Pushing the accelerator on integrated care

Posted by Benedict and Geraint on 18 May 2015 |

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We are entering a new era in healthcare – one where we re-orientate our health system around primary and community care. With a growing and ageing population and a rise in chronic and long-term conditions, such as diabetes and heart disease, we have a challenge on our hands to integrate services and systems across the health spectrum and empower our healthcare users to keep themselves well and at home – away from unnecessary trips to hospital.

This renewed interest in integrated care has resulted in a number of projects, campaigns and improvement initiatives taking place across Counties Manukau. Each project has a specific goal, but ALL have the needs of the patient and family/whaanau at its core.

Today I’m joined by Benedict Hefford, Director of Primary Health and Community Services to talk about how projects such as ARI (At Risk Individuals) are starting to make a real difference to the lives of people living with one or more long-term conditions and other risk factors such as inadequate housing or low health literacy. As Benedict will explain people in this group are at greater risk of poor health outcomes, including unplanned trips to hospital, and they use a disproportionate amount of healthcare services.

Recently I gave a description of the challenges we face here at Counties Manukau to some of our colleagues from four Local Health Districts in Australia. I told them of that of our ½ million residents, 100,000 of them are obese or morbidly obese. Over 60,000 have a long-term chronic condition, including 36,000 diagnosed diabetics, and presumably many more are either undiagnosed or pre-diabetic. I said that a ¼ of our children are growing up in poverty, and that we had one of the highest rates of rheumatic fever in the developed world. On top of all that, we have a growing and rapidly ageing population and we’re now reaching capacity limits in areas ranging from Tiaho Mai Mental Health Unit, to the Manukau Superclinic, to Information Technology.

Clearly the scale of this challenge isn’t something that we can realistically meet by just doing more of the same. Like healthcare systems everywhere, we’re subject to funding constraints so we’re going to have to use fewer resources, more wisely, and to better effect if we’re going to improve patient outcomes and reduce the demands on Middlemore. The good news is that we on the way with that difficult transition across the whole system, with improvements and collaboration focused on initiatives ranging from population health, to primary prevention, to safe and effective secondary care. It would be a very long blog if I covered every integration and improvement initiative, but here are a few key facts and figures for you!

In the last couple of years we’ve achieved a child immunisation rate of 95%. Nearly all smokers are now routinely offered brief advice about quitting at every healthcare appointment, and that’s reflected in a tripling of numbers stopping smoking compared to a few years ago. Likewise, we’ve gone from 50% to over 90% of patients now being routinely screened for diabetes and cardiovascular disease risk. Over 5,000 South Auckland homes have been insulated through Warm Up Counties (you will have seen the stickers on the back of our cars!), and 24,000 kids have been treated through the Mana Kidz programme. Through these initiatives we are collectively reaching huge numbers of patients and putting them on a different trajectory which will delay or prevent them from ending up at the hospital door.

Things are improving for people who already have chronic disease too. It’s been over a year since I last blogged with Geraint about the ARI Programme, which at the time was just starting to get off the ground. To refresh your memory, ARI is about proactive care planning and coordination for patients who will benefit from integrated care. The programme is based around patient-led goal setting, along with clinical pathways, multi-disciplinary case conferencing, and a flexible range of medical, social, and behavioural interventions. The process is supported by an electronic shared care system that the whole team, including the patient, has access to.

To date 92 practices and over 7000 patients are enrolled in ARI and, despite some IT and other teething problems, we still expect that number to double over the next year. To support this integrated approach, community and specialist teams have started organising themselves around general practice clusters within localities, with a focus on admission avoidance and enhanced community care. ARI builds on successful initiatives such as Chronic Care Management and the (Beyond) 20,000 Days collaboratives, particularly VHIU (Very High Intensity User) and Early Supported Discharge which produced a 30% and 15 day reduction in hospital admissions and length of stay, respectively.

So is all this integrated care actually working at scale in terms of patient outcomes and unplanned hospitalisations? Well, in a complex, interactive system like healthcare we’re never going to get a simple unequivocal answer to that question. But there are some early indications that things are going in the right direction. Overall life expectancy is increasing, mostly due to lower cardiovascular mortality. Acute medical bed day growth is below demographic rates, and Middlemore’s standardized hospital mortality rate is amongst the lowest in Australasia. Rheumatic fever rates have dropped, as have the number of children with Group A Stretococcal positive throats and skin infection related hospitalisations. More recently, the number of people being admitted to rest homes has come down too. Nonetheless, it is all early days and we still have some ongoing key challenges to address, such as the continuing increase in numbers presenting to Emergency Care, and the need to improve early intervention for people at risk of renal disease.

Now is the time to push the accelerator on changes that keep people well at home. We need a greater focus on complex families and households, and further improved alignment of community based staff with enhanced General Practice clusters and social service networks. To further support this ‘healthcare home’ concept, CM Health community teams, NGOs, and primary care will all need to continue to build up their capacity to deliver proactive care coordination, admission avoidance, early discharge and rehabilitative care at a larger scale. Project SWIFT will be a key enabler of this primary and community care enhancement, as will the Manaaki Hauora Supporting Wellness campaign being facilitated through Ko Awatea.

I’m very optimistic about our collective ability to meet the challenges. Together we are all continuously designing and building across the whole system through a cumulative process that is producing sustainable results. This is a transformation that was never going to be about a single defining strategy or one grand programme or a killer innovation. It’s about continuous learning and leadership: step by step, action by action, turn by turn, in order to integrate care in a way that is wide as well as deep.

Benedict and Geraint