The document discusses integrating primary health care in New Zealand by establishing multi-disciplinary teams to better manage patients with long-term conditions. It provides examples of Group Health, a not-for-profit health maintenance organization, that implemented a medical home model with improved coordination and patient experiences. Preliminary results from Group Health showed reductions in hospitalizations, emergency visits, and care costs despite increased primary care spending.

1. 2009 + Integrated Primary Health Care

2. The Background Need to support the development of new business models for General Practice – while retaining “the caring”. Midland workforce reports pointing to significant fragility and a pending collapse of the required workforce. Drs, Nurses and others. Failure in the implementation of the PHCS to see the establishment of integrated primary health care teams.

3. The NZ Health Sector The next phase of progressing the Primary Health Care Strategy provides an opportunity for the sector to contribute to the Government’s overall objective of “Better, Sooner and More Convenient” health services. The Government’s priorities for primary health care development are: improving patient access to a wider range of health and social services in convenient locations, through integrated service delivery models, including co-location of services via integrated family health centres; promoting clinical leadership and multi-disciplinary teamwork to improve the management of long term conditions (LTCs), and to promote earlier intervention and prevention aimed at keeping people well; and shifting more services from secondary to primary care settings to enable patients to get faster access to a range of diagnostic tests and services, including minor surgery and procedures delivered in general practice.

4. The NZ Health Sector Primary health care providers struggle to access the full range of services that could help them keep their patients well in the long term and out of hospital. This is particularly apparent in relation to the increasingly complex health needs of an ageing or high need population where the evidence suggests a broader range of services delivered by a multi-disciplinary team that’s effectively linked to a range of social services will be required. It is therefore seen that the MoH will: Put in place requirements and incentives to make DHBs more responsive to the needs of patients currently being managed in primary care; Put in place requirements and incentives to improve the management of patients with LTCs; Increase the ability of primary care providers to access and shape a wider range of services directly. This could include the devolution of budgets for: General Medical Services (GMS) (with appropriate recognition of out-of-hours practices), chronic disease management programmes (e.g. Diabetes Get Checked), some Ministry-funded services including maternity care, public health services, and some disability support services; routine laboratory tests including non-schedule tests, and all Pharmaceutical Schedule pharmaceuticals prescribed for enrolled patients to PHOs; elective surgery.

5. Group Health Not for Profit x HMO 500,000 patients (10% of total state pop.) Started in 1947 first to provide full insurance and comprehensive medical care Group Health Cooperative Group Health Cooperative was opened in 1947 by a community coalition dedicated to making quality health care available and affordable. Governed by consumers rather than internal executives. Group Health Options, Inc It offers a variety of health plans in Washington and Northern Idaho that provide choice and flexibility to meet the needs of large and small employers. These range from a defined physician-network plan to point-of-service (POS) plans in which members can get care from outside the network for higher out-of-pocket costs. Group Health Permanente Physicians have played a key role in Group Health Cooperative's history and continue to oversee every aspect of clinical care and quality. Their commitment to family medicine and prevention has shaped a broad approach to care at Group Health, one that focuses on the whole patient, not just an illness or condition. After more than 50 years as Group Health staff, our doctors formed Group Health Permanente (GHP), an independent professional corporation, in 1997. This multispecialty medical group is under exclusive contract to provide care in Group Health-owned or -operated facilities and works in partnership with Group Health Cooperative management. www.ghpmd.org/index.html

6. Group Health – Medical Home Design principles The relationship between the personal care physician and the patient is core. The entire delivery system and the organisation will align to promote and sustain the relationship. The personal care will be a leader of the clinical team and be responsible for coordination and integration of services and together with patients will create collaborative plans. Access will be centered on patient needs, be available by various models 24/7 and maxmise the use of technology Clinical and business systems are aligned to achieve the most efficient, satisfying and effective patient experience Activated patients in relationship with prepared physicians and teams = lower cost trends and more predictable/better outcomes

7. Group Health – Medical Home Functions Flow staff MA/ PN PN Team Registered Nurse GP Physician Assistant Clinical Pharmacist Core RN Practice Visit Outreach to patient prior to visit Attend daily huddle Meet with GP to anticipate visit support need Perform and/or assist provider with procedures Schedule appointments - FU Attend daily huddles Co-lead daily huddles with GP Clinical nursing resource for the team Patient education in 1:1 and group visits Perform complex nursing procedures Co-lead daily huddles Review schedule & huddle with MA, in preparation of visits Shared decision making with collaborative care planning Lead group visits Attend daily huddle Routine and acute care as extension of the team Attend daily huddle Complex patient med review and education Clinical resource to team related to medication use Participate in Group visits related to meds Attend daily huddle Triage drop in Perform routine & complex procedures Call & secure messages Answer patient phone calls Manage delegated messages Triage patient phone calls Team resource for MAs Triage patient phone calls Team resource for MAs Answer patient phone and emails Answer patient phone and emails Answer patient phone and emails Answer patient phone and emails Outreach care Make planned care calls Outreach ED discharges Outreach to hospital and home Direct outreach care performed by clinical team members Make planned care outreach calls related to medication use Outreach to hospital discharges as referred by RN Care co-rdination Coordinate referrals Outreach and active management of high risk patients Refer patients to Team RN etc Outreach and active management of high risk patients FTE 1 0.3 0.3 1 0.3 0.3 0.3

8. Group Health – Medical Home Make team roles and GP leadership explicit to patients Point of care Outreach Best practice alerts Longer appt times (30mins) Planned care exception reporting MyGroup health Health maintenance reminders Secure messaging – secure emails High risk outreach Health Profile Pr – visit reviews and outreach Call management Hospital outreach Health Coaching Collaborative care Plan Birthday letters After visit summaries New patient outreach Feedback Group Visits Performance reporting Huddles Exception reporting Living well with chronic conditions

10. Group Health – Preliminary Results Significant improvements in all measures of patient experience. Significant improvements in a variety of composite and patient centred quality of care measures. Significant less burnout among care team members, particularly less emotional exhaustion. Significantly greater work satisfaction. Fewer avoidable hospitalisations, consulting nurse calls and emergency/urgent care visits. Significant shift in primary care delivery to fewer in person visits and higher e-mail messaging and more telephone encounters. Despite significantly higher primary care costs, the medical home appears cost-neutral at one year. Group Health starting to exit secondary services The new approach was designed by Factoria (10,000 patient practice) in a 5-day intensive workshop followed by immediate implementation (‘rapid process improvement’). The practice was closed for the 5 days, all team members attended the workshop, and a number of patients also attended. As a result of the approach, 25% of patients had a change of doctor, and practice staffing expenditure was increased by $1m pa.

11. Breaking the cycle First level funding DAR SIA C+ Etc…..

12. Breaking the cycle First level funding DAR SIA C+

13. Core data set Who What How Build all responses, programs and resources up from the need

14. North Hamilton - IFHC North Hamilton 15,000 patients 3 existing practices On site pharmacy at all practices All staff employed by PHCL (not for profit) Physical space for change On site pharmacy at all practices Current spend $148 per patient on staff (excludes other expenses) SIA, HP, CarePlus = $80k (one site for mobile nurse + small SIA service income) High quality, accredited sites Access to 100% above + + additional contracts eg: medications review, sexual health, PMH etc would add additional flexibility

15. A new look - 1900 $303,000 (excluding expenses) per 1,900 patients ($159 esu) $282,800 Current income( excluding expenses): capitation, Quality, co-payments, diabetes, SIA ($148 esu) $297,905 = 100% above + 100% SIA, HP, C+, DAR & Imms ($156 esu) $159 per ESU + expenses vs $148 per ESU + expenses GP Nurse Admin Pharm Specialist Nurse Mobile Nurse 1 0.7 0.7 0.2 0.2 0.1 $200,000 $35,000 $31,500 $17,000 $13,000 $6,500

16. Further work underway FSA/follow up assessments – volume, current waiting times, capacity in primary, capacity in alternative providers for diagnostics Minor surgery and procedures – volumes within patients base, capacity elsewhere Primary options for acute services (non social) Risk holding for Pharms Possible risk holding for Labs/other diagnostics Incentives around prevention PM/facilitation costs

17. So….via the MoH 24 mths in advance guarantee 100% funding (unbundled so overtime may be less) Agreed outcomes – clinical and process Upfront top up in lieu of downstream savings Including PM/facilitation $ Offset with capped risk to demand driven costs Set formula based on site population with a minimum scale Forced DHB investment in acute care services as per guidance letter

18. Big Picture Test Tackling the long-term conditions epidemic. Reducing demand on expensive secondary and tertiary services. Improving quality and reducing unexplained variability. Increasing productivity within available resources including workforce. Maintaining a sustainable funding path. Ensures accelerated development of the primary health care sector through a focus on consolidation of the sector, increased efficiency and quality, and the development of vertical (between secondary, primary health care, and prevention services) and horizontal (across networks of primary health care, and prevention service providers) service integration. Ensuring that there is clinical leadership in service and quality improvement, and investment in infrastructure to support and facilitate all of the above.