Maori Integrated Care Initiatives

• What is Integrated Care?
• Why Integrate Care?
• Delegated Purchasing
• The Health Sector Environment and "Integrated Care"
• Examples of Developments of Maori Integrated Care Initiatives
• The Crown Objective for Maori Health
• Policy for Maori Health – Whaia te Ora mo te Iwi (Strive for the Good Health of the People)
• HFA Treaty of Waitangi Policy Development
• A Proposed Framework
• Maori Aspirations for Integrated Care
  • A Maori Viewpoint of Integrated Care – Broader than Just Health
• Criteria for Integrated Care Initiatives
• References

What is Integrated Care?

For the purposes of this paper, integrated care is defined simply as:

A model of healthcare where a defined range of services is provided to a defined population within a defined budget.  ¹  

Integrated care can refer to the co-ordination of primary and secondary services; it can mean placing the responsibility for provision of several services with a single agency; or placing the responsibility for provision of services with many agencies to co-ordinate their decisions. There are certain key features common to all integrated care models. These are:   ¹  

• improved communication between providers
• easier access to treatment for consumers
• clearer flows of information
• clearer accountability for service quality and health outcomes
• a key person organising care
• more convenience for consumers
• more co-ordinated clinical and financial management.

An integrated care model may or may not involve the financial management of services. It may simply involve a group of providers with common service interests or common clients coming together and better co-ordinating their services OR it may extend to an agency holding the funds for a very wide range of services for a defined geographical area and funding co-ordinated services (such as a Health Funding Authority (HFA) regional office). An integrated model may involve providers of one service, or providers of many services. In its broadest sense, it may even involve integration of non-health services to integrate wider social services for the benefit of consumers.

Thus, there can be many forms of integrated care depending on the motives and desires of providers and funders, and the needs of consumers. In New Zealand, it is apparent that many forms of integration already exist but it is also clear that many providers and other organisations are still contemplating how they might participate in integrated care models.

The most important thing to realise is that integrated care means changing the way that patient care is delivered. This mere fact of change is fundamental to Maori aspirations as it is clear from Maori mortality and morbidity statistics alone, that the current methods of Maori patient care are not working for Maori.

Why Integrate Care?

One of best ways to improve service delivery to consumers is by New Zealand providers working more closely together to align their services, making the services easier for consumers to use and access. If services are working well, it is possible for illness to be prevented in many cases, thus making savings which can be reallocated to more preventative health care. Integrated Care Organisations (ICOs) can place more focus on wellness rather than illness through co-ordinated strategies, closing gaps in services, reduction of duplications, better provision of and quality of information to consumers, and better referral practices between providers.

For Maori providers, the goal is to reverse the trend of increasing numbers of Maori entering hospital for complex illnesses, by focussing more on whanau health education and early treatment. Hospitalisation incurs high costs and uses a lot of the health resource; if hospitalisations can be reduced, freed resources can be used for education and preventative health care.

Delegated Purchasing

One way of integrating care is delegating the decision-making role from the HFA to providers or ICOs who know more about effectiveness of services “on the ground” and what their local community’s and consumers’ needs are. Such decision-making would involve a provider prioritising and making planning decisions based on what they think is important and where funding should be targeted.

These organisations, both providers and ICOs, can also focus on achieving health outcomes for their populations, rather than health outputs. The HFA would measure improvements (or declines) in health status across the community rather than how many interventions, consultations or programmes were provided by individual providers.

Iwi and Maori health care organisations are particularly interested in the ability to be delegated purchasers , a role which would allow them to plan services and make decisions about what their Maori community health needs are. This approach aligns with increasing Maori participation in decision-making about their health needs and where health resources should be used.

The Health Sector Environment and "Integrated Care"

Since the 1993 health reforms, there have been many forms of integrated care (although they may not have been labelled as such) but these developments have occurred primarily in the mainstream provider sector (rather than the Maori provider sector).

Examples include:

• the maternity services model in the Wellington region
• Independent Practitioner Association (IPA) budget-holding for GMS, pharmaceuticals and laboratory to integrate the provision of these three services
• alcohol and drug (A&D) services (former Central region of the HFA) where A&D residential providers allocate limited residential funding and use savings to put into other A&D services. This is integration across a spectrum of A&D services
• the Facilitated Access to Co-ordinated Services (FACS) service which manages the budget for disability clients, determines eligibility, conducts needs assessment and pays providers to provide allocated hours of care. This integrates care across needs and co-ordinated service provision.

There are many other examples across New Zealand and, whilst savings have been made in some areas, there is yet to be a full evaluation of the effectiveness of some of these models in terms of improved quality of care, co-ordination of provider services and consumer satisfaction. For this reason, the HFA is testing several demonstration models of integrated care initiatives from 1998, in order to evaluate the effectiveness of such initiatives.

While these types of funding arrangements have been made in recent years, there has been a parallel development of new Maori providers the health sector. Many of these providers are iwi (tribally) based but many are pan-tribal organisations (eg, the Maori Women’s Welfare league) or are independent trusts and societies. As the number of these organisations has grown to around 240 nationally, there has been an increasing need to encourage the integration of these providers and services in order to provide a more seamless range of care for Maori. Many Maori providers have increasingly wished to work more closely together, to network and share experiences and to collaborate in the interests of providing a more seamless range of services. This trend will give rise to greater opportunities for formal and informal integration with mainstream services.

On the other hand, many Maori providers have become frustrated with the decision-making process about where funds are allocated (ie, that not enough funds are allocated to Maori health thus impeding their growth potential). They have also become increasingly anxious about the growing number of mainstream fund-holding arrangements and the likely detrimental impact these will have on Maori providers’ ability to attract more funding for future growth.

Some iwi can see themselves becoming delegated purchasers, having the responsibility of managing resources, planning services, and making decisions about what services are funded and the quality of care provided for their own people.

These issues have led Maori health care organisations to take a more proactive interest in integrated care as a more formal model and, in the last 12–18 months, many organisations have grasped the idea of integrated care and made significant steps towards making it a reality.

Examples of Developments of Maori Integrated Care Initiatives

The following are examples of growing initiatives in New Zealand.