Integrated Care at Scale and Pace
Watch the Video https://vimeo.com/user16918463/review/67260587/a5d9dc2176
Read the King’s Fund Report http://www.kingsfund.org.uk/publications/population-health-systems/counties-manukau-new-zealand
In 2012 Counties Manukau Health was faced with a rapidly ageing, growing and increasingly chronically ill population. The options were stark: either double down and systematise the long standing ‘Counties’ approach of innovating and re-designing care, or open many more acute hospital beds. Demand projections showed the former approach was the only viable option. The question was ‘how’? Over two years, Benedict led key changes:
Workforce:
Existing DHB community health, public health, and mental health teams were re-organised into locality based clusters, working more closely with each other and their primary care and NGO colleagues.
Hospital specialists supported the clusters with clinical advice and liaison and the ‘virtual’ MDTs came together when needed to case conference.
200 clinical pathways for the most common conditions were localised, allowing clinicians throughout the system to agree and follow best practice.
Systems:
An algorithm was developed to stratify the patients most at risk of unplanned hospitalisation.
An e-shared care API was deployed across hospitals, community and primary care which allowed key clinical information and messages to be shared and the patient’s goals, context, and care plan to be recorded. Patients and their carers can see their plan and message their virtual care team.
Primary care was supported to re-engineer their practices into a ‘Healthcare Home’ model which freed up capacity to more proactively manage chronically ill patients.
Outcomes:
Over two years, 35,000 complex patients received integrated, locality based care. Rates of hospitalisation reduced to below demographic growth levels, and a cumulative saving of 75,000 acute hospital bed days was achieved between 2013-2017.
Independently verified analysis showed that after one year, patients receiving integrated care had greater self management ability, reduced systolic blood pressure, and better glycemic control (all statistically significant).
Maori and Pacific people were enrolled in disproportionately higher numbers, reported higher rates of satisfaction than with usual care, and had even greater improvements in glycemic and blood pressure control than the total population.
From District Nursing to Hospital @ Home
Benedict had seen services under stress before, but never like this. Counties Manukau had the lowest per capita district nursing and allied health workforce in NZ, serving a high needs population with many living in chaotic and sometimes unsafe households. Fax machines distributed across multiple bases were used for referral triage, whilst clinicians relied on paper records, diaries and shared (1990s era) mobile phones to manage their workloads. With very limited community rehabilitation services available, patients were often assessed for long term care before hospital discharge - with predicable impacts on aged residential care entry and acute re-admissions. The re-design journey was about letting clinicians be clinicians:
Workforce:
Frontline teams visualised a new way of working through a facilitated discovery process, resulting in a change of name and focus. The four ‘Community Health teams were trained in re-ablement and multi-disciplinary assessment, so that they could multi-task and delegate to newly appointed Community Health Assistants who augmented the capacity of the teams.
The teams had closer collaboration with co-terminus primary care clusters, and some wound care was transferred (with funding) from district nursing to practice nurses to support continuity of care.
The first Community Nurse Prescribing programme in NZ was rolled out across Counties, allowing senior community nurses to work at the top of their scope of practice. As capability grew, the teams were able to build a falls programme and a Hospital at Home service to provide the equivalent of 45 acute medical beds in the community.
Systems:
The workforce was enabled with tablets and smartphones which allowed schedules, records, and clinical notes to be accessed efficiently ‘on the road’.
A ‘lone worker app’ and new processes improved worker safety and supported 24/7 service coverage.
A new Community Central function replaced multiple referral points with a single, technology enabled process for clinical triage, allocation, scheduling, patient/carer liaison, and logistics support. Community Central gave primary and secondary care clinicians confidence in the community teams’ ability to respond rapidly to hospital at home and other urgent referrals.
Outcomes:
Over three years, 1,000 re-ablement patients experienced significantly improved VAS, ADL, and EuroQol scores, confirming greater physical function and better quality of life. Aged Residential Care usage dropped by 15%.
Hospital at Home recorded high satisfaction than usual care for all patients but particularly Maori and Pacific people, who represented nearly half of all referrals to the service.
Workforce productivity increased by 12% and staff reported feeling safer, more supported and more motivated.
Merging and Modernising Social Services
Read about the Tri-borough:
By 2010 the Global Financial Crisis had hit the UK public finances in a big way. As Director of Commissioning for the ‘Tri-borough’ London councils, Benedict faced a huge challenge: Reduce management costs by 35% by bringing together three large social care departments. That newly merged directorate then had to reduce baseline expenditure by 25% over three years - in a system with an ageing and increasingly economically disadvantaged population where services are largely accessed based on statutory entitlements. From day one a systematic change process was deployed:
Workforce:
Affected employees and their union representatives were involved from the outset in co-design of the new Tr-borough organisational structure and job descriptions. Regular engagement events emphasised the ‘why’ of the Tri-borough and the opportunities for staff.
A voluntary resignation scheme helped minimise disruption and move on change resistant staff quickly. Within 18 weeks all staff had certainty of their employment status in the new structure.
Joint training days in core generic skills - negotiation, communication, resilience - gave the new teams a chance to bond and form a common language. The phrase “Better for Less” became the strap-line for meeting the challenge ahead.
Systems:
Frontline professionals were engaged in a systematic service by service Lean review process to identify opportunities to remove waste and simultaneously increase efficiency and quality. Every service activity and Council owned asset was prioritised, costed, benchmarked, and subjected to market testing - leveraging the Tri-borough scale (700,000 residents).
Care pathways and joint intensive intervention (for at-risk families); re-ablement & rehabilitation (for frail elderly); and rapid response (for the chronically ill) services were co-developed with the NHS to improve social & clinical outcomes.
Individual budgets replaced care entitlements as the default option for thousands of social care clients, giving them greater choice and control at a lower total cost. The NHS and Tri-borough began routinely co-investing in jointly funded individual care budgets.
Outcomes:
By year two, management and back office costs had been reduced by 30% and all outsourced services had been re-procured with higher quality specifications at a 10% average lower price. $100m in under utilised Council assets were re-purposed to economically productive uses.
The new joint health & social care services reduced residential care activity by 15% whilst improving educational, employment, and health outcomes. The local acute hospital was able to permanently close an entire ward.
The required GFC savings had been achieved without any “slash n’ burn” and the Tr-borough social care services received ‘Good’ and ‘Outstanding’ CQC quality ratings.