Models of Integrated Care in New Zealand-The PrimeHealth - FirstHealth Model --- Professional- Community and Management Support Organisation

• Introduction

• PrimeHealth – Mission and Values
• PrimeHealth’s Path to Integrated Care
  • Professionalism
  • The Management of Clinical Outcomes
  • Consumer Input
  • The Management Support Organisation
• The Joint Venture with First Health

• Integrated Care
• The PrimeHealth ICO (PHICO) Proposal
  • Introduction
  • Issues for PHICO
• References

Introduction

PrimeHealth Network Limited was formed in 1993 to develop integrated care - care integrated both within the primary sector and between the sectors. The Network includes 60 GPs, 60 practice nurses and around 60 receptionists, practice managers etc. The company operates in the Western Bay of Plenty in New Zealand, an area with a population of 120,000, 80,000 of whom are enrolled with PrimeHealth practices.

The PrimeHealth model is unique in New Zealand and as such tends to be misunderstood. However, as time passes, the assumptions that underlie the structures of PrimeHealth have been vindicated.

PrimeHealth is a professionally driven, evidence-based organisation that has chosen to use a culture of continuous improvement to drive change. PrimeHealth was established in order to develop a platform from which integrated care could be generated. The first part of this article looks at the three components that PrimeHealth has developed for the primary care organisation. This introduction sets the scene for the detailed discussion in of the proposed PrimeHealth model for integrated care.

The evidence for health care reform had been available to the medical profession for 30 years prior to the New Zealand reforms.   ^{1  ,   2  ,   3}   The problem was that the medical profession did not take a lead in implementing reform, rather it waited to have reform legislated by government.

There are many currents of change affecting the health sector in developed countries all over the world. The major themes of change are:  ^{4  ,   5}  

• Continuous Quality Improvement
• Accountability
• Equity
• Increased importance of consumers and their effect on health service delivery
• The development of the multi-disciplinary primary care team for shared care  ⁶  
• The information/communications revolution, the electronic medical record  ⁷  
• The development of the concept of responsibility for population at risk as well as the individual contact for delivering personal health care
• The development of constructive relationships with management
• Defining the practice population and obtaining the denominator for measurement of practice activities
• Becoming more flexible in the way health services are delivered, particularly to address the poor health outcomes for Maori and other minority groups in society
• To move from a “sickness” model of health care to a “wellness” based model  ^{8  ,   9}  
• Measurement and evaluation  ¹⁰  
• To move towards the Charter of Ottawa, Healthy Cities and community development.

PrimeHealth – The First Six Years

PrimeHealth Mission and Values

The idea of movement towards a wellness model of health care was well articulated by Vuori in 1984.  ⁹   PrimeHealth is moving along this path to changing the professional model. This is reflected in PrimeHealth’s structures and achievements.

PrimeHealth has managed to move forward on all these fronts since the beginning of the pilot in 1992. PrimeHealth has made coherent progress because it was founded using clear values that inform all decisions and guide its strategy. There is also a mission statement that is used as a guide to policy implementation.

The values that inform the PrimeHealth structures and direction were chosen in 1992 and were designed to be robust enough to survive radical changes in the political environment. They are:

QUALITY
EQUITY
ACCOUNTABILITY

PrimeHealth’s mission statement, also written in 1992, is:

“To provide comprehensive, high quality health care to a registered population, delivered by a team of professionals in a way that respects patient choice, autonomy and cultural dimensions.”

PrimeHealth’s Path to Integrated Care

PrimeHealth’s path to integrated care, involves three key elements:

• Professionalism and the development of a model based on professional values
• Consumer Input and the development of multiple consumer interfaces with PrimeHealth
• Management Support Organisation and the development of a strategic relationship with FirstHealth to provide high quality management support.

Professionalism
The PrimeHealth Network mission statement clearly signalled the intended direction as far back as 1992. The intent in the values and mission statement can now be measured against actual achievements made since PrimeHealth Limited started contracting in 1994.

The following grid demonstrates this progress.

Values and Mission Measured Against Achievements for PrimeHealth
To provide comprehensive	The intention from the beginning was to integrate health services within the primary sector and then across the primary/secondary interface with an Integrated Care Organisation (ICO). There is a proposal for such an organisation developed and being negotiated.
High quality care	Appointed a Quality facilitator (the first appointment). Developed and implemented three Annual Quality Improvement Plans. Developed an Annual Practice Report for measuring quality improvement. Undertaken an Annual Quality Workshop. Used an educational model for improving prescribing and laboratory utilisation in PrimeHealth, using peer review groups and a pharmacy facilitator. Developed best practice prescribing guidelines. Appointed a Diabetes Nurse Educator. Appointed a Special Projects Manager to ensure Maori input to all projects.
To a registered population	Capitation was chosen to: Define the denominator Encourage delegation to practice nurses  11  ,   12  ,   13  ,   14   As a signal that PrimeHealth take responsibility for a population at risk as well as the presenting client  15   To allow measurement of prevalence and incidence rates of diseases in the PrimeHealth population. Capitation has been implemented since 1994. PrimeHealth is in a position to implement the Population Based Funding formula.  16  .
By a team of professionals	Practice nurses as directors of Network company. Appointment of practice nurse development officer. Managers and receptionists included in all team activities. Practice development programme designed for all practice members. Consumers form part of practice team and there are many consumer initiatives to include the consumer voice: Trust for community development Consumer director of Network Collaboration with Diabetes Society and Asthma Foundation Work with Hillary Commission.
In a way that respects patients’ choice	PrimeHealth is not a monopoly provider in the Western Bay of Plenty. There is choice of another IPA and also some unaligned GPs.
Autonomy	PrimeHealth encourages consumer input and community involvement. PrimeHealth focusses on patient-centred consultation.  17
And cultural values	The PrimeHealth Network name was translated into Maori with the assistance of the local tangata whenua. PrimeHealth has appointed a full time Special Projects Manager to ensure that all projects and policies are bicultural. The Manager assists in ensuring that practices are delivering culturally appropriate services. The Special Projects Manager is Director of the PrimeHealth Network Limited.

The Management of Clinical Outcomes
In the PrimeHealth model, the management of clinical inputs, processes and outcomes is clearly identified as the responsibility of the clinicians.

A Clinical Policy Committee (CPC) is constituted as a sub-committee of the PrimeHealth Limited Board. This committee, made up of local general practitioners and practice nurses, oversees all matters of clinical importance, ie:

• Quality
• Communication, information
• Guidelines, disease management, outcomes
• Nursing
• Child Health and Women’s Health
• Ethical issues, medico-legal issues, privacy, Health & Disability Commissioner, mentoring
• Professional issues, ie, RNZCGP, NZNO
• Pharmacy and laboratory quality management
• Issues from Network and/or PrimeHealth boards
• Integrated care issues
• Maori Health issues.

The different members each hold portfolios and give support to staff at the PrimeHealth office:

Portfolio of CPC Member	Support Personnel
Quality	Quality Services Manager.
Pharmacy & Laboratory	Pharmacy Facilitator.
Ethical issues	Clinical Directorate.
Professional issues	RNZCGP, IPA Network, NZNO.
Nursing	Practice Nurse Development Officer. Child Health Development Officer.
Communication, information	FirstHealth information team.
Women’s and Child Health	Child Health Development Officer.
Guidelines, disease management, outcomes	Clinical Directorate.
Legal issues	PrimeHealth legal adviser or FirstHealth corporate counsel.
Board issues, integrated care, Maori Health issues	Boards of Network and PrimeHealth. FirstHealth Clinical Directorate and management support. Special Projects Manager.

Members of the committee are also involved with their secondary care colleagues in the local hospital. The CPC maintains linkages with a number of professional bodies, for example, the RNZCGP, NZNO and the National IPA Network.

The clinical/professional part of the partnership is critical both to successful innovation and to maintaining clinical governance  ¹⁸   at the level of the Network.

The CPC is supported by the PrimeHealth office staff and by the FirstHealth Clinical Directorate which will assist and support the development of new initiatives for the Network.

The CPC helps develop and implement the Annual Quality Plan and has an overview role in ensuring that the Network meets its goals. It will play a central role in the development of the ICO.

Consumer Input
Following a model based on continuously improving quality demands that the consumers of health care, the patients, are involved in the development of new health structures. This has been integral to PrimeHealth processes from the beginning.

A number of communities in the Western Bay of Plenty were identified. Ways were examined to inform them of PrimeHealth’s presence, values and purpose.

Issue	Community Groups Involved
Steering Group for Tauranga Primary Care Network 1992/3	Community Representative.
Tauranga Primary Care Network: Management Committee 1993	Community Representative.
PrimeHealth Network Ltd Board of Directors 1993–present	Community Director.
PrimeHealth Ltd Board of Directors 1994–present	Community Director, from Network company.
Maori consultation 1992–present	Iwi, Joint venture, Te Tatau Pounamu, Poutiri MISO (Maori Integrated Service Organisation). Te Puna Hauora at Western Bay Health. Many PrimeHealth GPs have been involved in marae-based clinics. Iwi representation on Board of the Trustees for Community Development. Special Projects Manager: full time at PrimeHealth offices. Practice Development Programme includes maoritanga section.
Team development 1998	Practice Development Programme which includes one diploma that aims to improve the quality of patient-focussed service delivery.
Annual Patient Satisfaction Survey 1997/8	Second annual survey to assess performance of practice and practice staff.
Annual Diabetic Survey 1996/7/8	Third annual survey of known diabetics to assess quality of care and satisfaction with services.
Asthma education 1997	PrimeHealth has worked with the local asthma society and has made their education programme available to practice nurses.
Annual Practice Report 1998	PrimeHealth has developed an Annual Practice Report to be the base document for measuring practice performance and to give general practices a useful quality improvement tool.
Publishing Quality outputs in local paper 1998	PrimeHealth has taken two full-page advertisements in the local paper to report performance.
Open Day 1998	PrimeHealth has held an open day for local community groups and politicians.
Advertisements/Radio	The PrimeHealth marketing committee oversees the budget and co-ordinates the promotion of knowledge about PrimeHealth.
PrimeHealth Trust for Community Development 1995–present	Intersectoral trust looking at investing resource in the community using a model of community development based on the Treaty of Waitangi and the Ottawa Charter.  19   Appointors to the Trust:  20   Tauranga District Council. Western Bay of Plenty District Council. COVIT (Council of Volunteers in Tauranga). TCAC (Tauranga Community Arts Council). The three Iwi of Tauranga Moana. PrimeHealth Ltd. The trust is looking to set up an intersectoral committee for health communities and schools and to support the government’s “Strengthening Families’ policy by working locally on intergenerational issues. PrimeHealth has provided funding to the Trust, obtained from budget-holding savings, to lead projects that will enhance the health and well-being of the community.
Public talks 1992–present	PrimeHealth is committed to informing the community about activities and has spoken to large numbers of groups in the town and surrounding areas including: Rotary. Probus. Grey Power. Tauranga Council for Social Services. Lions. Businesswomen’s Group. Chamber of Commerce. ZONTA. Local Council.

The Management Support Organisation

PrimeHealth began as one of 10 pilot projects funded by the Government in 1992-3 as part of an initiative in purchasing primary care. At the end of the pilot in 1993, it was clear that this group, then comprising 45 general practitioners, was not going to develop a New Zealand system of integrated health care based on the primary sector. Skills were significantly lacking in:

1. How to manage integrated care;
2. How to develop the information systems for integrated care;
3. How to handle population risk.

Aetna Health (New Zealand) had some of the skills and access to others through its association with Aetna International. Therefore in 1994, a 50:50 joint venture between PrimeHealth Network Ltd (the local multi-provider organisation) and FirstHealth (a fully owned subsidiary of Aetna Health (NZ)) was created to develop the management infrastructure for a New Zealand model of integrated care.

FirstHealth is responsible for provision of high quality management, leaving the providers to deliver the highest quality health care.

FirstHealth delivers the following services to the Network:

• Management support services
• Contract negotiation and maintenance
• Quality framework
• Outcomes management
• Information framework
• Communications framework
• Treasury
• Clinical Directorate support
• Business analysis and business plan development
• Marketing expertise
• Commercial support
• Access to world’s best practice in evidence-based medicine
• Financial risk management.

As a result of the management support relationship, PrimeHealth has managed to negotiate sustainable contracts for capitation of GMS and practice nurse subsidy; pharmaceutical budget management (with risk); a Diabetic Nurse Educator; and a Child Health Nurse. PrimeHealth has managed to introduce capitation, sustainable contracts and be part of a financially viable organisation that can move to integrated care.

The aim was to develop a transportable system that other groupings could use. There are now four networks in the Midland area and four networks being developed in the Northern region.

PrimeHealth has an evenly balanced structure, The Network manages the clinical content and the Management company manages the financial risk.

The Joint Venture with FirstHealth

This organisational structure illustrates the three key components discussed: professionalism; consumer input, and management support organisation.

Integrated Care – Future Developments

Having dealt with the implementation over the first six years, the balance of this paper discusses the purpose of this infrastructural development – integrated care.

Integrated Care

“The main goal of funding a health care system is to improve the health status of the population in a way and at a level appropriate to that country.”  ²¹  

The purpose of integrated care is to unite the various health care providers with a common vision to improve the health status of and health outcomes for their patients and local population with due regard for their use of scarce resources. In short, models of integrated care must combine the pursuit of the best possible outcomes within the constraints of finite resources. This will be best achieved when the funders of health care work closely with the providers of health care and their communities. PrimeHealth believes that this approach will demonstrate the need to integrate funding in order to integrate the services. Integration of funding is a very powerful argument to assist change management.

At PrimeHealth, it is also believed that intersectoral guidelines will best be developed and implemented in a framework of integrated funding and service delivery, which will in turn lead to better health outcomes. Budgetary responsibility will enhance capacity to align incentives and improve service quality.

The PrimeHealth ICO (PHICO) Proposal
 

Introduction
The structure of the PrimeHealth ICO will look like the current joint venture and will seek to integrate the services to its 80,000 registered patients. A series of integration sub-projects will start within areas identified as having willing partners within the hospital system.

Information, communication and quality systems will be built around these activities.

The data sets collected will fit into a data model that has the capacity to measure some outcomes,  ²²   track disease management programmes, and predict utilisation costs. Thus a core data set will be used to maximise both clinical and financial outcomes.

PHICO will be in a position to purchase services from other hospitals, pharmacies, general practitioners, physiotherapists and specialists. Flexible purchasing will be able to drive efficiencies in the sector and also drive change in a measured way.

PHICO will be able to relate to other funders both in the private and public sector. Most importantly, PHICO will have the capacity to work closely with newly formed Maori purchasers to assist in improving health outcomes for Maori.

PHICO will have the responsibility for funding access to services for the enrolled population. It will need to establish a common vision for local providers and to align incentives to produce a cohesive, patient-centred health service.

A model based on local solutions to local problems is likely to be more successful than a distant bureaucracy.

Issues for PHICO
PHICO will be a change agency that will need to develop effective relationships with professional groups and the local community. A number of tasks must be accomplished in order to deliver better outcomes for the local population in both clinical and financial terms:

1. Improved communications between providers
2. Agreed data sets and open systems architecture for information systems
3. Common coding systems (or systems that can be cross mapped)
4. Performance measures for health professionals  ²³   and their organisations
5. Measures of health status
6. Measures of health outcomes
7. Measures indicating health gain
8. Management of demand in the primary sector
9. Management of demand in the secondary sector  ^{24  ,   25  ,   26  ,   27}  
10. Developing alternative care pathways
11. Developing case management and service co-ordination capacity  ²⁸  
12. Re-configuring the nature of the primary/secondary interface
13. Moving away from proceduralism
14. Development of integrated health care management teams for specific conditions
15. Improved accountability and involvement of the community.

The PrimeHealth ICO is looking at all these aspects of a changed health sector and looks forward to making progress as it develops its model of integrated care in New Zealand.

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