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Integrating healthcare: the Counties Manukau
experience
David Clarke, Joe Howells, John Wellingham and Barry
Gribben
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Abstract
In 1998, Counties Manukau District Health Board (CMDHB)
was experiencing rapidly increasing demands on its secondary services. It was
finding it increasingly difficult to meet the health needs of its relatively
deprived population. There was widespread evidence of “systems
failure”, with poor coordination of primary and secondary
services.
A strategic plan was devised to meet identified priorities
and this was subsequently implemented with extensive community involvement. A
“disruptive change” model was utilised. Thirty separate projects
were undertaken to improve coordination and integration of health services.
Brief summaries of all projects are presented, and full evaluations were
performed of major projects.
Factors critical to project success were: dedicated and
effective leadership; involvement of clinical staff; early engagement of the
Maori and Pacific community; careful selection of stakeholders; reassurance for
providers about privacy issues; close monitoring of project progress; realistic
timeframes; and adequate initial funding.
CMDHB believes that the critical factor to success in
improving the performance of the health sector will be the ability of our key
leaders in primary and secondary care, in both management and clinical roles, to
adopt a systems view to problem analysis and solution building.
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Counties Manukau District Health Board* (see endnote after
references), its provider arm South Auckland Health (SAH), and the primary care
sector, service a large community of people living in relative deprivation in
the largest city in New Zealand. CMDHB faces growth rates in acute healthcare
utilisation that are greater than most, with fewer resources than most to meet
these demands.1 Public and political
expectations, and those of healthcare staff, have continued to increase
unrealistically in comparison to both the funds available and the level of
quality the system is capable of delivering. This situation has been compounded
by the fact that general practice is increasingly less financially attractive as
a profession, for both GPs and practice nurses, and it is therefore becoming
more difficult to attract and retain a talented primary care
workforce.
This paper describes the response of CMDHB to what was
perceived to be an imminent crisis in the provision of healthcare to its
population. We briefly describe the situation in South Auckland in 1998; the way
that the issues to be addressed were identified; the processes followed to
develop projects; the major barriers encountered in implementing projects; and
factors that were identified as critical to the success of the
response.
The situation in 1998 – drivers for change
In 1998, CMDHB faced the difficult
task of providing health services to a very high-need population, with a rapidly
increasing utilisation of services in a situation demonstrating what could best
be described as “system failure”. Community
needs
The Counties Manukau community has always had a high level
of health need, as demonstrated by the following small sample of available
statistics:1
- Thirty
four per cent (or 128 000 people) live in decile 9 and 10 – ie, in a
situation of poverty – compared to 20% nationally.
- All
the high deprivation communities have a large cohort of children, and there is a
significant health status gap between these children and the national
average.2
- Maori
represent 17.5% (66 000) and Pacific people 17% (64 000) of the Counties Manukau
region population. Maori life expectancy at birth is eight to nine years below
the national average, Pacific five years lower.
- Fifty
per cent of Pacific children have an episode of care in Middlemore Hospital in
the first year of life.
- Of
the 76 000 school-age children in Counties Manukau, 23 000 or 30% attend decile
10 schools vs 10% nationally.
- Diabetes
is a major contributor to disability-adjusted life years lost in the region, and
chronic obstructive pulmonary disease (COPD) and lung cancer are significant for
Maori, reflecting their high smoking
rates.1
- Maori
and Pacific mortality is twice the age-adjusted mortality of Europeans, and
Maori followed by Pacific have the highest avoidable mortality
rates.
Growth in
acute demand
This high-need population had been making increasing demands
on the secondary care services provided by CMDHB. At Middlemore and
KidzFirst™ Hospitals (SAH), Acute Adult and Paediatric Medical growth was
9% a year over 10 years, despite a population growth of only 2%, swamping the
hospitals.
Such growth was likely to cost Vote Health $40 million in
excess of what was required to fund “best practice” over the next
five years if nothing was done. There was the very real prospect of a new
Medical Hospital and Emergency Department being needed to serve Counties Manukau
within five years, at a capital cost of $300–$400 million in addition to
the extra running costs of such a hospital. We calculated that in 1998 there
were 12 000 avoidable admissions to Middlemore annually. Furthermore,
readmission rates were running above best practice based on Health Round Table
benchmarking. (The Health Round Table comprises seven hospitals throughout
Australasia.)
Strong evidence of system
failure
As the first step to responding to this high growth in
demand for services, CMDHB commissioned international health management
consultants Milliman & Robertson, Inc. to undertake an extensive independent
review of the healthcare delivery system in Counties Manukau. Their report was
completed in October 1998.3 Although performing
well on many measures, the review found that the system was deficient in the
following respects:
- failing
to help reduce disparities in health status of people in the poor
communities;
- encouraging
overuse of hospital/specialist resources;
- not
delivering appropriate support to many people with chronic disease;
- not
delivering appropriately targeted assistance to children missing out on
immunizations, well child checks and breast-feeding support;
- ineffective
integration and use of available communication and information technology;
- lack
of utilisation of quality improvement technologies;
- a
climate of distrust between hospital specialists and general
practice.
Communication between primary care
providers was limited, and communication between the hospitals and primary care
in 1998 was paper based, and often erratic. The ability of the primary care
sector to manage its enrolled population in any meaningful way was seriously
hampered by this.
Interventions proven to improve quality of life for people
with chronic disease were often not delivered. For example, an audit of COPD
admissions to Auckland Hospital May–July 1996, published in the NZMJ,
demonstrated the mean age of patients was 71 yrs, 45% lived alone, only 21%
would have thought about visiting their GP if their breathlessness increased
significantly, and only 8% would have started antibiotics or
prednisone.4 An audit of diabetes care showed
that in most Counties Manukau GP practices, 40% of people with diabetes were
“out of control”, with HbA1c levels greater than 9. Many primary
care providers did not keep a register of their patients with chronic
disease.
Childhood and at-risk adult immunizations are evidence-based
interventions that prevent serious illness and hospital resource usage. Yet in
CMDHB, the primary care sector,’s ability to identify those children
missing out and to deliver immunizations to redress the situation appears to be
very low, as evidenced by low immunization rates
(65%).2
The relative inability of the health sector to adopt
validated systems improvement techniques, such as Total Quality Management (TQM)
and Continuous Quality Improvement (CQI), meant important tools had been
ignored. The existing health system provided no economic benefits to clinicians
for improving quality.5
Primary care serving the high-need population was
demonstrably underdeveloped in comparison to that serving more affluent
communities. Data from the Ministry of Health demonstrated that in 1997 Central
Auckland had 1142 people per GP FTE, and that South Auckland on average had
1467.6 Related to this was much lower per
capita spending on disadvantaged populations, inclusive of General Medical
Subsidy, laboratory and pharmaceutical services.
Response
This evidence of systems failure
suggested a systems response. The response of CMDHB was to develop and implement
a strategic plan to make the best use of the available resources, material and
human, to improve coordination and integration of healthcare activity. Special
attention was paid to privacy issues, and significant investment was made in
establishing a facilitating information technology (IT)
infrastructure. Setting goals specific for
Counties Manukau
A Strategic Plan for the Next Five Years was developed by
CMDHB.7 The Plan identified specific priorities
base upon three criteria:
- a
good fit with Government health strategy;
- the
greatest potential out of all available alternatives to make a difference to
health status and Middlemore Hospital acute growth;
- a
demonstrable favourable long-term rate of return on money
spent.
The specific priorities were to:
- improve
delivery of healthcare to Maori and Pacific communities failing to access
existing services;
- develop
systems to increase immunization delivery and well child checks, and improve
breast-feeding rates;
- improve
the management of people with chronic disease;
- develop
alternatives to referral to Middlemore by improving the range of acute medical
service interventions available to primary care;
- find
solutions to the overuse of Middlemore’s Emergency Care (EC)
department;
- provide
the communications and IT infrastructure necessary to support these
projects.
Implementing
the Strategic Plan
It was seen as important to attempt evidence-based
solutions, with urgency, and to avoid “paralysis by analysis”. Quick
initial “proof of concept” was aimed for. What the healthcare
providers and community of Counties Manukau said they didn’t want were
more consultation, rhetoric, and large planning documents. The aim was to learn
and modify quickly, focusing finally on the concepts proven capable of
delivering the most gain. The level of change required could be classified as
“disruptive change”, as described in a recent article in the
Harvard Business
Review.8
The initial step was establishment of a combined “all
player” think-tank, which included community groups. This developed a
common vision of seamless integrated care focused around the individual, and a
common intent addressing community need. A Statement of Intent was presented to
the Crown in November 1999 as a “burning platform” for
change.9
A business case was developed that supported the application
to the Minister of Health and Treasury for funding. The primary care sector was
engaged in a planning process and a guiding coalition was formed through a
Primary Care Organisation/South Auckland Health Group. Many of these groups had
not worked together before and were even competing with each other for health
contracts. It took considerable time to build trust between
organisations.
Privacy
issues
A strategy based around the coordination and integration of
care raises important privacy issues. Coordination of care between the primary
and secondary sector requires ready and easy access to selected, structured,
searchable, retrievable clinical data by each clinician involved in the care of
the patient. Privacy and security for electronic clinical data in a technical
sense is easy. It is the governance of these data that is of concern to the
primary sector. Primary care data are seen as an asset by GPs, and in the past
there has been unauthorised use of these data by funders and
purchasers.
There was thus understandable concern that data provided to
integration projects were not used for other purposes. CMDHB resolved this
through:
- establishing
a Privacy Governance Group independent of CMDHB that determines the rules and
methods for shared data use;
- undertaking
that CMDHB would never access individual patient- or provider-specific
data;
- performing
a privacy impact study for each individual
project.
Information
system support
The extent of coordination of information needed at a
regional level usually requires a shared database that is probably only
affordable and maintainable by the local district health board. Development of
such a capability was seen as critical to the long-term success of integration
projects.
The pioneering development of an Integrated Care Server has
so far supported Well Child, Breast-feeding and Chronic Care Management
development projects. It is able to coordinate the use of electronically
interfaced self-care in the home, which is currently being piloted. A full paper
describing these advances in more detail is included in this series of
papers.
Results
There were 30 original projects,
with 11 continuing beyond 2001. These are described in Appendix 1, with brief
summaries of key outcomes (Appendix 1 can be found at the end of this article).
This series of papers describes some of the important projects in more detail,
including an overview of the Chronic Care Management programme. From these projects, four strategic directions have been
established:
- Maori
and Pacific healthcare delivery development;
- chronic
care management and acute demand management;
- child
health;
- communications
and information technology.
The disease management
projects and some of the other work will be incorporated into a generic approach
to chronic care, as recommended by the Chronic Care Working Group in their
report entitled ‘Plan for chronic care management in Counties Manukau
2001–2006’, published in July
2001.10
Figure 1 presents a graphical summary of ten major projects
that were formally evaluated by an external evaluator (Auckland Uniservices)
between November 2000 and October 2001.11 The
vertical scale (z-axis) represents the evaluators’ assessment of
population health gain. The x-axis represents their assessment of achievable
secondary care savings, and the y-axis indicates their certainty about these
assessments.
For example, the evaluators were confident that the diabetes
programme could achieve both large savings in secondary care expenditure, and
significant population health gain. The Maori and Pacific primary care
extensions, while likely to achieve population health gain, are unlikely to
reduce secondary care expenditure in the short term.
Complete evaluations of all projects and an evaluation
summary are available on the CMDHB web site.
Lessons learned from the Counties Manukau integrated care projects
Overall, CMDHB believes that
“it is 15% vision and 85% implementation” that makes for project
success. The following is a summary of what we learned from implementing these
projects in Counties Manukau. Each programme needs a
dedicated and effective leader
- Each
programme needs a dedicated and effective leader who is focused on the project
and on “uncovering the rocks”. CMDHB believe that the most important
critical success factor for change management projects is effective leadership
– we provided training in this – and leaders were selected
carefully. Most pilots take 12 to 18 months, so project leaders need to be
committed for this length of
time.
The
programmes must be clinically led
- The
programmes must be clinically led and have quality clinical time available to
them, preferably with practising GPs, nurses and community health workers
engaged on the project staffing.
- Ideally
the programmes should be led by primary care, but must engage with specialists
– generally CMDHB projects had specialist clinical
sponsorship.
Stakeholders
- Overall
governance and accountability to the Crown lies with the District Health Board
as it is the District Health Board that will be held accountable by the Crown
and the community for these programmes.
- All
projects must have buy in from the Board, CEO and CMO (Chief Medical Officer or
equivalent) of each organisation involved (eg, DHB, IPA etc).
- Be
very specific about populations, patient groups and providers.
- Not
all GP practices can accommodate project-driven changes – select
carefully.
- There
was a desire to have at least one project with each major stakeholder (there
were over 10 primary care organisations in Counties Manukau). In retrospect,
this was not feasible. Some stakeholders will necessarily miss out. CMDHB
believe that a careful selection process should be used based on:
- population
needs;
- the
scale of potential to make a difference;
- potential
for return on investment (most integrated care projects will not make a return
in their own right, but must demonstrate that on wider application there is at
least a $2 return for each $1 spent (some US HMOs insist on a $5 to $1 hurdle
rate));
- provider
capability and
enthusiasm.
Cultural
lessons
- When
dealing with Maori, Pacific and other cultures (which is almost always the case
in Counties Manukau), engagement of the appropriate Maori and Pacific
stakeholders must commence from the very outset.
- Cultural
competency must be built into projects from Day 1. Be careful to clearly define
cultural competency. Involve patients in the design of, and feedback from,
projects.
Data and
information management
- Privacy
issues should be on the early project planning agenda in order to resolve them
effectively.
- Information
and communications system development is complex, risky, and expensive. In
Counties Manukau this responsibility fell on the CMDHB for funding and advanced
skills. The minimum level of security was SSL, but IPSEC is preferable. ADSL
speed is
desirable.
Monitoring
and evaluation
- Some
projects did not produce expected results. Close monitoring by the DHB General
Managers ensured that projects in difficulty were either terminated early, or
modified to increase their chance of success. The balance between terminating
and altering project course too early and thus thwarting innovation, and
managing effectively to minimise money spent ineffectively is a very fine one.
It requires a sleeves-up attitude from the DHB General Managers, and a
“loose/tight” approach to managing the projects – loose to
ensure project ownership and innovation, tight on achieving results.
- Do
the numbers to determine accountabilities, return on investment, and
output/outcomes prior to commencement. Five key performance indicators (KPIs)
are better than 50 – minimise reporting – but insist on monthly
reporting of the project progress against key milestones and KPIs. Use a
balanced score card approach and ensure clinical quality is one of the
indicators.
- Significant
District Health Board/IPA/provider management will be required. Three District
Health Board General Managers were dedicated to oversight in Counties
Manukau.
- No
project should proceed without independent evaluation being contracted and
determined up front – the initial setup must include input from the
external evaluator. The evaluator should report to the DHB
CEO/Board.
Change
- Change
management principles apply. Some providers will be trailblazers, some early
adopters, many late adopters and some may never embrace the changes. Picking
providers with the characteristics of trailblazers is the key to early
success.
- Try
disruptive change – doing something with some degree of sense, with
urgency, that at least begins the journey. Recognise this approach will make
some people unhappy and uncomfortable – do not try to please
everyone.
- Do
not underestimate the fiscal importance of reducing the rate of hospital
admissions. This is a critical issue in the eyes of
Treasury.
Time
- Perfection
is the enemy of the good. Projects were initiated when there was sufficient
evidence of need and buy in. Projects were modified continually as evaluation
and feedback happened throughout the life of the project, not just at the end.
It takes a long time to make changes to traditional healthcare systems, and
effective application of complex change management theory is required.
Implementation of regionally integrated care represents a 10-year programme for
a population of 400 000.
- The
rate-limiting steps for CMDHB were clinical behavioural change and information
systems development.
- Recruitment
of patients into programmes was harder than expected. Estimates of the number of
suitable patients and the rate of enrollment to projects was generally
optimistic – by as much as 600% too high in some cases (enrolled 100,
projected 600 in first 12
months).
Resource
allocation
- The
programmes will realise a 3–5 year payback, so require an initial
“hump funded” investment. CMDHB extrapolations indicate a peak in
Year 3 for expenditure of about 3% of total district government funding; split
roughly 40/60 for child health programmes and chronic care.
- A
budget of 20% to 25% of expenditure needs to be set aside for the overheads to
manage, coordinate, research, and evaluate programmes. About 5% should be put
aside for independent evaluation.
- CMDHB
attempted too many projects early. This spread the skill base too thin and it
meant slower than desirable progress on some projects.
Conclusions
These general observations,
together with the results of specific projects reported in the remainder of this
series and on the CMDHB web site, provide a rich source of experience for the
New Zealand health sector, and perhaps international health systems. The
challenge for Counties Manukau is to translate the results of these projects
into effective purchasing strategies that can be rolled out throughout the
region. A governance group has been commissioned by the DHB to implement the
single generic approach to chronic care in the region recommended in the report
of the Chronic Care Working Group, July 2001. 10
A similar governance group has already been established to oversee the
implementation of child health strategies. Some immediate challenges for the future include building a
stronger capacity to deliver results from intersectoral collaboration, and
extending the chronic care management approach to include mental health
(specifically depression) and palliative care.
Whilst strategic directions and structural changes regularly
emanate from Wellington, the innovation required to transform healthcare
delivery can occur only at the coalface. The work in Counties Manukau has pushed
providers’ boundaries, caused angst, and seen flurries of
“political” activity. The work of the past four years has begun
building new foundations, not simply placing new bricks on existing structures.
David Clarke, CEO of CMDHB tells the story of two bricklayers – when asked
what they are doing one replies “Laying bricks,” the other “I
am working on a cathedral”.
CMDHB believes that the critical factor to success in fixing
the health sector will be the ability of our key leaders in primary care and
secondary care, in both management and clinical roles, to adopt this systems
view to problem analysis and solution building.
Author information:
David Clarke, CEO, Counties Manukau District Health Board (CMDHB); Joe Howells,
General Manager, Integrated Care CMDHB; John Wellingham, Medical Director,
Integrated Care CMDHB; Barry Gribben, Senior Research Fellow, Department of
General Practice and Primary Health Care, University of Auckland,
Auckland
Acknowledgements:
Organisations visited or referenced: Group Health Cooperative, Puget
Sound Seattle; Tom Payne- Veteran’s Administration Seattle &
University of Washington; Milliman & Robertson – Seattle USA; Sutter
Healthcare, Sacramento; Kaiser Permanante, San Francisco; Intermountain
Healthcare, Salt Lake City; Project Vida, El Paso; Thomason Hospital El Paso; B4
Babies, Colorado; Seattle Indian Area Health Board; South Central Foundation,
Anchorage, Alaska; Sacramento Urban Indian Health Board; Tiwi Island Health
scheme, Australia Northern Territories; The Australian Integrated Care Trials;
Primary Care Trusts, UK
Correspondence:
Dr John Wellingham, Medical Director, Integrated Care Unit, Counties Manukau
District Health Board, Private Bag 94052, South Auckland Mail Centre. Fax: (09)
262 9501; email: JWellingham@CMDHB.org.nz
- Jackson
G, Palmer C, Lindsay A, Peace J. Counties Manukau health profile. Manukau,
Counties Manukau District Health Board, 2001. Available online. URL: http://www.cmdhb.org.nz/News_Publications/Publicationsframe.htm
- Clark
P, Dalton M, Jackson G, et al. The health of children and young people in
Counties Manukau. South Auckland Health, October 1999.
- Milliman
& Robertson, Inc. South Auckland Health actuarial models. Report to South
Auckland Health, 31 August 1999. Unpublished.
- Poole
PJ, Bagg B, Brodie SM, Black PN. Characteristics of patients admitted to
hospital with chronic obstructive pulmonary disease. NZ Med J
1997:110;272–5.
- Malcolm
L, Wright L, Barnett P. Emerging clinical governance: developments in
independent practitioner associations in New Zealand. NZ Med J
2000:113;33–6
- Ministry
of Health. Purchasing for Your Health 1996/97. Wellington: Ministry of Health;
1998.
- South
Auckland Health. Strategic plan for the next five years. South Auckland Health,
1998. Available online. URL:
http://www.cmdhb.org.nz/Establishment_Plan/EstablishmentPlanFrame.htm
- Christensen
CM, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harvard
Business Review, 1 September 2000.
- Submission
to the Health Funding Authority and the Minister of Health from the providers
and the Community of Counties Manukau. Counties Manukau District Health Board,
November 1999.
- Plan
for chronic care management in Counties Manukau 2001–2006. Available
online. URL: http://www.cmdhb.org.nz/Service_Areas/Integrated_Care/CCMSept2001.pdf
Accessed February 2003.
- Gribben
B. Counties Manukau District Health Board integrated care evaluation
2000–2001: overview and summaries. Auckland: Auckland UniServices; 2001.
Available online. URL: http://www.cmdhb.org.nz/service%5Fareas/integrated%5Fcare/E-Final%20Evaluation%20Report.pdf
Accessed February 2003.
*In 1998, the state-owned base hospital (Middlemore)
in the Counties Manukau District was run by a Crown-owned enterprise (South
Auckland Health) funded by a Health Funding Authority. The legislative change to
a “District Health Board”, responsible for all health services in
the district, occurred during the implementation of the projects
described.
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1. Maori GP/Case
Management
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Develop by Maori for Maori healthcare provision capacity
in the region, with a particular focus on their ability to provide services to
those hard to reach or care for Maori who otherwise pose a risk of high-cost
interventions, and with a view to improving the overall health status of Maori
in our region. Identification of at-risk individuals includes hospital referrals
of those with unmanaged chronic illness for case management
Clendon Clinic
has enrolled over 2000 clients over a four-month period
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2.
Breast-feeding
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Identification of women with a high risk of not achieving
breast-feeding of their baby, and providing them with support to help them
breast-feed for longer than otherwise would be the case. Improve overall
breast-feeding rates in our region
Cooperative venture between Middlemore
Midwives, Plunket, Putea Pua and South Seas Healthcare
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3. Well Child
Immunization
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Through coordination of information on a specially
developed information system, identify the children who do not access
immunizations and well child checks, and through supporting the development of
care provision appropriate to their needs, and coordination of providers, ensure
that they are able to access care, and that children at serious risk of harm are
identified and appropriate services targeted to them
Piloted in Otara over
the new birth cohort since August 2000, with excellent results so far
Second
pilots at Papakura and Franklin in place late 2001
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4. Influenza
Campaign
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Increase the level of immunization of individuals at risk
of hospitalisation as a consequence of flu in the region
Lowered the age for
free vaccination from 65 to 45 for selected South Auckland suburbs in the 2001
winter
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5. Primary Care
Extension and Pacific Case Management
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Develop by Pacific for Pacific healthcare provision
capacity in the region, with a particular focus on their ability to provide
services to those hard to reach or care for Pacific people who otherwise pose a
risk of high-cost interventions, and with a view to improving the overall health
status of Pacific people in our region. Identification of at-risk individuals
includes hospital referrals of chronic illness for management
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6. Acute Demand
Managment Programme
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Through Middlemore EC and ward discharges, target
individuals who have a high likelihood of requiring avoidable and costly
secondary healthcare, and take actions as appropriate to ensure that their
healthcare risks are reasonably mitigated, in particular ensure that they are
connected with an appropriate primary healthcare provider and that they have an
ongoing care plan on discharge that is well communicated to the patient,
relevant whanau and their GP
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7. Alternatives to
Admission (POACS)
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Provide GPs with some alternatives to referral to
Middlemore with likelihood of admission by enabling them to use services with a
cost per episode of approximately $300
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8. COPD Trial (various
GPs)
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A two year trial commenced in 1999 which aims to prove
that enhanced primary care level support for patients with COPD results in lower
usage of hospital resources and improved quality of life for patients
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9. Dyspepsia Project
(ProCare)
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Install guidelines for the treatment and referral of
dyspepsia in primary care such that only appropriate cases are referred for
diagnosis work up, meaning that resources are better targeted.
Historically,
misdiagnosis and inappropriate treatment of the H. pylori infection (quite
common in our community) has resulted in needless avoidable illness for the
patient, and avoidable costs to the health system. In particular, the number of
inappropriate referrals for gastroscopies at Middlemore (long waiting list) has
been dramatically lowered
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10. Care of Elderly
(EastHealth)
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Provide support for high-risk elderly through a
coordinator of services for the elderly ensuring that they are able to access
appropriate and coordinated services, lowering their risk of use of high-cost
health services and improving their outcomes and quality of life
A pilot
project with EastHealth has demonstrated excellent outcomes so far.
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11. COPD/Asthma (First
Health/South Seas)
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Regularly survey patients with diagnosed chronic illness
as to their understanding of their health condition and perceptions of
healthcare using market research techniques, and then feed back the collated
information to their care givers, and track changes over time. Overall objective
is to educate and motivate patients and their families, and to increase the
effectiveness of care provision, lowering the patients’ risk of unmanaged
acute exacerbation of illness
Early results demonstrate a dramatic drop in
hospitalisations as a result of the measures implemented in the pilot
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12. CHF
(SouthMed/ProCare)
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Through the use of guidelines and audit and feedback to
GPs, increase the level of compliance with the guideline and the health of the
patient resulting in lowering the patients’ risk of unmanaged acute
exacerbation of illness
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13. Diabetes
(MHRT/RHOT)
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Develop and install a diabetes guideline and audit and
feedback process to GPs to increase the level of compliance with the guideline
and the health of the patient, resulting in lowering the patient’s risk of
unmanaged acute exacerbation of illness. This project is also developing an
information system, which will enable the tracking of key success factors over
time, the development of a patient care plan, and reminders for the patients and
caregivers of appropriately timed interventions. The resulting database will be
available to all providers of care to the individual (with their permission) and
will provide important information to enable better planning and management of
the delivery of care
The GPs and specialists that we have implemented with to
date are extremely “bullish” about the potential of this system to
change the face of general practice, and the need for specialist-based care for
people with chronic illness
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14. Generic Chronic Care
management strategy
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Pull together the learning from the above five chronic
care pilots and devises a single cohesive plan for implementing chronic care
management in a sustainable way throughout South Auckland
Support this work
with a custom-designed information system that makes doing the “right
thing” (based on current international best evidence-based practice) the
easiest thing to do for the doctor, and which supports the patient with
reminders and follow ups appropriately scheduled and tracked
In particular,
there are significant opportunities through ACE and statin drugs to lower
patients’ risk profile significantly – the impact of systematised
support for GPs in respect to this alone is predicted to have a dramatic impact
on avoidable hospital admissions and improve patients’ quality of
life
This is ground-breaking work that has attracted international interest,
and which our research demonstrates has not been well achieved anywhere else in
the world to date
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15. Child Health
Guidelines Project
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Develop, install and monitor the use of guidelines in
hospital services and in primary care for the treatment of childhood :
cough
and wheeze
gastroenteritis
cellulitis
asthma
respiratory
infections
We have reduced the number of inappropriate referrals to EC and
the incidents of inappropriate medication significantly over the pilot GP
population of SouthMed and ProCare GPs
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16. GP
Connectivity
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Use information technology to increase the effectiveness
of interchange of information between primary care and secondary care such that
improved efficiency and patient care results from this, the following are
key:
referrals
discharge letters
mutual access to diagnostic
information and patient records
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17. ED Avoidable
Attendances
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Research the reasons why consumers use Middlemore EC in
preference to existing primary and community care
Advertising campaign
– have and use a family doctor – and save Middlemore EC for
emergencies
GP liasion role in Middlemore EC being trialled
Alternative
primary level emergency and after hours care being developed and working with
after hours and emergency care providers
Alternatives for low acuity patients
at EC being explored
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Pre 2000
projects
|
18. MHRT Diabetes
National Demo Project
–closed
19. SouthMed Diabetes
Audit – closed
20. Cardiology,
access to ECHOs – ongoing
21.
Smoking Cessation, EastHealth –
closed
22. Services Directory –
now regional
23. Middlemore Post
Acute Care – closed
24.
Combined Respiratory Clinics –
closed
25. First Trimester Bleeding
– closed
26. Continuing Medical
Education – ongoing
27. GP
Survey of SAH Services –
ongoing
28. HARP –
closed
29. Nurse Phone Triage
(ProCare) – closed
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30.
Evaluation
|
All projects from 2001 were evaluated under a single
contract with the Auckland School of Medicine (UniServices) RNZCGP Research
Unit
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