Transcript Northland Integration

Northland Integration
Dr Nick Chamberlain
July 2014
Ko te pae tata, whakamaua, kia tīnā
Ko te pae tāwhiti, whaia, kia tata
This whakataukī, provided by Professor Sir
Mason Durie, might be interpreted as “secure the
horizons that are close to hand and pursue the
more distant horizons so that they may become
close”, or he suggests it can be put even more
simply as “manage today and shape tomorrow”.
New Zealanders
enjoy good health
outcomes ...
14,000
Potential years of life lost
per 100,000 population age 0-69
10,500
Amenable mortality
(PPYL) rates are around
the OECD average
7,000
3,500
0
1960
1968
1976
NZ male
OECD male
In-hospital mortality following heart attack
16
1984
1992
2000
2008
NZ female
OECD female
13
Acute care quality. Hospital
fatality rates for heart attacks
are among the best in the
OECD
9
6
2
2000
2002
2004
2006
2008
New Zealand
OECD unweighted average
2010
So, Everything is going well!
Northland Health Services Plan (NHSP) Drivers
Growth in
acute
services, ED
Growth in
GP
services
Ageing
population
170 extra beds
If we carry
on as
before, in
15 years:
Long term
conditions
(esp diabetes)
No extra
funding
$70m in the red annually
Getting the balance right = The Triple Aim
All decisions
should be made
by balancing
three factors...
Population
health
Improving health
status overall and
reducing inequities
Simultaneously
Value &
sustainability
How wisely we use
our resources;
value for money
Patient
experience
How the system
deals with people;
quality and safety
... there are some
areas for concern.
4.0
Amenable mortality in New Zealand
age standardised rate per 1,000 population
aged 0-74
3.0
Marked income and
ethnic disparities,
suggesting barriers
to access for some
2.0
1.0
0.0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Maori
Total
400
COPD hospital admission in adults, 2011 (or latest
year)
age sex standardised rate per 100,000 population
300
200
0
Japan
Portugal
Italy
Switz.
France
Mexico
Slovenia
Finland
Czech Rep.
Chile
Luxemb.
Netherl.
Sweden
Slovak Rep.
Canada
Poland
OECD26
Norway
Spain
Germany
Belgium
Korea
US
UK
Israel
Iceland
Denmark
Australia
Austria
NZ
Ireland
Hungary
100
Pacific
Other
Primary care performance
appears mixed
e.g. Admission rates for
asthma and COPD are
relatively high
We have high quality General Practice but
still:
Inequities - funding (Our VLCA issue),
Access, and health Outcomes
– Fragmentation and Multiplication - feedback
– Unco-ordinated, Unconnected Care
– No clear focus on high risk population
– Acute demand….
–
Population Changes
Key Points:
• 3% increase overall in
Northland population
since 2006 - but depopulation especially in
economically deprived
areas
• 29.6% of Northlanders
identify as Māori
• Māori represent 48.3% of
the <5yr population;
overall the <15 year
population is declining
Key Points:
• A net loss of more than 5600 people in the 30-50 year age group in
Northland since 2006 (14% decline).
• 1065 were Māori; of these 774 were from FNDC
• Ageing: >50 years, growth in all age bands…
Explaining Inequities in Health
•
•
•
Differential access to health
determinants or “exposures”, leading
to differences in disease incidence
Differential access to health care, and
Differences in the quality of care
received.
Camara Jones (2001)
Drinking and smoking
• Small decline in hazardous drinking
• Decline in regular smoking (2006-2013 Census
data) – but rate of decline lower for Māori (16%)
than for Non-Māori (28%)
18,750
Regular smokers in Te Tai Tokerau
2006-2013 Census data
15,000
11,250
Maori
Non Maori
7,500
3,750
0
2006
2013
Obesity –NZHS 2013 data
• Just under half of Northland Maori
surveyed (48.9%) had a BMI indicating
obesity
• Increasing obesity was seen for Northland
Maori women (from 44% to 54%)
• and non-Maori women in Northland (from
23% to 27%)
Differential access to health care
in Te Tai Tokerau
•
National and local evidence for differential
access e.g. rates of GP utilisation, NZHS
data re cost and other barriers, etc
•
Large inequities in Ambulatory Sensitive
Hospitalisation (ASH) rates in Te Tai
Tokerau across age groups and conditions
Unmet need in primary care
Prescriptions unfilled due to cost
100%
75%
50%
25%
0%
Children
Adult
Visited dentist only for pain,
or never visited
100%
75%
50%
25%
0%
Adult
Case Study: ASH Respiratory Admissions in
Children <15yrs
Te Tai Tokerau (2010/11 – 2012/13)
Māori
Non-Māori
Primary Diagnosis
Total
2010/11 2011/12 2012/13 2010/11 2011/12 2012/13
Asthma
URT and ENT
infections
Respiratory infections
Bronchiectasis*
Total
101
87
72
43
37
37
377
73
82
64
57
53
41
370
92
69
61
58
44
32
356
0
1
16
0
2
4
23
266
239
213
158
136
114
1126
• Overall decline in ASH respiratory admissions in <15yrs olds
• Represents ~100 fewer children admitted/year in 2013 compared with 2011
• Healthy Housing insulation programme and better asthma management in Primary Care are
likely contributors to this improvement
• But inequity remains (Māori rate double non Māori)
General Practice
• “A marvel to get through the morning
without any mistakes but a miracle to get
through the afternoon as well”
• Don’t know error rates, but likely to be as
high as 20%
• Adverse drug events are the fourth largest
cause of admissions to ED in USA
Workforce Slide from NZ Doctor
Workforce Slide from NZ Doctor
Now
•
•
•
•
•
2 PHO CEOs on DHB ELT – Everything shared
NPHOs
Four IFHC projects – little integration so far
100% E-referrals for 2 years. Specialist E-advice
significant reduction in FSAs. Multiple Integration IT
pilots.
Maori Provider nursing, District Nursing, Aged Care
Nursing, HBSS, Physios, OTs, Social Workers,
Dieticians, Pharmacists, Ambulance – plenty of
resources, multiple organisations disconnected with
General Practice
What you’re saying about Hospital Care
- GP Survey
•
Response rate:
•
Only 1/3 of GPs have responded. A higher response from TTT
•
This compares with 80% in BOP survey.
•
A high level of appreciation for service responsiveness
•
Areas of concern
•
Three services stand out in terms of concern: Pain management,
Orthopaedics, Dermatology.
•
Timeliness and content of discharge summaries
•
Other themes:
•
Need for better communication, integration and more joined up services,
•
eReferrals work well but could be further developed
•
Doctor etiquette
England, 4 case studies
Disease management
GP based integration
‘My integration is your fragmentation”
1. Integrated CHD/stroke service
• Disease management carve out.
lead provider is specialty hospital.
Commissioned for outcomes. Eg
85% of eligible people complete
cardiac rehab
2. Pennines musculoskeletal
partnership - GP triage and
management of MSK referrals.
3 & 4. Virtual wards in Torbay and
Devon
Care planning and MDT for frail older
people and those with diabetes.
Working in clusters of 30k-50k
geographic localities
• GP practices participating in care
planning. Monthly mdt to review
complex patients. Risk stratification.
• Whole system governance, shared
IT system
• Target: avoid 1 admission per month
per GP
• Early evaluation shows that it is
working to reduce ARC and acute
hospital admissions.
7
Greenwich Integrated health and social care
•
Single point of access for referrals and
immediate response to prevent admission
•
Joint emergency team – provides care at home
within two hours. Stays with patient for a max of 5
days. Runs 13 hours a day. 24 staff in team.
Nurses, swk, physio. Covers population of 270k
•
Five collocated cluster teams – FTE numbers
needs based core team: social worker, care
coordinators, DNs, podiatry, physio. In future also
mental health
•
Three re-enablement teams – 6 weeks rehab plus
ongoing care - mainly health care assistants
directed by physio, OT
•
Risk stratification approach - targeting hi risk, hi
need individuals.
8
Tower Hamlets on the Isle of Dogs
•
Federation (network) of localities with
4-5 GP practices per locality - about 30k
pop
•
Achieving better outcomes and
managing acute demand. Winning
tenders for further services
incrementally, e.g. cardiac rehab,
mental health, etc
•
Incentives - in the order of $8m for 35
practices. 280k pop
•
Tele health - Hurley group is aiming for
80% consults outside the building.
Using structured e-consults, symptom
checkers and pt initiated risk
stratification
9
Zorggroep, Almere, Netherlands
• Living at home as long as possible in a supportive environment.
Admission as short as possible
• Locations in the neighbourhood Strong infrastructure of primary care
in a healing environment
• One philosophy - Planetree
• GP surrounded by pharmacist, midwife, nurse, dietician, social
worker, mother and child care, physio, dentist
• 3 X 15,000 population practices to form 40,000 population nodes
Built around the patient rather than the GP. Around them is informal
caregivers, then primary Health care, then intramural hospital care
Don Berwick Keynote
• “manage today (and together)
let’s shape tomorrow”
Leadership
"Never doubt that a small group of
thoughtful, committed people can change
the world. Indeed, it is the only thing that
ever has."
Margaret Mead
Leadership
http://www.youtube.com/watch?v=t3DDjeV
eJu4&feature=related