PHCS: Nursing
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Transcript PHCS: Nursing
Evaluation of the Implementation of
The Primary Health Care Strategy
2. Presentation Outline
Introduction to the project
Dr Antony Raymont
Quantitative Findings
Dr Barry Gribben
Qualitative Findings
Dr Antony Raymont
Nursing Issues
Prof. Margaret Horsburgh
Discussion
Jon Foley on continuity of care
3. PHCSE: The Project
Antony Raymont / Jackie Cumming
Health Services Research Centre
Victoria University of Wellington
The Primary Health Care Strategy
Published February 2001
Aims
Better access to health care for individuals
Care of identified populations (not walk-ins)
Better co-ordination (community and second)
Means
Increased subsidisation of primary health care
Capitation funding (with enrolment)
Primary Health Organisations
5. Set-up of Evaluation
“The Strategy [] will be supported by ongoing
research during its implementation” (p.26)
Funded by MoH, ACC & HRCNZ (2003)
Health Research Council of New Zealand
called for proposals
Selection followed the usual HRC process
6. Research Team
Host organisation
– Victoria University of Wellington
Health Service Research Centre (VUW)
Jackie Cumming and Antony Raymont
Anne Goodhead, Mariana Churchward,
Janet McDonald, Mahi Paurini
CBG Health Research Ltd (Auckland)
Barry Gribben and Carol Boustead
Nikki Coupe and Fiva Fa’alau
7. Research Team
Auckland (Nursing)
Margaret Horsburgh and Bridie Kent
Wellington Medical School (GP)
Tony Dowell and Roshan Perera
Canterbury (PH and GP)
Pauline Barnett
Ministry and Treasury
Bronwyn Croxson, Durga Rauyinar
International
Nick Mays and Judith Smith
8. Governance - Steering Group
Constitution
Four research managers, Four funder
representatives (1 ACC), and HRC as chair
Function (serially)
Discuss and comment on the project plan and
research instruments
Monitor progress and review and approve any
variations in the project plan
Review reports and publications
9. Research Themes I
The relationship between the Ministry, DHBs,
PHOs and PCOs.
Governance and internal financial arrangements of
PHOs.
Changes in the role of consumers and local
communities in the development and management
of primary health care services.
Enrolment processes and efforts to address
population care.
10. Research Themes II
Efforts to identify and correct inequities in access
to health services.
The development of new services, other changes
in service provision and the achievement of
comprehensiveness in primary care.
Efforts to improve service quality.
Developments in information collection and
quality.
11. Research Themes III
The impact on primary health care services for
Māori.
The impact on primary health care services for
Pacific peoples.
Changes in the primary health care workforce.
The development of multidisciplinary teams
within PHOs particularly the role of nurses.
Moves to coordinate services between PHOs and
other organizations
12. Research Themes IV
How the PHCS has increased access, and
reduced inequalities in access, to services.
The impact of the PHCS on health status and in
reducing health inequalities.
The impact of the implementation of the PHCS
on injury care provision.
Changes in the quality of primary care services
(including use of drugs, laboratory tests and
referrals).
13. Structure of the Research
Key Informant Interviews
A Postal Survey
Quantitative assessment
Economic analysis
Time line (three years)
Phase I to June ’05; Phase II to Dec ‘06
14. Key Informant Interviews
Purpose
Understand the experience and activities of
Primary Health Organisations and their
member practices in responding to the
Strategy
Time line
Interview 1 – Mid 2004 (Report April ’05)
Interview 2 – Jan – June 2006
15. Postal Survey
Purpose
To investigate the issues raised during the key
informant interviews so that their extent and
distribution can be specified.
Timeline
To follow each phase of the informant interviews
16. Quantitative Assessment
In summary
Will use data from administrative data sets and
from practice PMS to assess
patient costs
rates of consultation
use of nurses
changes in ACC claiming
Results will be presented by Barry Gribben
17. Economic analysis
Will use national and practice level data
Assess net cost of the Strategy
Evaluate distribution of expenditure by
Population group
(pop. vs govt.; low/high SES)
Service type
(primary vs secondary)
18. Quantitative Assessment
Analysis plan
Barry Gribben
CBG Health Research Ltd
19. What are we evaluating
What is the PHCS exactly
PHOs / pop health focus
Improved funding
SIA / RICF / CarePlus
NIR / BSA / NCSP
Improved 1º / 2 º care integration DHBs
IPA-led quality initiatives / HCA
RNZCGP MOPs programmes
20. Original plan
PHCS = PHO / funding / pop health focus
Evaluate with a cohort study with control
group of non PHO practices
But PHO sign up too rapid – much faster than
we expected – now 3.8M pats
Potential control group too biased
Plan B = analysis of longitudinal data from
PHOs
21 Attribution difficult
Regard PHCS as a single entity
encompassing many interventions
Some clear cut components - fees
Qualitative data critical to interpretation
22. Data sources
National data sources
PHO data – registers / utilisation / quality
NMDS
ED / OP national databases
Practice survey
Consultation rates
Consultation types
Co-payments
Roles
23 National data 1
PHO upload data
PHO register structures
Utilisation data – first submitted Oct 2004
Quality Indicators – not yet implemented
No data prior to PHCS
Long phase in with incomplete data capture
for first few cycles
24. National data
• Link PHO databases and NMDS
• Get excellent data from NMDS
• But NHI not 100% on registers
• Can examine non-PHO data “by subtraction”
PHO DateReg
xxx yyyyqq
Ethnicity Gender Quintile AgeGrp
Maori
M
0 0-4
Pacific
F
1 5-17
Other
2 18-44
3 45-64
4 65+
5
Quarter Cohort with NHI ALL PAH ASH DM Asthma IHD CX Mam
qtr cnt n
n
n
n
n
n
n n
25. Practice data
Sample of 60 practices in a before / after
design, from PHOs participating in evaluation
Sufficient power to detect changes in
utilisation rates / copayments of 10%
Complete data collection of register / visits /
copayments / role of provider (Dr/nurse)
26. Sample to date
• Small numbers practices
involved so far (50%)
• So analyses are illustrative
only
• Are not estimates of national
rates
Practice or PHO
considering
approving
participation
24 PHOs chosen
representing
different types
5 non-PHO
practices
recruited for
interviews
Random sample
of practices, but
min 1 each type
n=81
All 5 invited to
participate
14 ineligible
8 declined
2 ineligible
1 declined
leaving n=59
leaving n=2
n=5
Data collected
n=30
• …but show trends over time
•29 practices
•220,000 patients
Data returned
successfully
n=27
Data returned
successfully
Access 5
Interim 22
n=2
•4 million consultations
Data returned
successfully
Final data set
n = 29
27. Next stages
Much more analysis to do reconciling PHO
start dates / capitation funding / subsidy
increases in a single analytical framework
Complete national data extraction
Explore interesting features qualitatively in
next rounds – eg low ACC copayments in
Interim practices
Expand practice sample
28. Key Informant Interviews
Phase One (formative)
Antony Raymont
29. Appreciation
Thanks to all those in sector who have been
badgered for information, interviewed and
asked to reveal their experiences with the
implementation of the Strategy.
Practice Nurses
Medical Practitioners
Community Representatives
Managers and CEOs
Bureaucrats from IPAC to MoH
30. Numbers
77 primary care organisation identified
including PHO, incipient PHO and PCO
Characteristics of PHO
Focus - Maori 18%, - Pacific 9%
Funding – Ac’s 51%, Mix 16%, Int. 32%
Site
- < 100k 60%
- >100k 38%
Size - Small <20k 49% (11% popn.)
- Large >20k 50% (89% popn.)
31. Selection of PHO
PHO partitioned on key characteristics
(Focus, funding, size and urban/rural)
One in three chosen from each group
(So as to equalise region, age and overlap)
26 PHO chosen (interviews done at 23)
(1 not established, 1 disestablished, 3 refused, 2
of these replaced)
Essentially no PCO at time of interviews
32. Interviews Undertaken
PHO(8) – CEO/Manager or Chair
- Maori, Pacific, Community reps.
- General practitioner rep.
- Nursing rep.
Practices (Approx. two per PHO)
- GP and P Nurse (Separately)
Independent practices
Other Informants (MoH and GP Orgs.)
33. Process
Semi-structured interview guides
Interview recorded and noted
Issues abstracted with supporting quotes
Interviewee asked check the record
Issues partitioned into themes – iterative
process starting with proposed list
Themes described with supporting quotes (no
interpretation at this stage)
34. Qualitative results
35. Positive Response
Better access with reduced fees
More flexibility with capitation funding
Nurse visits, phone FU, proactive care
Ability to identify and care for population
Small Ethnic PHO to City PHO
Rejuvenation of General Practice
Higher income
36. Wariness
GPs noted
Threats to viability of practices
Compliance, bureaucratic, cost increase
without clinical benefit
Devaluation of medical role
Others mentioned
Failure to realise full benefits
Gradual increase in trust
37. Implementation I
Problems
Payment processes
Data errors
Detection of duplicates
Treatment of casual visits
Context
Rapid uptake; three levels of data
38. Implementation II
Problems
Targeting of subsidy
Well off in Access practices or 65+
Context
Multiple targeting are in use on the way to
universal coverage
Access (geographical); Age groups; CarePlus
(health need)
39. PHO Governance
Boards included representation of:
Community including Maori and Pacific people
Medical and Nursing professionals
Community reps - shoulder tapped,
nominated or elected by community groups
Problems
Comm’ity development vs Medical/Corporate
Community uninterested (Size related)
40. PHO Management
Focus on setting-up
Now moving to new initiatives
Small PHO capacity issues
Management fee
Efficiencies of Scale
Larger (ex IPA) PHO
Benefit of changes (esp. population approach,
community involvement) less obvious
41. Other Organisations
Co-operation between PHO
(Large interim PHO and small access one)
Difficulties in case of overlap
(Patient and practitioner poaching)
Various moves towards combined work
with eg WINZ, Schools, Police etc.
42. Primary Care Workforce
Fears of inadequate capacity
Issues and solutions
Address income disparity (docs and nurses)
Ensure adequate training
(Spaces in FMTP; financial support PNs)
Changing expectations – eg benefits of
Team work (vs being in charge)
Salaried employment (vs business worries)
Independent practice (vs handmaiden role)
43. PHCS: Nursing
Margaret Horsburgh
School of Nursing
University of Auckland
44. PHCS : Nursing
Expanded role for nursing
Strengthen and enhance phc team
Teamwork and collaboration
Aligning nursing practice with community
need and service delivery
Population and personal health strategies
45. Nursing perspective:
Implementation
Uneven development
Development depends largely on preferences
of general practitioners
Focus on primary medical care versus
primary health care
46. Challenges
Dominant private business model
Employer/employee relationships
Differentiating nursing role
Leadership
47. Way forward
Articulating primary health care nurse role
Career pathway
Recruitment and orientation to primary health care
including mentoring
Nationally recognized standards of practice
Financial recognition for skill level
Increasing training opportunities
Reducing barriers to education
I think there is the potential to achieve an expanded
role, and it is happening particularly in rural areas
where there are not enough GPs to provide services
Nurses are really struggling at the moment to see
how they fit into the whole structure. Some of them
have embraced the idea then been knocked back by
the PHOs who are really GP dominated
It depends on the attitude of the GPs, and the nursedoctor employment arrangement is often a barrier
49. New Services
Great variability by PHO and Practice
Greater accessibility and
acceptability
Extended opening hours
Whole family visits
Recruitment of a female
practitioner
Home visiting
Medical clinics at schools
Assistance with transport
Information for new immigrants
24hour PHO Helplines
Cultural training
Interpreter services
Secondary care liaison
ED liaison services
Acute illness home care
Specialist availability in practice
Podiatry
Focused clinics
Care plus related activities
Diabetes and nutrition clinics
Asthma nurse clinics
Smoking cessation
One-stop-shop for youth
Free sexual health clinics
Cervical and breast screening
Programmes for mental health
Programmes for disabled persons
Extra-practice services
Radiology
Retinal screening
Refraction
51. Care of Injury
No change in actual care of injuries
Awareness of conflict between capitation and
fee-for-service systems
Incentive in favour of medical care for
patients (higher co-payments with ACC)
Incentive in favour ACC claims for
practitioners (second diagnosis)
52. Referred services
Labs and Pharms
- focus on historical mal-distribution
- need for devolution of budgets
Hospital services
- incentive to use EDs
53. Quality
Incentives for better focus of care with
capitation and population identification
Quality programme in process
(IPA programmes on hold)
54. Information
Population data much improved
(Reporting more complete but individual visit
data not required)
55. Typology of PHO
Small
Inadequate management
resources
Access funded
Low co-payments
Previous capitated NGO
Salaried doctors
Increasing use of nurses
Established community
governance
Low material investment
Māori, Pacific, Low SES
Large
Well resourced
management
Interim funded
Higher co-payments
Previous fee/service IPA
Doctors own practice
Nurses underused
Establishing community
governance
Established IT, premises
General population focus
56. Distribution
(Current data)
37 Small – 8 Interim (22%)
41 Large – 11 Access (27%)
(Guesstimate)
37 Small – 11 IPA (30%)
41 Large – 32 IPA (78%)
57. The Future
Need to ensure that the goals of
Strategy are reached:
Inexpensive care
Expansion of primary health care team
Population focus
Inclusion of the community
Co-operation with other services
Monitoring outcomes
We [said] that if you are just doing this to
reconfigure general practice you are wasting
your time and money, it needs to be a bigger
more audacious goal than that and that is about
bringing in other services [and functions].” (DHB)