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This month’s edition of Healthcare Review – OnlineTM is the fourth in a series focussing on integrated care, and examines the development of delivery systems from a number of perspectives.
It is valuable to present practical experience of integration within New Zealand, as the views expressed contain useful lessons for others facing similar issues within the sector, including the development of services for Maori.
There are a number of recurring themes; the importance of setting clear goals, the challenge of changing established culture, the need for flexible models for delivery, the importance of management and information systems and the potential for funding to align incentives.
A contribution from Ray Anton and Malcom Macpherson from HeathCare Otago outlines this secondary care provider’s approach to integration and the aims and aspirations of such a secondary care organisation in pursuing integrated health care delivery.
The paper outlines the organisation’s commitment to integrating health services in order to achieve the best possible health of the community. Integration is seen to offer such advantages as enhanced focus on patient need, reduced duplication of effort and investment, improved health outcomes and easier access to services.
Anton and Macpherson recognise that a key aspect of integration is the need to change the cultures of the partners from competition to collaboration. This is required whether or not the funding environment has aligned the incentives for the collaborating partners.
The paper reviews integration initiatives already under way at HealthCare Otago including projects in diabetes service integration, primary maternity integration and mental health service integration.
The diabetes project was established to address fragmented care and associated late detection and progression of disease. A multidisciplinary team has worked to identify approaches to improve service delivery including professional education of GPs and practice nurses and reconfiguration of specialist services.
A key element of the integration project is the development of a diabetes database which will be the basis of determining whether health outcomes improve as part of the initiative.
The mental health service integration project has highlighted the unique role of Healthcare Otago within initiatives to integrate services which results from its position as the single biggest provider of mental health services in the region and the importance of relationships as a key ingredient of success.
HealthCare Otago’s experience with integration has been positive and is seen to reinforce the organisation’s commitment to integrated care.
Professor Gregor Coster of the Department of General Practice and Primary Health care at the Auckland Medical School, University of Auckland, provides an academic perspective on development of, and delivery systems in, integrated care.
Professor Coster reviews the aims, advantages and disadvantages of integrated care, focussing on some specific issues related to integrated care delivered by Maori for Maori.
In an analysis of the key issues facing providers in the delivery of integrated care, Professor Coster highlights the potential risks of moves into the largely uncharted territory of integrated care, in particular the lack of experience, in contracting for integrated care and in the project management skills needed to implement the required collaboration between interdisciplinary groups are examples.
The need for new systems for information management and financial management are other challenges to integrated care organisations. The need for care with risk management is highlighted along with the need for new approaches to clinical management.
Professor Coster outlines lessons to date relating to delivery systems in integrated care, considers appropriate approaches to delivering integrated care in New Zealand, and describes two possible models for provision of total health care for a population of 50,000–80,000. He concludes that there can be no one model of integrated care; a range of models can be seen in the integrated care pilot projects, all of which involve health providers working in collaboration.
Dr Jonathan Simon, Chairperson for PrimeHealth Network Ltd in Tauranga, describes the PrimeHealth experience with the development of integrated care.
PrimeHealth Network Ltd is a multi-provider organisation which was established to develop integrated care, within the primary sector and between sectors.
Dr Simon reviews the infrastructural arrangement which has taken place in order to deliver integrated care. Key to this arrangement is the joint venture with FirstHealth, a subsidiary of Aetna Health (New Zealand) which was created to develop the management infrastructure for a New Zealand model of integrated care. FirstHealth provides the management support and manages the financial risk required while PrimeHealth manages the clinical content such that it can deliver the highest quality health care. This level of management support has allowed PrimeHealth to introduce capitation, negotiate sustainable contracts and be part of a financially viable organisation that can move to integrated care.
Dr Simon identifies two other key elements of the PrimeHealth path to integrated care: professionalism including the development of a model based on professional values, and the involvement of consumers in the development of new health structures.
Dr Simon highlights the PrimeHealth view that it is necessary to integrate funding in order to integrate services; funding integration and budgetary responsibility will enhance the capacity to align incentives and drive change.
In the second part of his paper, Simon describes the proposed PrimeHealth integrated care organisation (PHICO) which will aim to integrate services to its 80,000 registered patients. A series of integration sub-projects will take place in areas where willing partners are seen to exist within the hospital system.
Dr Simon concludes by identifying a comprehensive list of tasks which will need to be completed in order to deliver the desired outcomes for the enrolled population including management of demand, measurement of health status and health outcome, development of alternative care pathways and approaches to reconfigure the primary/secondary interface.
A contribution from Rotorua GP, Dr Harry Pert, summarises experience with integration initiatives from a GP perspective, broadly discussing issues identified and their solutions or potential solutions.
Dr Pert considers the incentives for integration and reviews an initiative in Rotorua to integrate child health services. He also highlights local IPA activities in Rotorua around integration. On a more cautionary note, Dr Pert suggests that changes in health delivery should be introduced after testing and analysis as would happen with a new therapeutic approach or pharmaceutical.
He points to the lack of strategic direction and leadership around the move to integrated care and the increasingly change weary workforce which has been exposed to numerous health systems ’solutions’ which were subsequently withdrawn.
The next edition in the integrated care series of Healthcare Review – OnlineTM will review the role that funding and development processes play in integrated care development.
Subsequent issues will consider the influence of technology on the development of integrated care.
