Problem: Demand for complex care needs among aged and low income populations; long wait times and frequent emergency visits; need to adopt a model of care that emphasises on patients achieving long-term behaviour change, while providing care in home settings.
Solution highlights: The model of care provides early and planned interventions, establishes general practice as the centre of coordinated healthcare, provides care based on patient set goals and improves access to a range of specialist and community services; uses risk profiling as means to identify and judge patient eligibility; care goals are set and progress overseen by an assigned care coordinator; funded by flexible regime managed by the providers to ensure care goals can be achieved.
Description of practice
Counties Manukau Health District Health Board’s (Counties Manukau Health) provides health care to a third of the population of New Zealand’s largest city, Auckland. Part of Counties Manukau Health service area population is significant socially deprived and has a rapidly growing proportion of older people. While the population grew by 2% in the 1990s, over the same period adult acute and paediatric medical service demand increased by 9% reflecting frequent emergency department (ED) admissions and regular returns to hospital due to poor long-term condition management.
As part of Counties Manukau Health’s long-term strategy to improve health outcomes for patients with chronic long-term care needs, a new model of care for chronic disease management was initiated. The At Risk Individuals (ARI) programme responds to rising demand through its emphasis on supporting patients to achieve long-term behaviour change and to keep people well in their homes. The model of care intends to address hospital re-admission rates and patient outcomes by providing early and planned interventions, establishing general practice as the centre of coordinated healthcare, providing care based on patient set goals and improved access to a range of specialist and community services. Through a set of clinical risk measures, an assessment framework quantifies the programme’s eligibility criteria. Identified patients in collaboration with a care coordinators set care goals that are translated into an individual care plan. The care coordinator then arranges a care team that is able to monitor and update an electronic patient records as a means of assessing progress towards the patient’s goals. The care team’s work is funded from a flexible pool that may be used for a variety of services using a set payment schedule. To maintain the integrity of the pool, those items ineligible for funding are prescribed. Performance is managed through a set of agreed quality indicators comprised of patient and organisational measures. Patients report high satisfaction with the ARI processes, particularly regarding patient focussed time by their care coordinators and staff to enable them to better understand and empower self-manage their conditions.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
As the funder of services Counties Manukau Health took a lead role, working with Primary Care Organisations and their provider networks to develop the requirements, procedures, and IT components for the programme. A range of Primary Care providers beyond general practices, such as community pharmacies, allied health, community mental health and community based nursing services as well as the family, were engaged in the programme as part of care provision and programme coordination. The programme is clinically-led so its development, implementation and monitoring involves significant leadership input from hospital, primary care and nursing personnel. The programme uses previously designated chronic care funding that is pooled and distributed to fund care plans enabling a model of care beyond the 15-minute consultation paradigm and supportive of an environment where it is easier to do what is needed. Although, this change in culture required some adaptation and time to reconfigure and prioritise working practices for some providers.
The programme’s integrated nature places more emphasis on team-based Primary Care, with the patient at the centre through the personalised care plans. The programme also provides an opportunity for hospital specialists to be part of a wider community-based healthcare team assisting to manage patient care. Evaluations have found that patients value the programme due to the time that staff spend with patients to support self-management. This time commitment reinforces the model’s team approach, where a doctor may not always be the health professional seeing the patient, rather the care responses are reflected by what is needed by the patient at that particular point in time. This flexible approach enables a wider range of resources and interventions to be applied from home visits by GPs, longer-term care by community-based and primary care nurses beyond acute phases, multi-condition advice and interventions and by providing patients with evidence of their improving self-management. After two years in operation the ARI programme has 22, 520 individuals enrolled across the 115 participating general practices, with early data indicating a positive impact on acute admissions.
- Indrajit Hazarika
- WHO Western Pacific Regional Office