improved efficiency through greater clinician direct access to resources to manage patients in the community

Improved problem solving and care coordination in localities through LHNs

General practice amalgamation and service collocation

Changes roles and relationships within multidisciplinary teams (see workforce discussion) to support more costeffective care models

Shift of services to lower cost environments Alignment of DHB planning/funding/contracting to become more regionally focused Reduction in duplication and reinvention across planning, clinical programme design and implementation More shared services and pathways towards consolidation of PHOs Alliancing and reduction in cost of contracting overheads Logjams to change are addressed at the GAIHN Partner Group and Active Clinical Network, where key

stakeholder have a voice. Create an environment where collaborative action is easier and barriers lower.

1.3 Lead to the rapidestablishment of IntegratedFamily Health Centres inappropriate locations;

Development of environment across Greater Auckland to support market-led response to amalgamate generalpractice and develop collocated services. Seeking market-led response from general practice and A&Ms.


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Three Community Health Hubs developed during 2010/11, to support improved access to services, bettercapability for general practice to manage patients in the community and shift of hospital services into the

community. Further Community Health Hubs will follow. (see scope and magnitude in discussion above)

Whanau Ora Centres and Networks will be established. Local Health Networks provide a clinical network to support the effective functioning of locality infrastructure. DHBs are still working on appropriate locations for Community Health Hubs. Locations were proposed during

business case process but need for engagement response meant further dialogue is required.

1.4 Support the shift of servicesfrom secondary care toprimary care;

Community Health Hubs are being explicitly developed to support the shift of services from hospital tocommunity, as many services require scale and cannot be devolved to smaller sites. Three CHHs (one in eachDHB) will be established in 2010/11 to pilot shift of services. The three initial CHHs may service up to 300,000

people, depending on final location.

Where hospital services can be devolved to Enhanced General Practice and Whanau Ora Centres, they will be.

Shift of services will be strategically managed to ensure the GAIHN outcomes of Better health outcome, Betterpatient experience and Better use of money are achieved.

The regional Active Clinical Network and Local Health Networks will have a role in ensuring the shift of servicesleads to improved team-based healthcare.

Note links to workforce development, GAIHN performance indicators and learning environment to support shiftof service.

1.5 Reduce acute demand onpublicly funded hospitalservices;

GAIHN key performance target is to sustainably achieve zero acute demand growth.

Acute demand will be reduced through the systematic implementation of strategies across the regional focusing on:


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Model of care

long term conditions (and frail elderly),

acute (adult/child)

prevention (whanau focused)

Clinical enablers

improved access to diagnostics and IT

Locality infrastructure

Community Health Hubs (x3) initially

Enhanced General Practice

Whanau ora Centres

Local Health Networks (x6) initially

Workforce development and the focus on high needs populations

The package creates a new health environment within the community where clinicians have the skills, tools,relationships, teams and resources to prevent and manage disease in a community setting.

Initial financial modelling shows significant positive impact from a quite achievable impact on ASH rates and EDadmissions (see financial chapter)

1.6 Ensure a wider range ofhealth services are deliveredincluding but not limited toextended hours, walk-inaccess, telephone and email

Walk in access will be provided at Enhanced General Practice and Community health Hubs.

A regional telephone triage system is being rolled out, scaled from existing models.


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consultations, laboratoryspecimen collection andsome on-site processing,day-stay surgical proceduresand observation beds

On site laboratory testing is proposed for the Community Health Hubs and will be a component and EnhancedGeneral Practice. The CHHS will delivery a very wide range of services, including integration with existing

district nursing.

The Optimising General Practice approach is supporting txt reminders and improved use of technology forcommunication with patients and whanau.

The CHHs will support many services such as day stay surgery and observation beds (see details in localityinfrastructure and workforce chapters)

The new Locality Infrastructure will lead to team based care models and use of technology to support patientsout of hospital. Including on-line access to their own records.

1.7 Support better managementof patients with chronicconditions to slow diseaseprogression;

GAIHN will implement a comprehensive, planned and proactive approach to long-term conditions management

across the Network (1.25 million people). This will include management of the frail elderly and end of life care. In

Year 1 GAIHN will:

pilot a regionally consistent long-term conditions programme incorporating:self management

annual interdisciplinary review

standardized and consistent pulmonary and cardiac rehabilitation

(services will be accessed according to patient and family/whnau need)

establish Patient and Practice Health Navigators expand the CMDHB Chronic Care Management Depression programme, targeting people with long-term

physical health conditions.

GAIHN will implement best practice preventive health care that encompasses health promotion and primaryprevention.

In Year One, GAIHN will:

implement the Health Promoting Practices Quality Framework across at least 10% of practices - includingCHHs


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optimise General Practice systems for immunisation, screening, counselling and support.

GAIHN believes its focus on Maori, Pacific and high needs families, through improving access to skills, tools and

relationships will improve long term conditions management.

In the longer term the locality infrastructure is key to local health services and health teams better meeting the

prevention and disease management needs of local communities.

The Whanau Ora Centres and networks will focus on the long term health needs of Maori.

1.8 Increase the use of thewider primary health careworkforce and supportmultidisciplinary teams;

The development of new locality infrastructure (Local Health Networks, Enhanced General Practice, CommunityHealth Hubs and Whanau Ora Centres) is designed to bring about a new health environment, which supports

multidisciplinary teams within the new centres, and as virtual teams across the local networks.

The GAIHN workforce strategy points to changing roles and relationships across medical, nursing, pharmacy andallied health workforce. Workforce development to support these changes will be integrated with the

development of the new infrastructure.

Whanau Ora Centres will develop multidisciplinary teams and support new roles, such as health navigators.

IT solutions are being designed to enable multidisciplinary teams, along with new approaches to alliancecontracting.

The locality infrastructure supports teams that link into social services.1.9 Provide for workforce

development, training andinnovation in the primarycare setting;

GAIHNs workforce development approach is across four areas (details in workforce chapter):

Leveraging the new regional approach to support strategic workforce development at scale to enable newhealth roles (such as health navigators) and skills to support moves to multidisciplinary teams. Also to support

scaling of existing best of class workforce programmes to be implemented across PHOs and DHBs


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Supporting the LHN establishment especially with the skills required to support improved resourcing andcommissioning at a locality level.

Workforce development as a tool to enable multidisciplinary teams this will include training multidisciplinaryteams together as new centres are established

Addressing inequalities providing new skills through the Health Promoting Practice programme across multiplepractices to improve the clinician patient interaction in terms of the way Maori, Pacific and other high needs

people live their lives.

1.10 Achieve the aboveobjectives in a way that iscost effective and assuresquality and safety for usersof services.

The establishment of the regional Active Clinical Network, provides for a new leadership centre for clinicalprogramme design and quality. The ACN will also have responsibility for regional clinical performance measures

and all GAIHN partners have committed to new transparency in terms of their performance measures. Local

Health Networks reflect these functions at a locality level.

GAIHN is proposing new performance measures that will allow for much improved analysis of businessperformance and clinical performance.

Alliance contracts aim to lock in performance measures across multiple providers involved in delivering tocommon outcomes.

The fundamental approach to GAIHN performance improvement is to build from what works well now, make itscalable and roll best practice out across the network servicing 1.25 million people. GAIHN believes this

approach is low risk, does not involve reinvention and will deliver proven benefits to a very large number of

patients.


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2The capability and capacity of the respondent to deliver major service improvement initiatives in suppo rt of these benefits,

including:

2.1 Ownership and governancearrangements;

GAIHN is a formal network, in signing this Business Case the partners commit themselves to:- participate in a formal network- GAIHNs charter and principles (e.g. Information sharing)- participate in development of GAIHN Regional Annual Plan (outcomes/measures)- commit to implementation of plan which may require resource re-orientation- DHBs GAIHN Regional Plan in DAPS- PHOs GAIHN Regional Plan in contracts.

GAIHN is not an extra level of bureaucracy, but aligns and integrates existing capabilities.

GAIHNs core structure is the Partner Group and Active Clinical Network, and a small support office. Thestrength of GAIHN to implement its initiatives is via the strength of the partner organisations e.g. three large

DHBs and seven of the 14 largest PHOs in NZ.

GAIHNs partner organisations will individually and collectively take responsibility to deliver on the GAIHN goals and expect these actions to be reflected in formal performance accountability documents.

GAIHN will be supporting alignment across DHB funding/planning/contracting and across PHO services especially in consortia to support LHN establishment.

GAIHN believes consolidation of PHO structures will occur in an evolutionary manner as a progression of form-follows-function as the GAIHN agenda unfolds.

2.2 Strength and experience ofthe clinical leadership;

GAIHN draws on some of New Zealands most experienced clinical leaders from both a clinical andclinical/managerial perspective. Clinicians have guided many of the aspects of this business case.

The ACN and the locality networks will create new structures in which clinical leadership is more explicit,

embedded in key sector decisions and accountable.


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There is significant PHO experience with population specific services such as those for Mori and Pacific peoples

GAIHN brings together DHBs and PHOs into the same consortium, leading to new opportunities for integratedchange management that is not bound by cumbersome single-focus contracts and divergent strategies.

GAIHN will implement change through a Tight-Loose-Tight approach with key directions and performancemeasures in the GAIHN Regional Plan, with implementation being undertaken by existing capable and

experienced organisations.

GAIHN has explicitly proposed a stage-gate process to change management to embrace the need tosimultaneously manage risk and the need for rapid change. The proposal describes the stage gate process sin

detail.

2.5 Information managementthat enables new models ofcare, and improves qualityand efficiently deliverservices.

The GAIHN organisations include some of New Zealands largest and most experienced primary healthorganisations with regard to information management design and deployment in the primary care environment

GAIHN is working from existing platform for the Auckland regional IS strategic plan, that is driving the longterm IT infrastructure investment.

GAIHN is seeking to modify RIS10-20 to focus on key infrastructure for the proposed models of care and localityinfrastructure and clinician-based commissioning, including:

- Population health tools in general practice- Electronic shared care plans- Online resource management tools

By working within the framework of the RIS10-20 GAIHN is minimising risk and tapping into existing funding

streams to support IT development.


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3 The strength of relationships betw een the various parties, and partnership arrangemen ts with key stakeholders, including;

3.1 The degree of engagementand/or support from DHBs,specialist clinicians,practitioners from a range ofdisciplines;

The Business Plan outlines the significant effort GAIHN has put into engaging with the health workforce andhealth leaders (including on-line surveys, summits, well attended clinical workstreams, NGO forums, mini-

summits at hospitals and normal PHO and DHB communication channels).

There has been robust clinical dialogue around many of the GAIHN initiatives. For example the detaileddiscussion around IHFCs led to a change from the approach proposed in the original EOI. Clinicians have

designed the details of the clinical initiatives in GAIHN.

GAIHN is very aware of the very large number of clinical stakeholders and that as the initiatives develop,ongoing clinical communication, leadership and ownership are critical.

The three Auckland DHBs are GAIHN partners. They have been involved in all aspects of the Business Casedevelopment and DHB senior staff have led several of the workstreams that have informed this business case.

DHBs are providing support with qualifications around the need to undertake further detailed work across manyof the initiatives which is a qualification all partners share.

3.2 Experience in meaningfulengagement with consumersand the community.

PHOs participating in the Network are committed to consumer engagement and many include consumerrepresentation within their governance structures.

Network members have dedicated community services which link with local communities, iwi, and communityorganisations. These relationships will be supported and strengthened through GAIHN.

Consumer representatives have attended the GAIHN summits and direct consumer involvement will increase asthe more detailed planning of GAIHN initiatives proceeds. GAIHN believes that developing Local Health Networks and the reorientation of PHOs to support LHNs will lead a

far greater linkage between health services and local communities. Establishing LHNs will involve creating

clinical and community networks. The evolving role of LHNs to potentially take on a locality

resourcing/commissioning role will empower the relationship with local communities.


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Whanau Ora Centres and networks will create a new infrastructure in which to engage Maori communities andhealth consumers.

Iwi have been invited to join the GAIHN partner group. There are opportunities for manawhenua involvement inlocal health networks.

Community Health Hubs will provide the infrastructure for more meaningful engagement around health servicesand local social and regional determinants of health, including the integration of social agencies such as MSD,

Housing New Zealand, Justice, ACC and others


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GAIHN Business Case Executive Summary FINAL

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