The Mission We Chose to Accept:Achieving Integration

Natalie Sullivan

General Manager Yarra Ranges & Angliss HospitalChief Allied Health Officer

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.

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

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

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

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

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

Getting from here to Utopia Recognising there is more to this than

goodwill and a good plan Jumping the hurdles, removing the

barriersEnablers

Funding models Workforce Integration tools Information management Partnerships

Can anyone give me the directions to Utopia?

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

Integrated Area Based Planning Approach

Population Health Planning Integration Planning Community Based Service Configuration

Planning Regional and Statewide Planning

The Planning Process1. Determine the needs of the local catchment population in

terms of the three areas of need

2. Profile the existing service system on the basis of the schema

3. Determine how the planning principles apply to the local service system.

4. Conduct an assessment of the local service system based and the application of the planning principles

5. Develop recommended priority actions to achieve integration goals and to move towards the future service configuration

The Planning Schema

Modes of Care

Settings of Care

Levels of Care

Modes of CareThe 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

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).

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

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.

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.

The Outer East Experience

Outer EastPop: 394,215Area: 2647m2

Knox, Maroondah, Yarra Ranges

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

How we went about it……….

Phase1: Initiate project Stage 1:Establish 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

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

Phase 2 continued…… Stage 4: Determine area priorities

Options:1. Undertake a priority defining exercise (pure

approach to planning)2. Use health priorities of EH PC&PHAC (diabetes, CV

health & Mental Health)3. 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

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

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

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

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

Phase 5: Prepare Report

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

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

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

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

From a dream to reality...capital developments Integrated Care

centres in Victoria

No single name

Integrated Care Centres

Health Precincts Day Hospitals ‘Superclinics’

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.

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)

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!

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

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)

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

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!

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)

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

HARP CDM Manager

Medical/ Chronic Disease case management

(includes clinics)

Liaison Unit (Including admin and intake)

Care coordination (Case

Management)

Allied Health, Nursing, Medical &

Pharmacy

Brokerage for additional services as required

Psychosocial

Aged(incl RACAS)

Steering Committee- Ambulatory Services

Reference Group

“Angliss Area”LGA based- Knox, and part of Yarra

Ranges

“Box Hill Area”LGA-Boorondara,

Whitehorse, Monash and part Maningham

“Maroondah Area”LGA-Maroondah &

parts of Manningham & Yarra Ranges

Eastern Health Executive

“Clinical”

GP Facilitation

HARP Chronic Disease Management (HARP CDM)

Program Structure

*Voice for clinical specific issues across region

*Specialty clinical support

*Assist with recruitment and give feedback for use in performance management

Clinician

Agency ManagerAREA

“leader”

Clinical “leader”

HARP CDM MANAGER

(EH Auspice)

Multidisciplinary case conferencing

Relationship building with area stakeholders (E.g. ED, PCP)

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

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.

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

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

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

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

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

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?

Hospital utilization

Health Condition Cluster

Emergency Department

Presentations

Emergency Admissions

Occupied Bed Days

Chronic Obstructive Pulmonary Disease

Up to 77% Up to 76% Up to 66%

Congestive Heart Failure

Up to 58% Up to 44% Up to 59%

Diabetes Up to 61% Up to 82% Up to 63%

Complex Care Up to 60% Up to 69% Up to 66%

Eastern Health Chronic Respiratory Disease ED Presentations

1

10

100

1000

1 2 3

No. of Presentations

No. o

f Pat

ients

Actual 2001-02

Projected 2004-05

Actual 2004-05

Trendline (Projected 2004-05)

Trendline (actual 2004-05)

Diabetes, COPD and CHF combined- number of patients with multiple presentations

1

10

100

1,000

10,000

1 2 3 4 5 6

No. Presentations

Pat

ien

ts

-80%

-60%

-40%

-20%

0%

20%

40%

%ch

ang

e

2001-02

2006-07

Variance between 2001/02 and 2006/07 in %

total ED changes

CHF and COPD as a total percentage of ED presentations

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

2000-2001 2001-2002 2004-2005 2005-2006 2006-2007

Financial year

Data and Outcomes

After mainstreaming, in 2006-07 year we have increased throughput of 42% increase in assessments32% increase in client service eventsApproximately 40% increase in GP contacts

Increased alignment and integration improved care continuity

HITHPAC

SACS HARP

Outpatients

InpatientCare: acute& sub-acute

CommunityCare

(HACC)

Emergency Care

Community Integration

Integrated Guidelines, Dataset & Funding Model

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

Thank you

Natalie.Sullivan@easternhealth.org.au