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| Journal of the New Zealand Medical Association,
13-April-2007, Vol 120 No 1252
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Chronic Care Management evolves towards Integrated
Care in Counties Manukau, New Zealand
Harry Rea, Tim Kenealy, John Wellingham, Allan Moffitt, Gary
Sinclair, Sue McAuley, Meg Goodman, Kim Arcus
Increases in the number of elderly people and of those with
long-term conditions are rapidly reshaping healthcare demands. Chronic
conditions in New Zealand are the leading cause of hospitalisations, use 70% of
health funds, and account for 80% of all
deaths.1 In the UK, 6 in every 10 adults have a
chronic condition.2
Chronic Care Management (CCM) is what Counties
Manukau District Heath Board (CMDHB) calls its system for managing people with
chronic illnesses by enhancing primary care using reminders, decision support,
and case management. Currently, this includes people with diabetes, congestive
heart failure, chronic obstructive pulmonary disease (COPD), cardiovascular
disease, and a pilot programme for depression. To be eligible, patients must
meet specific ‘high-risk’ criteria within each condition.
Integrated Care is a wider term that describes a
goal of ‘seamless’ care for patients with acute and chronic health
problems at any point in the healthcare system. At its broadest, Integrated Care
extends to encompass preventive care, social care, and care and support in the
home, recognising that social conditions impact on health and vice-versa. It
imposes the patient’s perspective as the organising principle of service
delivery. It is presumed that chronic care management can be most effective when
established within a wider system of integrated care.
The changing demand for care, due to the increases in the
number of elderly and those with long-term conditions, is recognised worldwide.
Integrated care models expect to address the growing complexity of patients
needs by responding in a coordinated fashion and by providing the appropriate
combination of social and home care in the community (www.socialeurope.com) We are concerned
that New Zealand is falling behind in the development of such care.
Neither Chronic Care Management nor Integrated Care seek new
treatments or technologies, rather, they seek to implement systems of structured
care that deliver current treatments and technologies to those who need them,
when and where they need them.3 We base our
comments on our experience in South Auckland over the last 20 years; our
interpretation of the literature; and our discussion with stakeholders and
observations of ‘best practice’ in New Zealand, the UK, and the
United States.
Theories and evidence supporting chronic care managementThe accumulating evidence around strategies to manage
chronic illness were first formulated as a single model by Wagner, who described
the Chronic Care Model in 1998.4 The key
strategies originally included were; mobilising community resources, creating an
organisation that promotes high quality care, enabling patient self-management,
promoting care consistent with evidence and patient preferences, and efficiently
and effectively using patient and population data. Since then, others have
variously added cultural competence, patient safety, care coordination, case
management, and health promotion.
Most chronic care policies in developed countries now draw
wholly or partly on this model.5 Single and
multiple components from this model have been tested for their effectiveness in
improving chronic care, with mixed findings as summarised in a recent systematic
review2 (Box 1).
Considerable uncertainty remains about which interventions
are effective when applied to a range of diseases and across different
healthcare systems, and which components are beneficial within complex
interventions. Two of the (many) difficulties with such research are that
interventions are usually complex and are typically compared to ‘usual
care’, where usual care may vary markedly across place, time, and health
system.
Box 1. Strategies to improve one or more of
patient experiences, quality of care, clinical outcomes, or resource use (from
Singh 20052)
The triangle shown in Figure 1 represents the whole
population broken into groups ranging from the many without chronic disease but
with risk factors—at the base—to the small number at the top who
have highly complex conditions and who intensively use the health
services.5
Integrated Care spans the whole triangle and multiple acute
and chronic diseases. This triangle model, which comes in many variations
relates closely to the Leading for Outcomes model used by the New Zealand
Ministry of Health.6 Other models are
summarised by Singh and Ham.5
The theory of Integrated Care has also progressed over the
last decade, although there is no standard definition. This is partly because
Integrated Care appropriately has different implications for those with
different roles in the health (and social care)
systems7 (Box 2).
Various trials using Integrated Care models in attempts to
improve health outcomes are currently underway, but as yet there is minimal
reported evidence.7
Figure 1. Appropriate service delivery strategy
depends on the risk and complexity of each sub-population (not to
scale)
 Box 2. Integrated Care means different things
to different stakeholders (from Lloyd and Wait
2006)7
Policy and opportunity development in New ZealandThe New Zealand Health Strategy, published in 2000, defined
high-level principles for the health system, including the need to reduce health
disparities; it specifically recognised the need to reduce the impact of
cardiovascular disease, diabetes, and mental illness, amongst other
conditions.8
Policymakers have recognised an important role for chronic
care management and integrated care in addressing these
disparities—traditionally considered outside the domain of ‘personal
heath services’.1 The new notion is
clearly expressed by Starfield:
“Personal health
services have a relatively greater impact on severity (including death) than on
incidence. As inequities in severity of health problems (including disability,
death and co-morbidity) are even greater than inequities in incidence of health
problems, appropriate health services have a major role to play in reducing
inequities in health.”9
The Primary Health Care Strategy, published in 2001, further
defined a focus on chronic disease care, to be delivered from strengthened
primary care.10 PHOs would replace Independent
Practitioner Associations (IPAs) as the organising focus within primary care.
PHOs would have more community input and population-health responsibilities than
IPAs.
Over the next 10 years, funding to pay GPs would shift from
fee-for-service to capitation, with greatly increased patient subsidies and
therefore greatly decreased patient fees. This funding change was the most
dramatic rearrangement of primary care payments and incentives in the last 60
years. Since then, 81 PHOs have been established around the country (with 3.9
million people registered), and some form of capitation payment is paid to 90%
of GPs.
In Counties Manukau, most GPs are paid by a mixture of
capitation plus a fee-for-service for patients older than 5 years, although in
many instances care is free to patients up to age 18.
Care Plus is a national programme, introduced in 2004, which
funds primary care to provide 2 hours of practice nurse (PN) and/or GP time
(over 6 months) to people who are considered likely to benefit from more
intensive clinical input. The system was aimed principally at strengthening
support for managing people with chronic illness. It potentially includes most
of those on CCM programmes, but each process is managed independently, and the
population target for Care Plus includes people ‘lower’ than CCM
patients on the triangle in Figure 1.
The Frequent Adult Medical Admissions scheme (FAMA),
introduced in 2003, is specific to Counties Manukau and targets people who have
been admitted to hospital more than twice in 12 months for a total of 5 or more
days. The programme offers case management by PNs and GPs together with care
coordinator nurses who are based in secondary care.
The most recent change is the PHO Performance Management
Programme which is currently being rolled out. This programme introduces, for
the first time, payment for performance against a small number of agreed
performance indicators and targets. Only two of the current indicators are
clinical and none addresses chronic diseases. These may start to be addressed
with the next round of indicators, due in 2007.
In contrast, the UK Quality Outcomes Framework has a great
many more clinical indicators. For example, the 2004 list includes 8 for COPD,
18 for diabetes, and 3 for left ventricular
dysfunction.11 Furthermore, in the UK,
performance incentives are paid to the practice and may account for a quarter or
more of a GP’s income, whereas the payments in New Zealand are a minor
proportion of payment to primary care, and are paid to the PHO.
Chronic Care Management in Counties ManukauCCM was initiated in 2001 as part of an urgent response to
an impending crisis of escalating admissions to Middlemore
Hospital.12,13 CCM, together with related
programmes instituted at around the same time, was credited with reducing the
annual growth rate in admissions from 9% to
zero,14 with a net reduction in
costs.12
Despite what appears to be an administrative and financial
drive for the programme, it was always acknowledged that CCM would be successful
only if health professionals could see that it improved patient care. Indeed,
the roots of both CCM and Integrated Care in Counties Manukau go back a further
decade to attempts to radically remodel care in some services, diabetes,
respiratory diseases, congestive heart failure, paediatrics, and mental
health.15-19
A core feature of the current CCM programme is funding,
training, and support for an increase of dedicated time spent with patients to
proactively manage their conditions. Most of this time is spent by PNs, who are
funded for up to 6 hours per year, and is supported by a computer template used
by both PNs and general practitioners (GPs). This template provides a series of
tick-boxes and drop-boxes that constitute a reminder and checklist for essential
care and recording. The data are sent to a server and guideline-based decision
support is automatically generated and returned asynchronously, so that the
delay may be minutes or hours depending on computer linking schedules.
Sending data generates payments to the GPs. The diabetes and
CVD programmes essentially involve documenting care, risk assessment, and
tailoring patient management to optimise risk-reduction by attempting to attain
evidence-based clinical targets. These are achieved using a combination of
patient-held ‘wellness plans’, lifestyle intervention and
medication. The programme can be completed by either the GP or the PN, though it
commonly involves coordinating both the GP and the PN with the patient.
As the enrolled patients with COPD and CHF are generally
‘sicker’ than those with diabetes and CVD, and the programmes were
specifically aimed at reducing hospital admissions, the care for COPD and CHF
involves more intensive ‘case management’ than the other programmes.
Patient numbers enrolled in each CCM programme vary
considerably. Currently there are approximately6500 with diabetes (of an
estimated 10,000 eligible); 300 with COPD (of an estimated 3000); 240 with CHF
(of an estimated 3000); and 500 with high-risk CVD (of an estimated 3000).
Clearly, the diabetes process has been more successful in
engaging GPs and PNs than the processes for the other chronic conditions. We
have already noted that the diabetes service was an early target for
integration.16 Furthermore, the CCM diabetes
process built upon the free patient annual review Get Checked that was
introduced nationally in late 2000 and was subject to intensive GP and PN
education and encouragement from the IPAs of the time.
The diabetes CCM process appears to benefit patients. For
example, the HbA1c of the first cohort of 1544 patients dropped by 0.34% after 1
year.20
The CHF patient numbers remain low despite the programme
being acceptable to the GPs and PNs who participated in the
pilot.21 Even the pilot evaluation, however,
noted problems with staff time and payment. The COPD patient numbers remain low
despite apparently good engagement of GPs and PNs in the randomised controlled
trial that preceded the programme.19 The trial
report noted, however, that both GPs and patients were volunteers, and that the
participation of the PNs working with these GPs and patients was variable. In
addition, the programme probably struggled to maintain momentum after the
departure of the enthusiastic nurse who coordinated the project. The
intervention was something of a “black box” and included not only
evidence-based care plans but attention to social and home support.
Likely barriers to the uptake of these programmes include
the need for patients to have an echocardiogram prior to entering the CHF
programme, and spirometry prior to entering the COPD programme. Access to
echocardiogram and spirometry has been partially improved by adding a trial of
open-access echocardiography, separate spirometry clinics run by a Primary
Health Care nurse specialist and by a drug company representative, and by using
funding from Services to Improve Access (SIA). This funding stream was
introduced nationally in 2004 and can be used to improve access to services for
‘high needs’ patients, defined as Māori, Pacific, and those in
the lowest socioeconomic quintile.
Lessons from New ZealandOverall, we can see that need for chronic disease management
is well established for some conditions in New Zealand, particularly in diabetes
and mental health. However, details and effectiveness of implementation, even
for these conditions, appears to vary markedly around the country. We have only
a limited ability to recognise and transfer best practice. We are handicapped by
a lack of agreed standards for transfer of information that is vital to planning
and monitoring chronic disease management, including laboratory and medication
data. Such data transfer is further handicapped by lack of a national framework
for patient consent as to which pieces of data can be stored and transferred,
for what use and to whom.
We suggest that, in a state-funded chronic disease
management system, consent should be handled by an ‘opt-off’ process
rather than an ‘opt-on’ process. Despite funding and structural
changes in hospitals and general practice in New Zealand, it is rare to see
practice and attitudes changed sufficiently to provide the sort of care outlined
in Box 1. Moreover, moves to structured, multidisciplinary care are not served
by ad hoc attendances for acute events, fee-for-service funding, and increasing
demands for new technology and sub-specialisation.
On the other hand, comparative strengths in New Zealand,
include (in our opinion): a recent improvement in morale in primary care,
perhaps related to increased funds and capitation; and some striking examples of
entrepreneurial delivery of systematic care for chronic conditions such as those
shown in Box 3.
Box 3. Exemplar chronic care programmes in New
Zealand
Lessons from the United KingdomCompared with New Zealand and most other countries, the UK
has more fully-developed plans for managing chronic conditions. In their case
this has been possible due to all patients being registered with a GP, a
centralised system for managing and funding primary healthcare provision that is
free to the patient.
Centralised information systems enable primary healthcare
trusts (with a geographic base and a defined population) to define the
healthcare needs of their community. Quality Outcomes Framework uses multiple
clinical and process indicators to link practice and GP pay to performance. The
same centralised information systems help stratify patients according to
healthcare risks and need for interventions, and updated the information daily
to support practice planning and activities including recall.
The UK makes greater use (compared to New Zealand) of
‘healthcare centres’—some are nurse-led, thus giving members
of a multidisciplinary team a ‘home’ and facilitating a team focus
in their geographic community. Finally, the UK has committed a large amount of
money to the project. New Zealand appears to have under-estimated the funds and
human resources needed to support the change of practice required to establish
and run multidisciplinary chronic-care clinics in general practice.
Nevertheless, discussions with stakeholders in the UK also
indicate some negative factors which may undermine development of integrated
care. These include: demoralised GPs (partly due to repeated change and a system
of top down control); lack of local ‘buy-in’ for the same reasons;
GPs and nurses working in ‘silos’; and poor relationships between
hospitals and primary care.
How Counties Manukau might respond to new evidence and opportunitiesCounties Manukau is likely to enact all of the strategies
listed in Box 1, for which there is evidence. The DHB and PHOs have an ongoing
programme of health needs assessment for their populations, with a specific
mandate to address health inequalities. We consciously use the triangle shown in
Figure 1 to stratify people so that they can receive healthcare services
according to their needs and to their likely use of secondary care services.
We will continue to support care at home or in the community
where possible, rather than in hospital. We expect to increasingly use nurses,
pharmacists, and other health professionals to deliver or supplement systems and
processes of care. In some instances, this will replace doctors’ roles,
but will largely be additional, complementary to, and supportive of
doctors’ roles.
We will specifically support establishing multidisciplinary
teams in primary care supported by specialist advice. This advice will be both
in person as specialists work beside primary care providers as well as embodied
with information systems including templates, reminders, and decision support.
We have begun adapting established ways to support patient self-care for local
use. Suitable models include the Flinders
model,22 the Lorig
model,23 and the Expert Patient Programme from
the UK.24
As an embodiment of all these trends and intentions, the
DHB, together with the PHOs and the University of Auckland, hope to develop a
trial around community hubs or health centres which will provide nurse led care
with visiting GPs, hospital specialists, and providers of social / home support.
This will work best if supported by national systems and policies and include
training schemes, appropriate remuneration, and some standardisation of clinical
information systems, none of which is yet guaranteed.
It is clear both from experience and from the literature
that apparently-small differences in programmes may have a major impact on
uptake and effectiveness, even when comparing projects that are all based on
best-practice guidelines and designed specifically to enhance patient care.
Health systems are recognised as classic examples of ‘complex
systems’ in which the effects of interventions are unpredictable, and in
which ongoing evaluations are vital, both for current programmes and for any
further changes in the way health care is
delivered.25
Co-operation and co-ordination across traditional
professional and organisational boundaries must be specifically fostered and
managed. And, above all else, enthusiastic clinical leadership committed to
patient centred care is required for any integrated care project to succeed.
With this leadership, integrated care may progressively
become a reality despite imperfectly aligned incentives, and organisational and
professional boundaries. Without it, we will remain trapped in our current
system that, to paraphrase Berwick,26 is
perfectly designed to produce the same—inadequate and inequitable
results— that we currently ‘enjoy’.
Competing interests: Meg Goodman, Gary
Sinclair, Allan Moffitt, Kim Arcus, and Sue McAuley are (or were) employees of
Counties Manukau District Health Board (CMDHB). Harry Rea has a clinical
commitment to CMDHB; is a member of the DHBNZ-Research Fund Governance Group;
and Chairs its Chronic Care Steering Committee. Tim Kenealy has a general
practice in the CMDHB area. John Wellingham is Chair of the Quality Board of the
RNZCGP; is a Clinical Director of Enigma Publishing; is Chair of the DHBNZ
Research Fund for Diabetes research; and is a member of the DHBNZ Chronic Care
Steering Committee.
Author information: Harry Rea, Professor of
Integrated Care and Medicine, Department of Medicine, University of Auckland,
Auckland; Tim Kenealy, Associate Professor of Integrated Care, Department of
Medicine and Department of General Practice and Primary Health Care, University
of Auckland, Auckland; John Wellingham, Primary Care Advisor, Waitemata
DHB, Takapuna, Auckland; Allan Moffitt, Director, Primary Care Development,
Counties Manukau DHB, Otahuhu, Auckland; Gary Sinclair, Clinical Director,
Primary Care & CCM, Counties Manukau DHB, Otahuhu, Auckland; Sue McAuley,
Clinical Research Manager, Centre for Clinical Research & Effective Practice
(CCRep), Counties Manukau DHB, Otahuhu, Auckland; Meg Goodman, Primary Health
Care Nurse Specialist, Counties Manukau DHB, Otahuhu, Auckland; Kim Arcus,
Programme Manager, Primary Health Care Strategy Implementation, DHBs and
Ministry of Health, Wellington
Acknowledgement: The authors thank Dr Dale
Bramley (GM, Clinical Support Services, Waitemata District Health Board) for his
revisions of the manuscript.
Correspondence: Tim Kenealy, Associate
Professor of Integrated Care, Departments of Medicine and General Practice and
Primary Health Care, University of Auckland, Private Bag 92019, Auckland. Fax
(09) 373 7624; email t.kenealy@auckland.ac.nz
References:
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