integrated services

1

IntegratedServices

Primary Care Team

Person

Community

Strictly Private & Confidential

Primary, Community& Continuing Care

Reform Implementation

2

• The development of integrated person-centred care.

• Improved configuration and management of hospital care.

• More proactive prevention and management of chronic illness.

• Greater performance management.

• Engagement and empowerment of staff at all levels to deliver the reform programme.

HSE Reform Priorities

3

PCCC “Transformation”

The organisation of the totality of health and social care

services provided in the community in such a way as to

address the individuals assessed need at or close to home

through enhanced team working and the targeting of

resources to defined populations.

Components of the reform include:

4

Primary Care

Strategy

Primary, Community and Continuing Care environment

5

Primary Care

Strategy

MentalHealth

Act


6

DisabilityAct

Primary Care

Strategy

MentalHealth

Act


7

ChildcareAct / Children’s

Act

DisabilityAct

Primary Care

Strategy

MentalHealth

Act


8


Act

Disability Strategy

DisabilityAct

VisionFor

Change

EPSN

Primary Care

Strategy

MentalHealth

Act

Sectoral Plans


9

Drugs andAlcohol

Strategies

TravellerHealth

Strategy

SuicideStrategy


Act

Disability Strategy

DisabilityAct

VisionFor

Change

EPSN

Primary Care

Strategy

MentalHealth

Act

Sectoral Plans

HomelessStrategy


10

Palliative Care

Strategy

Drugs andAlcohol

Strategies

CounsellingService

SCA TravellerHealth

Strategy

SuicideStrategy


Act

Disability Strategy

OlderPersons

DisabilityAct

VisionFor

Change

EPSN

Primary Care

Strategy

MentalHealth

Act

Sectoral Plans

HomelessStrategy


11

Palliative Care

Strategy

Drugs andAlcohol

Strategies

CounsellingService

SCA TravellerHealth

Strategy

SuicideStrategy


Act

Disability Strategy

OlderPersons

DisabilityAct

VisionFor

Change

EPSN

Primary Care

Strategy

MentalHealth

Act

Sectoral Plans

HomelessStrategy


CriminalLaw

InsanityAct

NursingHomes

Act

12

Palliative Care

Strategy

Drugs andAlcohol

Strategies

CounsellingService

SCA TravellerHealth

Strategy

SuicideStrategy


Act

Disability Strategy

OlderPersons

DisabilityAct

VisionFor

Change

EPSN

Primary Care

Strategy

MentalHealth

Act

Sectoral Plans

HomelessStrategy

CancerStrategy

Immunisation


CriminalLaw

InsanityAct

NursingHomes

Act

13

Palliative Care

Strategy

CardiovascularStrategy

Drugs andAlcohol

Strategies

CounsellingService

SCA TravellerHealth

Strategy

SuicideStrategy


Act

Disability Strategy

OlderPersons

DisabilityAct

VisionFor

Change

EPSN

Primary Care

Strategy

MentalHealth

Act

Sectoral Plans

HomelessStrategy

CancerStrategy

Immunisation


CriminalLaw

InsanityAct

NursingHomes

Act

14

SchemesModernisationProgramme

Palliative Care

Strategy


Drugs andAlcohol

Strategies

CounsellingService

SCA TravellerHealth

Strategy

SuicideStrategy


Act

Disability Strategy

OlderPersons

DisabilityAct

VisionFor

Change

EPSN

Primary Care

Strategy

MentalHealth

Act

Sectoral Plans

HomelessStrategy

CancerStrategy

Immunisation


CriminalLaw

InsanityAct

NursingHomes

Act

15

SchemesModernisationProgramme

Palliative Care

Strategy


Drugs andAlcohol

Strategies

CounsellingService

SCA TravellerHealth

Strategy

SuicideStrategy


Act

Disability Strategy

OlderPersons

DisabilityAct

VisionFor

Change

EPSN

Primary Care

Strategy

MentalHealth

Act

Sectoral Plans

HomelessStrategy

CancerStrategy

Immunisation


Ophthalmology

AudiologyCriminal

LawInsanity

Act

NursingHomes

Act

?????

Podiatry

16

This presentation looks at 3 key questions

1. Why are we doing this? Why we need to transform primary and community care services.

This focuses on the emerging health care challenges, the current shortfalls and opportunities.

2. Where are we going? This provides a vision for the future of primary care and social

services? It also highlights the benefits that will emerge for patients, clients and those providing services.

3. How we will get there? Here we review the structures, road map and processes that have been

established to implement this reform programme.

17

1. Why Are We Doing This?

18

Time for Change

Ireland has a unique opportunity to develop a truly world class health care system. Reasons for this include:

• A clear mandate to develop a community based, patient/client centered, team-based integrated health system.

• A single, dedicated and unified HSE.

• A ground swell of support from all stakeholders.

• Excellent and committed staff and health professionals.

• A wealth of experience in establishing and learning from new service models.

• Islands of excellence, best practice and innovation across the health system.

• Access to public and private funding.

19

Emerging Healthcare Challenges in Ireland

There are several emerging challenges which make reform an imperative:

• Population Health problems such as: Obesity, Alcohol Dependency.

• Chronic illness

• Specialist provider shortages in numerous key areas.

• Health costs, growing faster than general inflation.

• Ageing population.

• Lifestyle and cultural challenges.

• Lack of integrated digital backbone.

20

Current Shortfalls • Varying levels of service quality across the country.

• Access to required health services can be both difficult and delayed.

• Person’s navigation is fragmented and complicated. Traditional System takes priority over patient access.

• No single, coherent view of Person’s needs and plan – no common ground amongst the different health professionals.

• Lack of cohesive working and multidisciplinary approach.

• Lack of trans-disciplinary approach.

• Undersupply of specialist services.

• Patchy OOH’s cover for front line and back up services.

• Over reliance on hospitals for non-acute needs

• Ineffective use of resources, wasted effort due to bottlenecks and duplicate assessment, storage and reporting.

• Poorly integrated infrastructure including information and measurement protocols, ICT systems.

Impact• Service inequities.

• Reduced care quality and health status.

• Excessive travel, due to non-local service.

• Person experiences disjointed and delayed services, left feeling stressed and subordinate to the system.

• Strained service points e.g. GP’s, A & E.

• Over or under utilised resources due to outmoded resource allocation.

• Multiple same diagnosis and administrative processes - effort diverted from the Person.

• Entrenched disciplines and work groups with little camaraderie.

• Stressed providers with reduced job satisfaction.

• Lack of confidence continuous criticism both externally and internally.

• Increased risk to persons and providers.

• Poor value for money, diverts resources from service improvement.

Challenges in Primary care

General Practitioner

Public Health Nurse

Physiotherapist

Occupational Therapist

Social Worker

GP

PHN

Phy

OT

SW

Overly Complex Service Organisation & Delivery

GP

OT1

SW 2

PHN 1

OT4

PhySW 1

PHN 4

OT3

PHN 2

OT2

PHN 3

Complexity Today from Non-alignmentof Providers and Population

PHN Phy

OT

GP

SW

Alignment Providers and Population:Increased Simplicity - PCT

Mr. Red also needs access to SW1, OT3 and PHN3.

Mr. Green needs access to SW2, OT1 and PHN1.

Same GP in local community but…

GP

PHN Phy

OT SW

Information and Service Flow Today- Non Integrated Local Service

Information and Service Flow Tomorrow- Integrated Primary Care Team

Direct Referral

Referral Service Feedback

Direct Referral and Feedback

PHN Phy

OT

GP

SW

Outdated Info & Service Flows - Bottlenecks

23

2. Where WeWant To Go?

Po

pu

lati

on

Today:

2006

Self Care

PCCC

Hospitals

No CareRequirement

Tomorrow:

2011

Po

pu

lati

on

Self Care

PCCC

Hosp.

No CareRequirement

Tomorrow:

2016

Po

pu

lati

on

Self Care

PCCC

Hosp.

No CareRequirement

• Shifting the emphasis towards community care:

• The diagonal arrow highlights that with the current approach people are drawn towards hospitals for services.

• However with the Integrated Primary and Community Care model, the emphasis is on providing services within local communities.

A Shift in Emphasis

25

“To provide each person with or easy access to all services that lead to improved health and wellbeing”

Aim of Primary, Continuing & Community Care:

This requires multi-disciplinary Primary Care Teams focused on the same community population that will:

• Identify and prioritise each persons needs.

• Service the majority of peoples needs, at or close to home.

• Access specialist services, at or close to home.

• Provide direct access to acute hospital services and continue to guide health improvement for that persons care lifecycle

Here is how it works …

26

It is about individual people…

27

It is about individual people and their families…

28

It is about individual people and their families that are part of a local community…

29

It is about individual people and their families that are part of a community – a defined local population of 8,000 – 12,000 people…

.

30

Most of their primary and social care needs are met by a single and local Primary Care Team (PCT)…

PHN

OT

GP

Phy

SW

n

31


The composition of the team is driven by the needs of each defined population.

Population A

PHN

OT

GP

Phy

SW

32


PHN

SLT

GP

MHN

SW

Population B

The composition of the team is driven by the needs of each defined population.

33

Teams will have common goals based on healthcare outcomes…

PHN

OT

GP

Phy

SW

Value for Money

Public Confidence

Satisfied Providers

Person Experience

Quality

Care

Population Health

Improved Healthcare Outcomes

34

Teams will have common goals based on healthcare outcomes… …and shared values, e.g. trust, safety, patient priority, equity, etc.

PHN

OT

GP

Phy

SW

35

Teams will have common goals based on healthcare outcomes and shared values…

…and shared standards and operating protocols such as: performance monitoring, clarity on boundaries, dedicated key workers for people, how to handle priority cases, leave cover, agreed outcome targets and review processes, quality, dissatisfaction and complaints.

PHN

OT

GP

Phy

SW

36

Teams will have core members that interact more frequently…

PHN

OT

GP

Phy

SW

i.e.WeeklyMeetingAgenda

37


…and extended members less frequently or as required, but are easily accessible and fully integrated to the PCTs ‘Way of Working’.

PHN

OT

GP

Phy

SW

Other

Psy

Dtn

Core

Extended

i.eMonthlyMeetingAgenda

Or as needed

38


…and extended members less frequently or as required, but are easily accessible and fully integrated to the PCTs ‘Way of Working’. These extended members are typically for specialised services, e.g. orthodontics, psychology / counsellors, addiction, etc.

PHN

OT

GP

Phy

SW

Other

Psy

Dtn

Core

Extended

39

An average of 5 PCTs make up a network – a Primary and Social Care Network (PSCN) – serving a wider but related population of 30,000 to 50,000 people…

PCT ‘A’

PCT ‘E’ PCT ‘B’

PCT ‘C’PCT ‘D’

Primary & Social Care

Network

40

An average of 5 PCTs make up a network – a Primary and Social Care Network (PSCN) – serving a wider but related population of 30,000 to 50,000 people…

PCTs in a network are integrated with one another and support each other.

Core

Extended

PCT ‘A’




Network

41

PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home…

Core

Extended

PCT ‘A’



• Orthodontics

• Other• Home

Help

• Counselling

• Psychiatry • Dietetics

• AlternativeCare

• Child Protection


Network

42


PCTs and PSCNs are integrated with hospitals…

IntegratedServices

PCT ‘A’Hospitals




Network

• Orthodontics

• Other• Home

Help

• Counselling


• AlternativeCare


43


PCTs and PSCNs are integrated with hospitals at the local…

IntegratedServices


• LocalPCT ‘E’ PCT ‘B’



Network

• Orthodontics

• Other• Home

Help

• Counselling


• AlternativeCare


44

PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home

PCTs and PCSNs are integrated with hospitals at the local and area level…

IntegratedServices


• Local

• Area




Network

• Orthodontics

• Other• Home

Help

• Counselling


• AlternativeCare


45

PSCNs include a pool of specialised resources that serve the PCT communities – at or close to home

PCTs and PSCNs are integrated with hospitals at the local and area level and with specialised hospitals.

IntegratedServices


• Local

• Specialist

• Area




Network

• Orthodontics

• Other• Home

Help

• Counselling


• AlternativeCare


46


PCTs and PSCNs are integrated with multi agencies…

IntegratedServices

PCT ‘A’

MultiAgencies

Hospitals

• Local

• Specialist

• Area




Network

• Orthodontics

• Other• Home

Help

• Counselling


• AlternativeCare


47


PCTs and PSCNs are integrated with multi agencies, private providers…

IntegratedServices

PCT ‘A’

• Local • PrivateProviders

• Area




Network

MultiAgencies

Hospitals

• Specialist

• Orthodontics

• Other• Home

Help

• Counselling


• AlternativeCare


48


PCTs and PSCNs are integrated with multi agencies at the private providers, voluntary agencies and

IntegratedServices

PCT ‘A’

• Voluntary




Network


• Area

MultiAgencies

Hospitals

• Specialist

• Orthodontics

• Other• Home

Help

• Counselling


• AlternativeCare


49


PCTs and PSCNs are integrated with multi agencies at the private providers, voluntary agencies and with support groups.

IntegratedServices

PCT ‘A’

• SupportGroups

• Voluntary




Network


• Area

MultiAgencies

Hospitals

• Specialist

• Orthodontics

• Other• Home

Help

• Counselling


• AlternativeCare


50

At the Core ofPCCC Reform:

the Person!

Our Core Principles…..

PersonCentred

LocalCommunity

• Persons needs always the common focal point.

• Easy access to appropriate services when needed

Core Principles

52

Primary Care Team

PersonCentred

LocalCommunity

OT Phy

SW

Other

GP



• Multidisciplinary team• Better team working environment, focused

on the same local community• Provides services that meet the majority

• of a person care needs

Other

Core Principles

53

IntegratedServices

Primary Care Team

PersonCentred

LocalCommunity

OT Phy

SW

Other

GP



• Multidisciplinary team• Better team working environment, focused

on the same local community• Provides services that meet the majority

• of a person care needs

• Single person file and plan

• Services integrated with wider multi agency and hospital services.

MultiAgencies

Hospitals

• Local

• SupportGroups

• Specialist

• PrivateProviders

• Voluntary• Area

Other

Core Principles

54

• a person…

• and their family…

• as part of a defined local community…

• served by a single multi-disciplinary team for most of their needs…

• that is part of a larger network which provides cohesion

and specialist support

• all of which are integrated with hospitals and multiple agencies.

• Throughout the person’s care lifecycle a key worker from

his/her PCT provides guidance and maintains contact.

But how is it supported, managed and integrated with the HSE at a National Level?

In summary our Reform Strategy is about:

55

Local Health Office: Population focused care for a defined geographic area

56

Local Health Office: Defined local communities

Individuals, Families & Communities

64

• Our People - The dedicated healthcare professionals, supports, managers and administrators. That are respected and have mutual respect for each other:

– Are well developed professionally and rewarded.

– Who share common goals, values and beliefs in relation to our Healthcare system and population.

• The widely dispersed Leaders and Managers who provide clear guidance and support for all to achieve better outcomes.

•

•This is enabled by a coherent infrastructure of digital backbone, integrated and streamlined processes, excellent facilities …

Improved OutcomesPopulation

Health

Quality Care Person Experience

Satisfied Providers

Public Confidence

Value for Money

PCCC Reform Success is dependent on…

65

Improved Outputs & Outcomes – Illustrative only

Outputs Outcomes

Population Health• Accurate information on health

status of enrolled members• More services available to local

population• Health promotion activities

delivered via PCCC providers• Major shift to self-care and

prevention

Population Health• Increased health status of

PCT enrolled population e.g. obesity

• Reduced service inequities• More health literate

population and taking more responsibility

• Life expectancy enhanced

66


Outputs Outcomes

Quality Care• Right quality services available

and easily accessed for each person based on their total health needs

• Holistic view of persons needs, plans and progress

• Integrated services delivery• Expansion of services

delivered out of hospitals and out of hours

Quality Care• Time to specialist services

reduced to xx time• Reduced time in care• % of clinical mistakes

67


Outputs Outcomes

Person Experience• Shared protocols and insights,

increased support and flexibility.

• Good evidenced based prioritization and actions

• Effective levels of central, local and individual autonomy – common ground easily found

• Integrated systems and processes

• Easy, joined-up access to information and services, when and where most appropriate – care continuum

Person Experience• Empowered persons, sense

of connection local health community

• Comfortable with information security

• Quick response to requests for service and information

• Waiting list times significantly reduced

• Satisfaction with care outcome

• Satisfaction with care experience

68


Outputs Outcomes

Public Confidence• Public are educated and

updated about the success of the health system

• Excellent systems for responding to public concerns, issues raised

• Good stakeholder involvement structures in place

Public Confidence• Increased quality and safety

and reduced risk • Internationally noted for world

class health system• Balanced and fair

69


Outputs Outcomes

Satisfied Providers• Systems for continuous

professional, personal development

• Competitive reward and recognition

• Equality of opportunity• Enlightened HR polices and

practices• Authentic partnership

philosophy working well

Satisfied Providers• High staff satisfaction, morale

and engagement• Minimal I.R. disputes and

issues• Flexibility and teamwork

characteristics of the whole organisation

• Living out the HSEs espoused values

• Renewed sense of purpose, reduced stress

• Mutual trust and respect amongst administrative service providers

70

Outputs Outcomes

Value for Money• Individual, team and group

responsibilities clear• VFM ethos embedded in

PCCC• Practical administrative

support for integration, workability and value

• Very high economic literacy• Widespread awareness of

best-in-class benchmarks

Value for Money• Year-on-year progress

across all sections of HSE in achieving VFM


71

Benefits of Primary Care Teams

• More services available to persons in the community

• Easier navigation of the system

• More resources available to teams

• Increased team working and camaraderie

• Economy of effort and time

• Greater networking between communities and providers

72

We Know

• Patients feel they get a better service from a multi-disciplinary team.

• Staff are happier working in well functioning multi-disciplinary teams

• Happier staff deliver better services

• Countries with advanced health systems are moving to this delivery model

73

Lessons Learnt from Pilot PCTs

• Flexibility and local ownership is vital

• Local health professionals should have significant input to the development of PCTs based on local needs and health professional readiness

• Good team design and development is essential and requires good facilitation in the early stages

• Team composition may change over time depending on the needs of the population highlighting the need for flexibility

74

• Reporting principles for professional development and clinical

governance should be maintained but a ‘new way of working’ is needed for team integration

• Community involvement is a key requirement for success

• Team meetings need to be well structured and managed

Lessons Learnt from Pilot PCTs

75

• National Health Strategy Quality and Fairness (2001)

• Primary Care Strategy (2001)

• Journal of Integrated Care

• Integrated Organisation Cases – Best practice for superior service, and satisfaction

Evidence

76

• Focus on reform with the purpose of better community service.

• Effort and focus on internal reform of structures and complexity.

• Greater synergies between services achieving economies of time and effort.

• Wasted time and effort.

• Shared healthcare outcomes with clear measures, targets and tangible benefits.

• Different, complex and or no clear performance measures.

• Many services delivered in the community health centres or at home.

• Overdependence on hospitals.

• Part of a team and supported by a wider network.• Isolated service providers.

• Dedicated key worker and primary care team guidance that has a comprehensive view of your needs and status.

• Frustrated patients, feeling disoriented in system.

• Clear access and open referral.• Difficult access to services, bottlenecks.

• Flexible ways of working focused on best meeting the defined population needs as a whole.

• Rigid work practices driven by history.

• Integrated structures shared processes and protocols. The team is the foundation.

• Separate and complex organisation structures and processes.

• Aligned - populations, services and service providers.

• Inconsistent segmenting of populations and allocation services and providers.

… To TomorrowFrom Today …

Summary of Reform

77

Things we need to address

• Reporting Relationships and clinical governance

• Professional and career development

• Patch versus silo management

• Skills mix and skills development

• Workforce Planning, training and action learning

• Extended Hours and out of hours services

• National Consistency and Standards

• Service working arrangements e.g. between PCT,s, PSCNs & acute and specialist services and voluntary agencies

• Eligibility

• Communications and Engagement

• Others ??

78

3. How We Will Get There?

79

PCCCND

PCCC Reform Implementation Steering Group

HSE Reform(PH & NHO)

PCCC NPF

Local Partnership

PlanningMonitoringEvaluation

ContractsANDs

Areas X 4

ExpertAdvisory Groups

Reform Implementation Structure

Project Mgt.

Service EnhancementProject Design

Change Mgt.

LocalImplementation

Groups x 32

Service EnhancementImplementation

PCT Implementation

RDO x 32Reform Project Unit

80

CITS, OOHs, Diagnostics, Ongoing Hospital Integration

Steps to PCT Implementation

Service Expansion Projects

Facilities

TeamDevelopment

TeamDesign

ServiceConfig.(To-be)

Pop.Needs

Assess.

ProviderReadiness

ImplementedPrimary

Care Team

Mapping(As-is)

ProviderInterest

HSE, Trade Union & Voluntary Sector – Change Management

Partnership Process

Reform Implementation Roadmap

81

100 PCTs, 100 Days – The Critical Path

Sep Oct Nov Dec 2007

28/08 04/09 11/09 18/09 25/09 02/10 09/10 16/10 23/10 30/10 06/11 13/11 20/11 27/11 04/12 11/12 18/12

ID Pop. Location

Initial PCT Members 1st PCT Meeting

Commence Enrolment

Assess PCT Dev. Needs

Facilities Identified

PCT DevelopmentGoals, Protocols, Ways of Working, Standards, Team

Development, etc.

LIG Est.

RPU Appt.

RDO Appt.

RDOLearning Sessions

Community Involvement

RDO & LIG Intervention – Engagement, Direction, Facilitation, Support

(Interim) RPU Development of PM Standards, best practise, capture and share learning

PCTPCTPCTPCT PCT

LHM Mtg.

LHM Mtg.

LHM Mtg.

LHM Mtg.

Mapping Updated / Initiated

Phase 1 Engagement, booklet, partnership, LHMs. RDOs, GPs etc. Phase 2 – Ongoing 2-Way Communications and Engagement

RDO Training design and Development

Today Different LHO’s are at different stages

300 Healthcare Professional Recruitment

82

• 11/08 GP expression of interest

• 04/09 Local Implementation Group’s established (some)

• 25/09 Recruitment of Reform Development Officers

• Identification of PCT communities and Mapping on-going

• Advertisement of 300 healthcare professional posts

• 05/09 Partnership Forum Meeting

• 25/09 Establish Reform Project Unit (Interim)

• 11/09 Commence Design training for PCCC RDOs, LHMs and PCTs

• 11/09 Develop detailed communications plan (1st Draft)

August & September

PCT Implementation Project Unit Co-ordination & Support

83

October

• 16/10 Reform Development Officer appointments

• 02/10 - 300 Healthcare Professional Recruitment

• 16/10 Commencement of some 1st PCT meetings

• 23/10 RDO Training

• 02/10 Reform Project Unit commencement of engagement activity, GPs and partnership

• 23/10 Completion of PCCC Reform Strategy Booklet

• 23/10 1st detailed status report on 100 PCT implementations (RISG)

• 31/10 LHM & GM working session


84

November & December

• 20/11 Agree on physical work arrangements

• 06/11 Development of PCTs, shared goals, ways of working, protocols, standards

• 06/11 RDOs fully dedicated to working with PCTs

• 06/11 Ensure that there is community involvement

• Mapping ongoing

• 06/11 Reform Project Unit – Lead appointment

• 06/11 Implement Phase 2 C & E - Embed consistent communications and engagement channels

• 06/11 Develop RDO medium term training plan and learning sets

• 20/11develop PCT training, modules


integrated services

Documents

management of hospital

social care services

management of chronic

greater performance

improved configuration

totality of health

proactive prevention

primary carestrategyprimary