The Mission We Chose to Accept: Achieving Integration

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The Mission We Chose to AcceptAchieving
Integration

• Natalie Sullivan
• General Manager
• Yarra Ranges Angliss Hospital
• Chief Allied Health Officer

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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.

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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

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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

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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

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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

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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

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Getting from here to Utopia

• Recognising there is more to this than goodwill
  and a good plan
• Jumping the hurdles, removing the barriers
• Enablers
• Funding models
• Workforce
• Integration tools
• Information management
• Partnerships

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Can anyone give me the directions to Utopia?

• Planning
• Who plans?
• How do we plan?
• What do we plan?
• What about existing plans?
• Planning burnout!

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Integrated Area Based Planning Approach

• Population Health Planning
• Integration Planning
• Community Based Service Configuration Planning
• Regional and Statewide Planning

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The Planning Process

• Determine the needs of the local catchment
  population in terms of the three areas of need
• Profile the existing service system on the basis
  of the schema
• Determine how the planning principles apply to
  the local service system.
• Conduct an assessment of the local service system
  based and the application of the planning
  principles
• Develop recommended priority actions to achieve
  integration goals and to move towards the future
  service configuration

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The Planning Schema

• Modes of Care
• Settings of Care
• Levels of Care

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Modes of Care

• The 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

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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).

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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

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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.

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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.

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The Outer East Experience
Outer East Pop 394,215 Area 2647m2 Knox,
Maroondah, Yarra Ranges
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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

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How we went about it.
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Phase1 Initiate project

• Stage 1Establish 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

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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

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Phase 2 continued

• Stage 4 Determine area priorities
• Options
• Undertake a priority defining exercise (pure
  approach to planning)
• Use health priorities of EH PCPHAC (diabetes, CV
  health Mental Health)
• 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

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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

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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

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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

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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

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Phase 5 Prepare Report

• Stage 11 Draft report
• Stage 12 Assess learnings
• Stage 13 Finalise report

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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

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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

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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

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From a dream to reality...capital developments

• Integrated Care centres in Victoria
• No single name
• Integrated Care Centres
• Health Precincts
• Day Hospitals
• Superclinics

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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.

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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)

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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!

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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

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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)

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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

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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!

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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)

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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

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Drive and vision
Specialty clinical support
Voice for clinical specific issues across region
Support
Assist with recruitment and give feedback for
use in performance management
Coordination
Multidisciplinary case conferencing
Relationship building with area stakeholders
(E.g. ED, PCP)
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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

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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.

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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

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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

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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

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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

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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

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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?

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Hospital utilization
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Data and Outcomes

• After mainstreaming, in 2006-07 year we have
  increased throughput of
• 42 increase in assessments
• 32 increase in client service events
• Approximately 40 increase in GP contacts

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Increased alignment and integration ? improved
care continuity
Emergency Care
Community Integration
Integrated Guidelines, Dataset Funding Model
Inpatient Care acute sub-acute
Community Care (HACC)
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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

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Thank you

• Natalie.Sullivan_at_easternhealth.org.au