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Local Initiatives and Delivery Systems --- The HealthCare Otago Experience

Saturday, August 1st, 1998
Ray Anton - Strategic Policy Analyst- and Malcolm Macpherson - Communications Manager--
HealthCare Otago- Dunedin- New Zealand


 


 

Foreword

Ray Anton is Strategic Policy Analyst and Malcolm Macpherson is Communications Manager at HealthCare Otago, PO Box 1921, Dunedin, New Zealand. Telephone +64 3 474 0999.


 


 

Background

HealthCare Otago (HCO) provides secondary and tertiary health services to a population of 176,000, covering most of the province of Otago, in the South Island of New Zealand.

Currently operating five hospitals, two in Dunedin and three in rural Otago, HCO has a staff of about 2,180 full-time equivalents and annual revenues of about $180m, and performs about 7,500 main-theatre operations and 4,000 day-case procedures each year.

HCO has a strategic plan with the following purpose and goals:

Purpose
We will work to achieve the best possible health of the community.
We will do this by integrating health services in partnership with the community and other health care providers.

Goals
We will provide leadership in:
1. Improving health outcome
2. Integrating health services
3. Improving the value of our services (where value = quality/cost).

HCO’s corporate view is that to achieve the best results from the resources available, services should focus on health outcomes. This is an integral part of its purpose as well as its goals as an organisation.

HCO also recognises that providers of health services span the continuum of primary, secondary and tertiary care, including long stay and residential care, home health carers, pharmacists, physiotherapists, nurse practitioners and an expanding network of other primary care providers.


Integration of Services – Advantages
There are a significant number of advantages to be gained through integration of services. Integration better focusses service providers on patient need, improves health outcomes, and minimises confusion on how and where to access services.

In addition, integrated care reduces duplication of effort, such as duplicate diagnostic procedures, duplicate patient-information gathering and unnecessary use of expensive resources. It also minimises duplication of investment in capital and human resources.

Other advantages that integrated care offers are that it:

  • uses limited resources to provide the best service at the least cost
  • clarifies the roles and responsibilities of the various stakeholders
  • improves information sharing at the patient level, and puts available information to better use.


Integration of Services – Disadvantages
There are potential disadvantages associated with integrated care which include:

  • possible unexpected impacts on the viability of services which are clinically and/or financially marginal
  • possible need for additional resources to resolve issues of distrust, poor communication, and control and governance
  • funding not being well aligned with the strategic intentions of the integration initiative making it necessary to eliminate or work around funding arrangements that produce perverse incentives.

Health funding practices frequently do not encourage service integration.


Primary Aims of Integrated Care
HCO has identified six primary aims for integrated services to be used as guidelines when planning or establishing new integration partnerships:

  1. Services should focus on defined user needs, to improve health and independence outcomes.
  2. Services should be delivered by the most appropriate provider or partnership (building on existing provider strengths) to yield best value.
  3. Services should be based on best practice principles, using guidelines (such as care pathways) to minimise variation.
  4. Good communication is a key component of any provider partnership for the sharing of patient information, identification and reinforcement of best practice, maintaining focus on key goals.
  5. Financial and clinical risks and benefits should be shared.
  6. Individual services should be delivered where most appropriate in the care continuum.


Key Issues
Seven critical factors have been identified for successful integration.

Parties need to:

  1. Agree on the key principles outlined above.
  2. Recognise mutual interdependencies.
  3. Have a clear strategy for aligning services to the expressed needs of patients.
  4. Share the planning of service delivery.
  5. Have a clear strategy for information sharing, electronic or otherwise.
  6. Pool resources, be prepared to share financial and clinical risk, and benefit.
  7. Develop guidelines for minimising variation and clarifying referral among providing partners (deciding who is going to meet what need and how).


Culture Gap
A key aspect of integration is changing the cultures of the partners from competition to collaboration, as illustrated in the figure below. This must be done despite a funding environment that has not yet aligned the incentives for the collaborating partners.

In its integration initiatives, HCO is relying on various techniques to aid in building partnerships, taken from Continuous Quality Improvement concepts such as customer and process focus, with solutions derived from good data.

From Competition to Collaboration


 


 

Integration Initiatives at HealthCare Otago

HCO is implementing integration incrementally, in a number of service areas, using the above principles as building blocks. This approach has been adopted because it gets “some runs on the board” and starts building bridges between the key stakeholders. Examples of integration initiatives follow.


Example 1 – Diabetes Service Integration
Caring for people with diabetes involves many different health care professionals, and so such care is often fragmented and less than optimal, resulting in late detection of complications frequently at a major cost to the individual patient and to the health system.

The Otago Diabetes Team (ODT) was established to improve service delivery, reducing the onset and progression of diabetes complications through co-operation and collaboration. A multidisciplinary 13-member team comprising diabetes specialists, diabetes nurse educators, general practitioners, general practice nurses, the funding agency, Diabetes Otago (consumer advocates), Maori, and HCO management was established.

Using a facilitated, structured approach the team focussed on the common goal and theorised about all possible barriers which prevented this goal being achieved. It then conducted an in-depth survey of 500 Otago people with diabetes, and all general practitioners and practice nurses in Otago.

Different questionnaires were designed for each group and an additional clinical questionnaire was designed for the two professional groups. The response rate for all three groups was about 70%. The questionnaires confirmed that the level of knowledge about diabetes was variable and there was a desire to improve it. 12% of diabetic patient respondents identified access and affordability as a problem.

The team proceeded to identify remedies, and formed sub-committees, each charged with one of the following objectives:

  1. Conduct professional education of GPs and general practice nurses
    This group recently concluded its first three series of educational sessions, attended by 72 GPs and 77 nurses in total. The reaction was positive. A further two courses are planned for this year. This group is also charged with developing diabetes management guidelines; these will be distributed to general practices this year.
  2. Create a diabetes database
    The purpose of the diabetes database is to monitor and evaluate the ODT project. Almost all GPs in Otago have indicated that they wish to participate in the register for their patients. After obtaining patient consent the register is starting to accumulate baseline data. The data are currently being collected by a project nurse. These baseline data will be the basis of determining whether health outcomes for people with diabetes in Otago have improved as the result of this initiative. Ongoing data collections from general practice will be on an annual basis.
  3. Reconfigure specialist services
    This group has reconfigured specialist services with the aim of improving patient access and quality of care. For example, the Dunedin Hospital diabetes clinic now offers a combined diabetes and renal clinic for those diabetic patients with renal complications.

The Otago Diabetes Team is in its third year of existence and describes its experience with integration to date as successful. While implementation of the plan is going well so far, it will be some time before the impact of the project on health outcomes will be known. The funding authority has supported the team’s efforts by participating in its deliberations as well as by funding a diabetes co-ordinator for a period of three years and more recently a project nurse for two years.


Example 2 – Primary Maternity Integration
HCO’s maternity services deals with about 2,000 births every year (of which about 1,200 are normal vaginal births) at Dunedin Hospital’s Queen Mary Maternity Centre and at maternity units in rural hospitals at Oamaru, Dunstan (Central Otago) and Balclutha.

On 1 July 1996, legislative changes significantly altered the funding of maternity services in New Zealand, with revenues for tertiary (hospital) providers coming from a combination of facility fees and payments to lead maternity carers (LMCs). Tertiary providers of maternity services were expected to secure LMC revenue by competing with independent practitioners.

A partnership between the Independent Practitioners Association (IPA), Health Link South - which represents about 80 general practitioners throughout Otago - and HCO has been established in part as a mechanism to secure the revenues from about 500 of the 1,200 “normal” Otago births  2   by encouraging IPA members to refer expectant mothers to the HCO service.

The partnership was also expected to secure ultrasound, antenatal, intrapartum and postnatal care fees, as well as facility fees, and to attract some non-DRG (diagnosis related group) secondary maternity services.

The partnership arrangement provides women with a choice of total midwifery care either from HCO’s Queen Mary Maternity Centre midwives, from the maternity centres midwives sharing care with another practitioner, or from specialist obstetricians.

Benefits of integration
At least four significant benefits flow from this integration of maternity services.

Firstly, the partnership between HCO and the IPA is a model of care which satisfies HCO’s strategic intentions to seek better health outcomes through integration of services.

Secondly, the collaboration will encourage more GPs to stay in obstetric practice (the legislative changes have acted as a disincentive to GPs to continue to provide maternity care), providing better continuity of care for women and babies.

Thirdly, the accreditation of HCO’s maternity centre as a teaching facility depends on adequate access to patients for university and polytechnic teaching. Greater primary maternity numbers will improve the viability of the centre’s teaching role, and will help preserve its clinical viability as a provider of secondary services.

And lastly, administrative efficiencies are a benefit (only two forms to be completed for each patient, for example, compared with 13 under the previous arrangements), as is the greater ease of collecting data for the funder (now the Health Funding Authority (HFA)).

Twelve-month review
The original agreement between the two parties provided for a 12-month review. This review has shown that some of the expectations of the original agreement were not achieved, and the relationship will need to change through time.


Example 3 – Mental Health Service Integration
HCO is the single biggest provider of mental health services for the Otago and Southland region, receiving $22.4m in revenue for the 1997/98 year.

Being the largest provider places HCO in a unique position within any initiatives to integrate services. Smaller providers look for signals of genuine integration intentions, particularly with respect to sharing management of resources. Evidence from the USA shows that until the major player makes a tangible move to establish its bona fides, minor providers remain reluctant to participate.

More so than any other component of the health system, a mental health service is truly a community of services which need to work in collaboration with each other. In Otago alone, apart from HCO and the general practitioners, there are over 20 organisations or groups, each playing some key role in the full spectrum of care.  3  

HCO is participating in a comprehensive integration initiative in the mental health area. Central to this initiative is a proposal for partnership arrangements between HCO’s mental health clinical practice group and other service providers, to provide the full spectrum of assessment, treatment, rehabilitation and support services.

The group of people initially interested in this idea was inspired by models of integrated care networks developed in New Zealand and other countries. There seemed to be real possibilities for something similar here.
.  .  .
Over several meetings it became apparent that there were shared concerns about how the present system of mental health is working and an enthusiasm for exploring new ways of doing things. Exploring these . . . might be the province of the whole mental health network, and that’s how the workshop proposal was born.  3  


HCO has identified its key principles as:

  1. Working with all providers of mental health services in the South Island.
  2. Being part of a network that provides the full spectrum of care from early intervention, community support to tertiary inpatient services.
  3. Accepting (with its network partners) accountability for improving health outcomes for the population, as both funders and providers of mental health services.
  4. Partnerships, and any other formal provider networks, will deliver only mental health services.


The first three reflect HCO’s strategic intentions. The last is to ensure there is no diffusion of focus and that mental health funds are ring-fenced – identified as an issue in the Mason report on mental health.

Working papers shared among early participants itemised the essential features of the integrated network:

  • it would be consumer focussed and consumer outcome oriented
  • it would include the full spectrum of care including health promotion
  • all stakeholders in the community would be involved
  • the leadership philosophy would be collaborative rather than competitive
  • the network would have both funder and provider functions
  • the network would recognise the value of non-clinical groups in the delivery of care.


The key ingredients of a collaborative relationship were also identified as:

  • acceptance of mutual interdependence
  • sharing of information
  • a common “language”
  • shared vision in the joint planning of services
  • sharing of responsibility
  • sharing of rewards and alignment of incentives to promote collaboration
  • effective methods for negotiation and conflict resolution.


The benefits of integration were seen as improved health outcomes (through an increased ability to do the right thing in the right way at the right time), more efficient use of resources, organisational strength through interdependence, and increased potential for responsiveness and for the development of new initiatives.

Service values identified in the working papers, and subsequently approved by participants as the values against which any proposed projects must be measured, included: consumer-focus, based on the need of the service users rather than of the service providers; co-ordination and integration at all levels to ensure the highest possible degree of continuity of care; sensitivity to changing needs; cost-effective outcomes.

Other service values included comprehensiveness and flexibility, so as to meet the wide range of frequently fluctuating needs of service users, and prioritisation, so as to give particular attention to the special needs of those with a serious or chronic disabling mental disorder.

The working party considered that services should be local, accessible and, to the greatest possible extent, delivered in the least restrictive environment. They should promote early intervention in order to reduce avoidable distress, minimise use of acute services and prevent long-term disability; promote partnership and participation of consumers, their families/whanau and support people, and service providers in working together towards common goals; and support the role of consumer and family groups.

It was also the working party’s view that services should: cause minimal disruption to the lives of consumers by fostering independence and enabling them to retain the fullest possible control over their lives; focus on the strengths of consumers to help them maintain a sense of identity, dignity and self-worth; be ethically and culturally appropriate; provide a balance between the individual rights of consumers to privacy and treatment in the least restrictive environment with wider community concerns for the proper management of high-risk disorders; be accountable to consumers, their families/whanau, personal networks and the wider community to ensure the continuing appropriateness, acceptability and effectiveness of services within available resources.

Integration processes
It was recognised early in the evolution of this initiative that “getting some runs on the board” was important – that making a start, even a quite modest start, would be critical to its development. Individual participants were encouraged to explore potential projects, and begin active collaboration.

A number of joint projects were identified and a process of joint project endorsement was established, the benefits of which were seen as the promotion of a focus on the vision and values of integrated care, the support of key stakeholders, and the sharing of advice, support and the assistance of others in the network. Collective “ownership” of the benefits, problems and risks and the establishment of benchmarks, standards, and best practice models were also recognised as benefits.

The criteria developed for project endorsement were:
  1. Groups working together in new ways to deliver better health outcomes.
  2. Demonstrable improvements in service against at least two of the key values.
  3. None of the network’s core values were compromised.
  4. Projects involve collaboration between two or more different organisations/groups in the sector and one of these must be a consumer group.
  5. Projects are clearly described, with specific, measurable outcomes.
  6. Projects are achievable within available resources and estimated time frames.
  7. Where cost savings are an expected result, the project clearly identifies how these will be reinvested to benefit health outcomes in accordance with two or more of the integrated mental health care values.
  8. Any new services to be established as a result of a project will be based on evidence of best practice.


Function before structure
In a “work in progress” presentation to a mental health conference, HCO’s General Manager for Mental Health, Susan Law, noted that trying to establish a structure before there is any active collaboration is likely to inhibit progress and to work against the interests of the initiative by focussing attention on territorial and sovereignty issues.  4  

A more productive approach, supported by HCO’s recent experience, is to establish a clear vision, work to ensure that the core interest group shares that vision, and establish a set of values that the whole network can and will adopt as guiding principles.

The next steps include forming project groups, evaluating projects against core values, working together to share learning, and constant reporting back to the wider workshop. Gaining support across the service and within the wider lay community is also an essential building block. Only when those elements are in place should a start be made on formalising the management and governance frameworks.

Then, with some real experience, growing confidence and a formal structure to cement-in operational confidence, the early projects can be extended to become the core of service provision, and an integrated service can become “the way it’s done here”.


 


 

Summary and Conclusions

HCO’s experience with integration has been positive. In the absence of a structured funding approach for integration, the incremental approach has borne fruit in improved clinician communication and improved health outcomes. Specific integration initiatives are very much “works in progress”, however, as the Crown Health Enterprise (CHE) learns how to set up, structure, monitor and evaluate integration programmes. Early results are encouraging, and reinforce the commitment of senior management as expressed in the CHE’s strategic documents.


 


 

Acknowledgements

Peter Bradshaw, Dr Patrick Manning, Ants Howie and Beverly Henderson made significant contributions to this paper.


 


 

References

  1. Silvestri F. Presentation at HealthCare Otago. Dunedin; 1997.
  2. Williams H, Ramsay H. Proposed joint IPA/CHE maternity consorium. Memo to the board of directors, HealthCare Otago. Dunedin; 1997.
  3. Allan C. A background to the workshop. Paper prepared for a workshop for Otago Providers of Mental Health Care on mental health integration, held in Dunedin, New Zealand. Dunedin; 1997.
  4. Law S. HealthCare Otago’s experience reconfiguring a mental health service – a rough and rocky journey towards real community involvement in the provision of mental health services. Presentation to an NZIHM conference on Integrated Care in New Zealand Health. Dunedin; 1998.


 

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