The Mission We Chose to Accept:Achieving Integration
Natalie Sullivan
General Manager Yarra Ranges & Angliss HospitalChief Allied Health Officer
Achieving Integration Policy – Victorian Vs Tasmanian – are they that different? Dust
collectors or roadmaps for service improvement?
Implementing the policy – system wide reform, integrated area based planning, enablers-are they that important?
What does it look like from a capital development perspective? Will bricks and mortar be the answer?
What can be achieved without capital investment? Making a difference where it really counts.
Eastern Health Experience – the good, the bad and the ugly.
Mission critical – my view on the success factors for achieving service integration.
Why is this concept relevant? 70% of the total burden of disease is attributable to 6
disease groups all with potential ability for community management
Chronic disease is now commonplace and continuing to affect increasing proportion of Australian population
2/3rd of medical separations and 1/3rd procedural separations are same day in Victoria
Across RHH, LGH & NWRH in 2004-05 7700 separations 30,300 beddays Approx 83 beds across the state.
Attributable to patients who potentially could have been treated in a non-inpatient setting
Our current health environment Older population have increased health care
needs Demand for health services will grow quicker
than the rate of population growth Escalating costs in hospitals Mismatch between what the community needs
and what out current health service has capacity to deliver
Declining bulk billing rates Overburdened hospital system Barriers to increasing community based care
System Limitations Fragmented primary and tertiary care
sector Lack of appropriate facilities and
infrastructure Cultural barriers to change (clinicians,
bureaucrats, community, patients) Complex funding arrangements Workforce pressures
Victorian Policy – Care In Your Community Care in your community provides a ten-year
vision for a modern, integrated and patient-centred health system. It is based on area planning and focussed on the following needs
chronic disease and complex care; episodic and urgent care health promotion and illness prevention.
Launched in April 2006
Aim of the policy Maximise access Maintain and/or improve quality Improve continuity of care Improve service flexibility Maximise opportunities for service substitution
and diversion Ensure optimal use of resources Determine capital developments to co-locate
services outside of the hospital environment
Getting from here to Utopia Recognising there is more to this than
goodwill and a good plan Jumping the hurdles, removing the
barriersEnablers
Funding models Workforce Integration tools Information management Partnerships
Can anyone give me the directions to Utopia?
PlanningWho plans?How do we plan?What do we plan?What about existing plans?Planning burnout!
Integrated Area Based Planning Approach
Population Health Planning Integration Planning Community Based Service Configuration
Planning Regional and Statewide Planning
The Planning Process1. Determine the needs of the local catchment population in
terms of the three areas of need
2. Profile the existing service system on the basis of the schema
3. Determine how the planning principles apply to the local service system.
4. Conduct an assessment of the local service system based and the application of the planning principles
5. Develop recommended priority actions to achieve integration goals and to move towards the future service configuration
The Planning Schema
Modes of Care
Settings of Care
Levels of Care
Modes of CareThe way care is provided. Inpatient admission Same day admission Specialist care: care that requires specialised
clinician, infrastructure or other support Primary care Group program: care that is organised for groups
of people with like needs Self-care: care that individuals undertake
themselves or with the aid of a carer or family member
Settings of care
Refers to the physical setting for the delivery of care and is classified into:
hospitals community-based health care facilities outreach (care delivered where a person
lives, through a mobile facility or in some other public or private location, such as the workplace).
Levels of care Level 4
health care provided on a day admission basis that must be delivered in a hospital setting, requiring inpatient back up in order to be safely and effectively delivered, e.g. ED, radiotherapy, day surgery or procedures involving high degree of clinical risk, Outpatient services required immediately pre-and post admission
Level 3 requires specialist resources and a large critical mass for
services to be effectively and efficiently delivered, Level 2
requires specialist resources, but a reduced level of back up resources and / or critical back up
Level 1 focused on delivering primary care in a minor centre
Integrated Area Based Planning Trials
Three trials across the state Southern Metropolitan Region Eastern Metropolitan Region Gippsland Region
Why these areas? Strong existing partnerships eg PCPs Strong local capacity and commitment Socio-economic demographics (high need and high
incidence of ambulatory care sensitive conditions.
Trial of integrated area based planning
Objectives to develop partnerships between key
stakeholders (building on existing partnership work);
to provide a focus for the further development of program planning parameters by individual DHS programs; and
to develop and refine the detailed area-based planning methodology for broader application.
The Outer East Experience
Outer EastPop: 394,215Area: 2647m2
Knox, Maroondah, Yarra Ranges
Key Health Organisations in OE One Metro Health Service
Eastern Health (Outer East component -3 acute sites, 2 EDs, Home and Centre Based subacute ambulatory and Inpatient)
The Outer East PCP 3 Stand alone Community Health Services
EACH, Knox CHS, Ranges CHS One integrated Community Health Service
YVCHS & Maroondah & Angliss integrated CH 3 Divisions of General Practice
Whitehorse, Knox & Eastern Ranges RDNS
How we went about it……….
Phase1: Initiate project Stage 1:Establish Planning Network
Senior Managers of all LGA and significant health providers Terms of Reference (inc. project outcomes, project management
responsibilities, stakeholder engagement responsibilities) Establish Project Management Group Clarify reporting relationship to DHS governance of three trials
Stage 2: Agree Project Methodology including consumer consultation PRINCE2 Methodology Community Engagement Strategy developed
Phase 2: Set priorities Stage 3: Examine existing material
Organisational strategic and service plans Eastern Health stategic plan and service plan for each site Mental Health Service Plan EACH RCHS KCHS
PCP Community Health Plans 2006-09 Aboriginal Service plan 2006-09 HACC Triennial Plan Palliative Care Consortium 2005-09 plan
Phase 2 continued…… Stage 4: Determine area priorities
Options:1. Undertake a priority defining exercise (pure
approach to planning)2. Use health priorities of EH PC&PHAC (diabetes, CV
health & Mental Health)3. Focus on areas defined by DHS in trial guidelines
(CDM-incl early intervention, community health counselling, renal services, dental services)
Decision – Option 2 plus renal and dental as outlined in DHS priorities
Phase 3: Affirm Context
Stage 4: Analyse population characteristics data Review of statistic data (ABS, Dept of Infrastructure
projections, DHS data on Victorian ACSC, Burden of Disease estimates)
Stage 5: Consult with consumer peak bodies Consulted with Chronic Illness Alliance, Migrant Info
Centre, Yarra Valley Indigenous Service, Carers Victoria
Confirmation of appropriateness of priority areas
Phase 3 continued……. Stage 6: Apply service schema
Public sector community based organisations in the region
Added further issues for description including Site ownership and accessibility issues DHS funding type and activity Planned service hours Key referring organisations Suitability of existing location Co-location service development opportunities
Phase 4: Develop Action Plans Stage 8: Scoping Papers
Acted as information resource & initiated dialogue with stakeholders, including service providers, consumers and carers.
Stage 9: Action Planning Statements Series of workshops were held for each priority area Workshops formulated action planning goals
Stage 10: Formulate Action Plans Scoping papers, consumer feedback and action planning
statement synthesised in to draft action plans Planning Network workshop considered all draft action plans and
associated recommendations
Action Plan Structure Description of underlying need Description of current service delivery arrangements and
partnerships Consumer (and carer) observations on the arrangements Specification of a preferred patient pathway List of planning network supported actions Assessment of the initiatives against the planning schema A client and system impact assessment Implementation requirements
Impact on Community Resources Risks Endorsement needs
Other ideas requiring further consideration
Phase 5: Prepare Report
Stage 11: Draft report Stage 12: Assess learnings Stage 13: Finalise report
Trial Outcomes – the Good Partnership and relationship
Continued partnership development Integration and strengthening of existing health planning activities
Communication Forums brought together key stakeholders from acute and primary
settings for the first time in some priority areas Formal inclusion of consumer and carer voice in a planning process
Methodology Elevation of regional planning from an organisational to a service
system perspective Direction Setting
Short, medium and long term plans Capital development
The Bad and the Ugly! Partnerships and Relationships
Relationship with existing planning forums and associated resource implications
Methodology Resource intensive CinYC process not well aligned to Local Gov planning role Recruitment of specialised planning skills Time lag on progress of enabler work Keeping action plans real and deliverable Highlighted communication issues between region and various DHS
programs Difficulty engaging medical specialists More work on interface with private
Direction Setting Taking disease focus put less emphasis on health promotion and
prevention Issues relating to issues such as transport were out of scope
Future of the Planning Network
Currently disbanded Have made recommendations regarding any
future establishment of Planning Networks or similar planning structure including a range of principles.
Progressing low hanging fruit actions from action plans
Awaiting DHS advice on future of the planning outcomes
From a dream to reality...capital developments Integrated Care
centres in Victoria
No single name
Integrated Care Centres
Health Precincts Day Hospitals ‘Superclinics’
Integrated Care Centres Cranbourne
Integrated Care Governed by Southern Health Dialysis, AH, Counselling,
Dental, RDNS, public and private consulting, Mental Health
PANCH Provides services in
partnership with, The Northern Hospital, Bundoora Extended Care Centre, Austin Health, Mercy Hospital for Women, Darebin Community Health, Dental Health Services Victoria and Darebin City Council.
The Super clinics
Melton, Craigieburn, Lilydale Melton & Craigieburn
Both Greenfield sites Similar service profile
Renal Dialysis Chemotherapy/Day medial Procedures Specialist Medical Allied Health Diagnostics Urgent Care (but not an ED) Other Community Health type services (paeds, antenatal etc)
Lilydale Super clinic – Yarra Ranges Health
Currently under construction
Construction $13M Due to open July 2008 Small site Responsible for
premature ageing and increased alcohol intake!
What makes YRH different to the others? Small and difficult site Built next door to independent community health
service No service planning prior to capital
announcement! Political imperative to commence building prior
to state election (before service profile was agreed)
Service Profile is quite different
Service Profile Proposed Services
Day Surgical services Day Chemotherapy Palliative Care Maternity Services Sub-acute Ambulatory Care Services Audiology Mental Health
Proposals on hold Early Referral & Response GP Clinics (managed by Ranges Community Health)
Co-located health services Independent Community Health Service
Presents challenges as well as opportunities Governance Funding models Treating patients in best space ICT compatibility Dual workforce Opportunity to extend community service types in to acute eg
Dental Surgery Eastern Palliative Care RDNS Royal Eye and Ear Hospital
Tips :Before you walk in my shoes
PLAN, PLAN, PLAN Make sure all branches of DHHS are on the
same page Ensure all partners are committed to the same
outcome Manage the political agenda Select your Community Advisory Group
members carefully Have an agreed service plan and recurrent
budget before you start building!
From the Good, Bad and Ugly to the Excellent! The HARP Story Objectives of program
To improve patient outcomes
To provide integrated seamless care within and across hospital and community sectors
To reduce avoidable hospital admissions and Emergency Department presentations
To ensure equitable access to healthcare
Care coordination and specialty clinical services (aged, chronic disease, pharmacy, allied health & Psychosocial)
Current Structure HARP Partnership between Eastern Health (5 sites),
Community Health Services (6), Divisions of General Practice(4), Primary Health Care Services(2) & Primary Care Partnerships(2)
In 06-07 2432 new clients (nearly 6,500 on books) $50M budget, over 50 multidisciplinary EFT Funding And Service Agreements (FASAs) Area based teams Clinical teams
HARP CDM Manager
Medical/ Chronic Disease case management
(includes clinics)
Liaison Unit (Including admin and intake)
Care coordination (Case
Management)
Allied Health, Nursing, Medical &
Pharmacy
Brokerage for additional services as required
Psychosocial
Aged(incl RACAS)
Steering Committee- Ambulatory Services
Reference Group
“Angliss Area”LGA based- Knox, and part of Yarra
Ranges
“Box Hill Area”LGA-Boorondara,
Whitehorse, Monash and part Maningham
“Maroondah Area”LGA-Maroondah &
parts of Manningham & Yarra Ranges
Eastern Health Executive
“Clinical”
GP Facilitation
HARP Chronic Disease Management (HARP CDM)
Program Structure
*Voice for clinical specific issues across region
*Specialty clinical support
*Assist with recruitment and give feedback for use in performance management
Clinician
Agency ManagerAREA
“leader”
Clinical “leader”
HARP CDM MANAGER
(EH Auspice)
Multidisciplinary case conferencing
Relationship building with area stakeholders (E.g. ED, PCP)
HARP: Achievements Consumers
Improved health outcomes Improved capacity of self management and knowledge Less time in hospital More support for carers Consumers like it!
Community engagement Community Hospital collaboration beyond HARP Flexible models of care developed System impacts and reduced demand acute services
Some of the changes that helped us achieve our goals. Changing from individual projects to one
program (Eastern HARP) that spans all organisations
Yearly funding to recurrent funding Changing funding from Input to Outcome
funding A Funding and Service Agreement (FASA)
created and implemented
Sustainability, when combined with guidelines ensures consistency and collaboration, yet
allows flexibility for local arrangements.
Eastern HARP guidelines
Based on DHS guidelines and regional
service coordination manual Includes defined point of entry, assessment,
intake and discharge criteria, care coordination role, care plan, brokerage, structures and accountability, GP notification and engagement, information management
Consistency across region and a great resource for orientation of new staff
HARP Access A defined point of entry Access point for all Eastern HARP services Central 1300 number (1300 661 141), fax number and
Eastern HARP e-referral Staffed by clinician and administration-greater satisfaction Used regional service coordination manual (PPPS)
principles Common eligibility tool utilized, priority rated and most
appropriate stream identified for care coordination
Simple for referrers to navigate the system and importantly more equitable access
Assessment Common assessment across all Eastern
HARP services that can be shared Specialist assessments have been created
for each area Assessments will auto populate SCTT and
the Eastern HARP care plan Also monitoring InterRai progress
Greater sharing across sectors and decreased duplication
Care Coordination & Care plan One and only one care coordinator across
HARP at any one time Communication by external providers occurs
through one person One care plan that is shared across all staff and
shared with other providers (eg. GPs)
Seamless care, greater knowledge of patient journey, and less duplication and confusion
IT System - Allied and Ambulatory Eastern HARP use the same system as Eastern Health Allied Health
and Ambulatory services (eg Allied Health, Post Acute Care, Sub Acute Ambulatory Care Services)
Connection of all sites both internal to EH and external partners
(community health, divisions of general practice) using Citrix, aventail environment
Sharing of information-common HARP assessment, SCTT, Care plan, screening tool, diary, GP notification and engagement, unique identifier.
Ability to track patients across the continuum from an allied health and ambulatory care view point.
Sharing of appropriate information across agencies, reduced duplication, improved consistency with data and improved
reporting of data
Did we make a difference to the patient hospital experiences?
Data to support our impact on the hospital Did we reduce ED presentations? Did we reduce the number of admissions?
Hospital utilization
Health Condition Cluster
Emergency Department
Presentations
Emergency Admissions
Occupied Bed Days
Chronic Obstructive Pulmonary Disease
Up to 77% Up to 76% Up to 66%
Congestive Heart Failure
Up to 58% Up to 44% Up to 59%
Diabetes Up to 61% Up to 82% Up to 63%
Complex Care Up to 60% Up to 69% Up to 66%
Eastern Health Chronic Respiratory Disease ED Presentations
1
10
100
1000
1 2 3
No. of Presentations
No. o
f Pat
ients
Actual 2001-02
Projected 2004-05
Actual 2004-05
Trendline (Projected 2004-05)
Trendline (actual 2004-05)
Diabetes, COPD and CHF combined- number of patients with multiple presentations
1
10
100
1,000
10,000
1 2 3 4 5 6
No. Presentations
Pat
ien
ts
-80%
-60%
-40%
-20%
0%
20%
40%
%ch
ang
e
2001-02
2006-07
Variance between 2001/02 and 2006/07 in %
total ED changes
CHF and COPD as a total percentage of ED presentations
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
2000-2001 2001-2002 2004-2005 2005-2006 2006-2007
Financial year
Data and Outcomes
After mainstreaming, in 2006-07 year we have increased throughput of 42% increase in assessments32% increase in client service eventsApproximately 40% increase in GP contacts
Increased alignment and integration improved care continuity
HITHPAC
SACS HARP
Outpatients
InpatientCare: acute& sub-acute
CommunityCare
(HACC)
Emergency Care
Community Integration
Integrated Guidelines, Dataset & Funding Model
Some parting thoughts…. Do we tackle this with evolution or revolution? Is it a pipedream? Will these innovative policies gather dust? Have we achieved the mission we chose to accept?
“It is not the strongest of the species that survives, nor the most intelligent, but the ones responsive to change”
Charles Darwin