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Lessons from Study tour: Implications for
Neighbourhood Healthcare Homes
Nurses Hui 16.4.15 Jenni Moore
Synthesis
Patient Centred Medical Home
Key elements
Enhanced
access
Patient engagement, activation and experience
Work with patients on all aspects of how you
relate. They must have a good experience
• My distillery slide
Better
patient
experience
Support people to be
healthier through
providing better care
Work in a team, and make sure the patient knows
the team: trust and relationships
Technology : Use all technology to enhance access
for patients, enable remote work, and
monitoring
Increased
worker
satisfaction
Know your patients: stratify into high medium
and low risk. Proactively manage medium and
high, engage with low by email, phone, Skype etc.
Appointment slots to reflect need. Post discharge
follow up
Reduced
costs
Implement lean processes. Consider ‘the flow’,
reduce waiting, use the right workforce to do the
right work, team huddles to coordinate
What did we like and what didn’t we
like
• Like:
• Patient centred: involvement of patients in co-design,
prioritising patient experience
• Acknowledgment of need to include social and
‘behavioural’ dimension- whole of person
• Belief in need to link effectively with network of
providers
• “improving health is a challenge that requires the
engagement of partners across the community to
address the broader determinants of health “ (IHI org)
• Innovative use of technology
….
Not so much
• Electronic tags
• Gouging out of middle level nursing roles, replacing with lay workers
• Still more work to be done in linking more
with external providers, but this is seen as
essential
Paradigm shift
Today
Future
Treating Sickness / Episodic
Managing Populations
Fragmented Care
Collaborative Care
Specialty Driven
Primary Care Driven
Isolated Patient Files
Integrated Electronic Records
Utilisation Management
Evidence-Based Medicine
Fee for Service
Shared Risk/Reward
Payment for Volume
Payment for Value
Adversarial Payer-Provider Relations
Cooperative Payer-Provider Relations
“Everyone For Themselves”
Joint Contracting
Evidence
• Patient experience is positively associated with clinical effectiveness and
patient safety
• Patients experiences should be included as one of the central pillars of
quality in healthcare
• Clinicians should resist side-lining patients experience as too subjective, or
mood oriented, divorced from the real work of measuring safety and
effectiveness
Doyle, C.;Lennox, L.; Bell, D. 2012 “A systematic review of the evidence on the links between
patient experience and clinical safety and effectiveness”
Evidence
• https://www.pcpcc.org/
• Reduction in Emergency department
attendances
• Reduction in Ambulatory Sensitive
Hospitalisations
So how does this line up with what
we are doing in Northland?
Northland Health
Services Plan
First 2000
Days
Fit for Life
Patient and Family
Centred Care
Neighbourhood Health Care
Homes (NHH)
Integrated Urgent
Health Care (IUHC)
The NHH project
•
Project manager for 12 months
•
Andrew Miller Clinical Lead
•
Rose and Chris sponsors
Neighbourhood Healthcare Homes
• A network of providers connected up with
General Practice and including consumers to
provide accessible, comprehensive,
coordinated patient centred proactive care.
• Relationships between patients and the
extended team, and within the extended team
are central to success.
Aligns to IHI triple aim
framework
Te Tiriti o Waitangi
Foundations of Primary
Healthcare
•
•
•
•
Excellent accessibility
Comprehensive
Coordinated
Continuity – relationship
(Barbara Starfield)
• Compassion (Dr Harry Rea)
• Community (Ben Rosenstein)
Wagner’s Chronic Care Model
Elements of a Neighbourhood
Healthcare Home
Collaborative
events: Drs
nurses
community
Re designing
patient flow and
reducing waste
Nursing services
collaborative
redesign
E health
Social worker
collaborative
redesign
Volunteer
network
Joint Data project
Risk stratification
Painting a picture
• Intentional linking and issue management
with consumer involvement
• Clarity around nursing roles and linkages , for
the patients and the health providers
• Proactive management of medium and high
need patients
• Accessibility for all: options
Difference is….
•
•
•
•
More than lip service to ‘patient centered’
Co design : listening and acting
Leveraging off technological advances
Focus on relationships
Its not rocket science:
Why is this project needed?
“I was dropped through the service and support gap in the hospital
systems and it has yet to be determined how far I have fallen”
(Patient complaint NDHB 2014)
“We are sick of falling through gaps. We are tired of organisational
barriers and boundaries that delay or prevent our access to care.
We do not accept being discharged from a service into a void. We
want services to be seamless and care to be continuous”.
(National Voices)
.
• To improve equity of access to health services and
health status
• Fragmented diagnosis and treatment as different parts of
the system fail to communicate effectively
• Patients miss out on care
• To develop a sustainable fit for purpose PHC system
• To take advantage of technological change
• Changing demographics and patterns of disease
• Increased demand for quality care by patients
• Patients not supported to manage their own health
Integrated care is centred around
the needs of users
• “The patients perspective is at the heart of
any discussion about integrated care.
Achieving integrated care requires those
involved with planning and providing
services to impose the patients perspective
as the organising principle of service
delivery”
• (Shaw et al cited on www.Kingsfund.org.UK)
Your assistance
•
•
•
•
•
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Support the kaupapa: stronger primary care
Nurses are central to the change
Key potential expanded roles
You are leaders in the health system
Be the champion in your practice for NHH
Help get the right people involved, including
consumers