southern primary & community care strategy...we will work with our communities and other...

SouthernPrimary&CommunityCareStrategy

Mihi

Karangaaturākingātangataotetaitonga;Neirāmātou,emihikauanakiākoutoutīpunakuaweheatu

kituaoPaerau.Tēnākoutoukatoa!

_______________________________

Wecalltoyou,thepeopleofthesouth;Wegreetandacknowledgeallofourancestorswhohave

passedbeyondtheveil.Greetingstoyouall!

3

Contents

► Overview 4

► Introduction 8

► Strategy 14

► Goal1– Consumers,whānauandcommunitiesareempoweredtodriveandowntheircare 16

► Goal2– Primaryandcommunitycareworksinpartnershiptoprovideholistic,team-basedcare 17

► Goal3– Secondaryandtertiarycareisintegratedintoprimaryandcommunitycaremodels 18

► Goal4– Thehealthsystemistechnologyenabled 19

► TransformingprimaryandcommunitycareforMāori 22

► Transformingprimaryandcommunitycareinruralcommunities 23

► ExecutingtheStrategy 25

► Appendix– PlanningFramework 27

4

Overview

5

Tēnākoutoukatoa,

WearepleasedtopresenttheSouthernPrimaryandCommunityCareStrategy,whichdescribesourvisionforprimaryandcommunitycareintheSouthernhealthsystem.Thisvisioncentresaroundourconsumers,theirwhānauandcommunities,andtheroletheSouthernhealthsystemneedstoplay in caringforandempoweringthemtolivewell,staywell,getwellanddiewell.Itreflectsthecallfromourcommunitiesforbetterintegratedservices,andfromourworkforcetostrengthenthecapacityandcapabilityofprimaryandcommunitycaretocontributetothewiderSouthernhealthsystem.

GiventhechallengesfacingtheSouthernhealthsystem,andthegenerationalopportunitythattherebuildofDunedinHospital presents,wehavedevelopedaboldandaspirationalPrimaryandCommunityCareStrategy.Fundamentally,wewanttofocusprimaryandcommunityservicesonfosteringwellness,reducinghealthinequities(particularlyforMāori),andprovidingtimely,holisticcareclosetopeople’shomes.Ouraspirationisthatconsumerswillexperienceprimaryandcommunitycarethatismoreresponsivetotheirneeds,isdeliveredbypractitionerswhoworkinpartnershipwiththem,andwhointurnarebettersupportedbyourhospitalservices.TodevelopaStrategythatreflectsthisaspiration,wehavebeenguidedbyfivequestions:

1. Whatcanconsumers,whānauandcommunitiesachieveforthemselves?

2. Whatcantechnologyhelpconsumersandtheworkforcetodomoreeffectively?

3. Howcancarebeprovidedclosertohome?

4. Howcanwedevelopamoreintegratedsystemofcareforourpopulation?

5. Howcanwedevelopthecultureandleadershipneededtodeliveronthisvision?

Thesequestionsareimportant,becausewerecognisethatfortoolongwehavetakenthecapabilitiesofourpopulation,whānau,andprimaryandcommunityservicesforgranted,andhavenotconsistentlyprioritisedinvestmentsandotheractionsthatcouldmostcost-effectivelyimproveaccessandoutcomes.

ThisStrategyhasbeendevelopedjointlybySouthernDistrictHealthBoardandWellSouthPrimaryHealthNetwork,withsupport fromtheUniversityofOtago,reflectingourcommitmenttoworkingtogethertoimprovethecontributionofprimaryandcommunitycaretothewiderSouthernhealthsystem.Itrecognisesourhistory,andthechallengeswefaceinrespondingtothechangingneedsofourcommunities,theincreasingpressuresonourhealthworkforce,andourresponsibilitytoprovideequitableaccesstoservicesacrossourlargeanddiversedistrict.

OurabilitytoimplementtheactionsunderpinningthisStrategywilldependonwhetherweareboldenoughandpreparedtomaketoughprioritisationdecisions.Wewillworkwithourcommunitiesandotherstakeholderstomaketheseprioritisationdecisions,whichwillrequireallofusto challengeourattitudes,beliefsandwaysofworking.WearecommittedtodoingourpartinchanginghowweoperateasleadersoftheSouthernhealthsystem,andlookforwardtoworkingwithyoutomakeapositivedifferencetoprimaryandcommunityservicesthatwecanallbeproudof.Mauriora!

Foreword

ChrisFlemingChiefExecutiveSouthernDHB

KathyGrantCommissionerSouthernDHB

Dr.DouglasHillChairWellSouthPHN

IanMacaraChiefExecutiveWellSouthPHN

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TheSouthernPrimary&CommunityCareStrategyandActionPlan

WHY?

WHAT?

HOW?

NewZealandHealthStrategyAllNewZealanderslivewell,staywell,getwell

SouthIslandRegionStrategicDirectionAsustainableSouthIslandhealth&disabilitysystem,focusedonkeepingpeoplewellandprovidingequitableandtimelyaccesstosafe,

effective,highqualityservices,asclosetopeople’shomesaspossible

SouthernWayVisionBetterhealth,betterlives,WhānauOra

VisionforSouthernprimary&communitycareExcellentprimaryandcommunitycarethatempowerspeopleinourdiversecommunitiestolivewell,staywell,getwellanddiewell,through

integratedwaysofworking,rapidlearningandeffectiveuseoftechnology

Goal1.Consumers,whānauand

communitiesareempoweredtodriveandowntheircare

Goal2.Primaryandcommunitycare

worksinpartnershiptoprovideholistic,team-basedcare

Goal3.Secondaryandtertiarycareisintegratedintoprimaryandcommunitycaremodels

Goal4.Thehealthsystemistechnology-enabled

Empowerconsumers,whānauandcommunitiestoself-care

Develophealthcarehomes(HCHs)toenhanceaccesstoprimarycare

Createlocalitynetworkstobettercoordinatecare

Demonstration Communicationsandengagement Providersupport

Strengthenedgovernanceandleadership

Whole-systemhealthandbusinessintelligence

Buildingworkforcecapabilityandculture

Integratedtechnologysolutionsandcost-effectiveuseofcaretechnologies

Results-focusedfundingandcontracting

Caremodels

Supportinginfrastructure

Supportingadoption

HeKorowaiOrangaHealthyfuturesforMāori,‘PaeOra’

7

TableofkeydefinitionsTerm Definition

Primarycare Primarycarerelatestotheprofessionalhealthcareprovidedinthecommunity,usuallyfromageneralpractitioner(GP),practicenurse,pharmacistorotherhealthprofessionalworkingwithinageneralpractice

Communitycare Wide-rangingcareprovidedinacommunitysetting,fromsupportingconsumerstomanagelong-termconditions,totreatingthosewhoareseriouslyillwithcomplexconditions,muchofwhichtakesplaceinpeople’shomes

Secondarycare Careprovidedbyaspecialistorfacilityonreferralfromprimary care(usuallybyaGP),requiringmorespecialisedknowledge, skills,orequipmentthancanbeprovidedinprimarycare.Thiscanbeprovidedeitherbyvisiting specialists,orinDunedin,Invercargill,orsomeruralhospitalsintheSoutherndistrict

Tertiarycare Specialised care(investigationandtreatment)usuallyprovidedonreferralfromcliniciansinprimaryorsecondarycare byvisitingspecialists,orinDunedinHospital (withsomeservicesprovidedoutsidethedistricte.g.,highlyspecialisedpaediatriccareatStarshipHospitalinAuckland)

Multi-disciplinary Ateamcomprisedofpeoplefromacrossdisciplineswithinthehealthsector,supportingthedeliveryofholistichealthcare.Thiscouldinclude,forexample,GPs,PNs,DNs,pharmacists,healthcareassistants,alliedhealthandotherrelevantrepresentatives

Inter-disciplinary Ateamcomprised ofpeoplefromthehealthandsocialsector,supportingthedeliveryofholistichealthandsocialcare.Thiscouldinclude,forexample,multi-disciplinaryteams,plusrepresentativesfromMSD,Corrections,Housing,MinistryforVulnerableChildren,OrangaTamariki andotheragencies

Carecoordination Supportingthecoordinateddeliveryofconsumer/whānaucare,either withinoracrossproviders.ACareCoordinationCentre(CCC)willsupportthisfunctionacrossprimary,community,secondaryandtertiarycareintheSoutherndistrict

Stepped care Acaremodelapproachthatsegments populationsintoincreasinglevelsofhealth(andsocial)need,withdefinedcareresponsesmatchedtopopulationsegments.Thehigherthelevelofneed,themoreintensethecareresponse.

HealthCareHome(HCH) Ateam-basedmodelofcareby primarycarewithstrongstrategicandoperationalrelationshipswithcommunity,hospitalandspecialistservices,withtheintenttoprovidetherightlevelofproactive,comprehensiveandcontinuoushealthcaretopatients

Localitynetwork The strategicandoperationalnetworkofprovidersandservicesrequiredtoprovidetimely,responsivecaretodefinedpopulationsbasedonanagreedminimumlevelofcare,withsomelocalvariationforparticularhealthneedsandservicecontexts

Communitycarehub Thepotentialphysicalinfrastructure requiredtoenableintegratedwaysofworkingwithinlocalitynetworks,withmodificationofthescaleandscopeofthehubdeterminedbypopulationsizeandexistinginfrastructure

8

Introduction

9

DevelopmentoftheSouthernPrimary&CommunityCareStrategyandaccompanyingActionPlanhasbeenledbytheSouthernDistrictHealthBoard(DHB)andWellSouthPrimaryHealthNetwork(PHN),withsupportfromtheUniversityofOtago,reflectingeachorganisation’scriticalroleinshapinghealthcareintheSouthernhealthsystem,commitmenttocollaboration,anduniqueteachingandlearningenvironment.BothorganisationshaverecognisedtheDunedinHospitalrebuildasagenerationalopportunitytoredistributeinvestmentacrossthesystem,anddothingsdifferentlyinprimaryandcommunitycare- deliveringabroaderrangeofservicesthroughapproachesandsettingsthatareeffectiveandconvenientforconsumersandwhānau,andfosterprofessionalsatisfaction.

DevelopmentofthisStrategyhasrequiredadifferentwayofthinkingandactivelyengagingwithconsumers,whānau,iwi,tertiaryproviders,andrepresentativesfromacrossprimary,communityandsecondarycare.Thisapproachwillbemaintainedthroughimplementation,andextendedtoincludeengagementwithsocialandprivatesectors.

TheStrategyisalignedwiththegovernment’sprioritiesandpolicies,includingtheNewZealandHealthStrategyandHeKorowaiOranga.IthasbeendevelopedtoaddresstheuniqueneedsandcircumstancesofthediverseSoutherndistrict,NewZealand’slargestDHBarea,andwithover40%ofitspopulationlivingrurally.TheStrategyandaccompanyingActionPlanisstronglyevidence-based,buildinguponleadingexamplesofprimaryandcommunitycareinNewZealandandinternationally,andanalysisofdemographic,accessandoutcomedata.

TheStrategyrecognisesthatSouthernprimaryandcommunitycareperformswellinmanyrespects.Mostpeoplehavetimelyaccesstogoodqualitycareprovidedbyhard-workingandwell-intentionedhealthprovidersandpractitioners.However,thestrainonsomeservicesisapparent,andinotherinstances,careproviderscanimprovetheirresponsivenesstopopulationandindividualneeds.Trustingrelationshipsbetweenmanyprovidersarebrokenordonotexist,andinmanycasesaprovider- orservice-centricapproachistaken,ratherthanplanningwithconsumersandwhānauatthecentreofcare.

Inparticular,thereremainlongstandinginequitiesofaccessandoutcomesforMāori,ruralandremotepopulations.

Lookingtothefuture,changesindemographics,diseaseprevalenceandworkforcecapacitywillincreasethestrainonprimaryandcommunitycare,ifcurrentcaremodelspersist.Changinghowprimaryandcommunitycareprovidersinteract,theservicestheyarecapableofdelivering,andtheirrelationshipwithhospitalandspecialistservicesisfundamentaltomeetingtomorrow’schallenges.

Stakeholderengagement,researchonleadingmodelsofprimaryandcommunitycare,andanalyticsofaccessandoutcomesacrossthedistricthaveledtoafocuson:

► Empoweringconsumers,whānauandcommunities

► Strengtheningtheabilityofprimarycaretoprovideabroaderscopeofservicesclosetohome

► Integratingcareacrossprimary,communityandsecondarycare.

Theunderlyingdirectionisenablingprimaryandcommunitycaretofocusitselfonpopulationhealthandwellness,deliveringcareclosertohome,andbeingabletosuccessfullytransitionpeopleacrosscaresettings.Thiswillrequirechangestothewayinwhich:

► Consumerandwhānauneedsareinterpretedandmet

► Servicesareplanned,fundedandcontracted

► Providersandpractitionersinteractacrossprimary,secondaryandcommunitycare.

Thisdirectionisarticulatedthroughavisionandsetofstrategicgoals.TheaccompanyingActionPlansetsouttheheadlineactionsandsupportingactivitiesthatwillbeprogressedduringinitialphasesofexecutingtheStrategy.Throughimplementation,theSouthernhealthsystemwillbeone,collaboratingtohelpconsumersandwhānaulivewell,staywell,getwellanddiewell.

IntroducingtheSouthernPrimary&CommunityCareStrategyandActionPlan

10

DevelopingthePrimaryandCommunityCareStrategyandActionPlan

Literaturescan• Keynationalandinternationaltrendsin

contemporarymodelsofcare

Stakeholderfeedback• Engagedapprox.525consumersand

primary,communityandsecondarycarestakeholderstounderstandtheiraspirations

Analyticalprofile• Profileddemand,access,equityand

capacityacrossprimaryandcommunitycare,andrelevantinterfaceswithsecondarycareintheSoutherndistrict

Casestudies• 10relevantcasestudiesfromNZ,

Australia,theUSandUK• Innovativechangesinmodelsofcare

PlanningFramework• Collatedandanalysedkeythemesto

informStrategyandActionPlandevelopment

Strategy• Enhanceprimarycare• Team-basedwaysofworking• Integratingcareacrosssettings• IntegratedITsolutions• Virtualhealth• Home-basedcare(includingremote-

monitoring)• Localityapproachestocaredelivery

ActionPlanBeinginnovative,courageousandrapidlylearningasimplementationprogresses

Buildingacriticalmassofinter-lockedinitiativesthattogethertransformcare

delivery

OngoingengagementThisoccurredthroughouttheprocessatkeypoints,withaSteeringGroup,aWorkingGroup,consumers,andprimary,community,andsecondarycare

stakeholders

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HowtheStrategyrelatestoothernational,regionalanddistrictstrategiesandplansNewZealandHealthStrategy(NZHS)

SouthernStrategicHealthPlan(SSHP)2015- 2025andImplementationPlan

54321 6

SouthernPrimaryandCommunityCareStrategy

SouthernWorkforceStrategyandActionPlan(June2018)

SouthernDigitalStrategy(June2018)

DunedinHospitalRebuild

DetailedServicesPlansA&B

IndicativeBusinessCase

DetailedBusinessCase(TBC)

SouthernStrategicServicesPlan

SouthIslandRegionalHealthServicesPlan

DevelopacoherentSouthernsystemof

care

BuildtheSouthernhealthsystemonafoundationofpopulationhealth,andprimary&community

care

Securesustainableaccesstospecialised

services

Strengthenclinicalleadership,engagement

andqualityimprovement

Optimisesystemcapabilityandcapacity

Livewithinourmeans

SouthernPrimaryandCommunityCareActionPlan

HeKorowaiOranga

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1 2 3

4 5 6

Ageingandincreasingcomplexitysuggestsasignificantincreaseindemandforhealthcare

Consumersandwhānauexpectamoreconsistentcareexperience,inwhichtheyplayamoreactiverole

SignificantvariationintheSouthernhealthsystemintermsofaccess,experienceandoutcomes

SouthernasanationalhubforeducationandtrainingofhealthprofessionalscandesignlocalapproachestoaddressworkforceshortagesanddevelopmentneedsincludingbuildingtheMāorihealthworkforce

TherebuildofDunedinHospitalisamajoropportunitytooptimisethemixofservicesacrosssettings

Consumerswanttoreceivecareinnewways,supportingtheuseofnewservice,workforce,businessandfundingmodels

Challenges

Opp

ortunitie

s

…variationinmedical/surgicaldischargeratesbyenrolledgeneralpractice

populations,whichcan’tbeexplainedbyage,ethnicityor

deprivation

3-fold73%…increaseinGP

consultationsexpectedfor65+populationby2036undercurrentmodelsofcare

11+medicationsdispensedonaverageto

Southernersaged85+years(2014)

*cf.197inNelsonMarlborough&280inCanterbury

40%…ofSouthernGPsintendtoretireinthenext8

years

WecandobetterforthepeopleoftheSoutherndistrict…

Primaryandcommunity

care

Secondaryandtertiary

care

Self-care

>1/6…Olderpeoplelivewith3+chronicconditions

193…DHBalliedhealth

professionalsper100,000population*

*Darkershading=higherrateofuse

Māoriare3x morelikelytodiefor

amenablereasons

Publichealth

Individu

al

preven

tion

LTC

managem

ent

Avoidinghospital

admission

s

Hospitalcare

Reha

bilitation

Endoflife

494 …MāoriDHBemployeesper100,000Māoripopulation^

^cf.510inNelsonMarlborough&392inCanterbury

494

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Ifwetakeanewapproach…Ifwemaintainthestatusquo…Weneedanewapproach…

Healthriskfactorssuchasobesitycontinuetoincreaseanddemandfortreatmentservicesgrows

Thereremainmanypointsofentrytothesystem,andhealthservicescontinuetooperatein‘silos’,withlimitedconnectionswithsocialservices

OurGP,nursingandalliedhealthworkforcestrugglestodelivertimelyaccesstoservices– creatingfurtherpressureonhospitals,andmakingprimaryandcommunitycarecareersunattractivetothenextgenerationoftheworkforce

Healthservicescontinuetobeprovidedintraditionalways,despitetechnologicaladvanceswhichcouldimproveaccess,qualityandefficiency

SouthernDHBstrugglestolivewithinitsavailablefunding,andDHBhospitalservicesconsumeanever-increasingshareofresources,limitinginvestmentopportunitiesinprimaryandcommunitycare

Hospitalcarecannotkeepupwithincreasingacutedemand,exacerbatedbyprimaryandcommunitycarecapacityshortages,andtheincreasingnumberofconsumerswithcomplexneedsandlong-termconditions

Newinitiativesarenotregularlymonitoredandadjusted,andscaledorstoppeddependingonperformance,resultingininefficientresourceuse

Consumers,whānauandcommunitiesunderstandhowtolivewell,andaresupportedbypreventivecareinthecommunity

Consumersandwhānauareabletoeasilynavigatethesystem,whichprovidescohesivecareacrossservices,settingsandorganisations,supportedbyintegratedsystemsandprocesses

Ourprimaryandcommunityworkforceisengagedandalignedthroughnewmodelsofcare,allowinghealthprofessionalstofocusonhigherskilledclinicalworkthroughnewwaysofworkingandsupportfromnewroles(e.g.healthcareassistants;clinicalpharmacists)

Newdigitaltechnologiessupportcommunityhealthliteracyandprovide‘virtual’linksbetweenconsumersandservices,supportingthedeliveryofcareinhomeandcommunitysettings

Investmentisplannedandprioritisedacrossthesystemtodriveanoptimalmixofcommunityandhospital-basedservices

Primaryandcommunitycareisdeliveredfromfit-for-purposefacilities,enablingteam-basedwaysofworking,andprovidingabroaderrangeofservicesinout-of-hospitalsettings,allowinghospitalcaretobefocusedonthosewiththehighestneeds

Acultureofcontinuousimprovementissupportedbythemonitoringandrapidevaluationofnewinitiatives,informedbyconsistentdataanduseofevidence-basedevaluationtools

2345678

Disjointedapproachesacrosssectorsresultinagrowinghealthinequitygap,particularlyforMāori

Joinedupapproachesacrosshealth,socialandeducationsectorsenablecollectiveactiontoaddressfactorsthatcontributetoinequityofaccessandoutcomes1

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TheStrategy

15

Thevisionforprimaryandcommunitycareis…

TheSouthernhealthsystemisbuiltonanoverarchingvision…

Betterhealth,betterlives,WhānauOra

Excellentprimaryandcommunitycarethatempowerspeopleinourdiversecommunitiestolivewell,staywell,getwellanddiewell,throughintegratedwaysofworking,rapidlearningandeffectiveuseoftechnology

Thestrategicgoalssupportingthisvisionare…

Primaryandcommunitycareworksinpartnershiptoprovide

holistic,team-basedcare

Secondaryandtertiarycareisintegratedintoprimaryandcommunitycaremodels

Thehealthsystemistechnology-enabled

Consumers,whānauandcommunitiesareempoweredto

driveandowntheircare

1 2 3 4

TheStrategy:Visionandstrategicgoals

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Goal1.Consumers,whānauandcommunitiesareempoweredtodriveandowntheircare

Whatthiswillmean:

► Consumerswillbeinvolvedindesignandreviewofprimaryandcommunityhealthservices

► Consumerswithmorecomplexneedswillhavealeadcarercoordinatingservicesacrossthecareteamaccordingtoasharedcareplan

► Consumersandwhānauwill:

1. haveaccesstoculturally-appropriateservicestoimprovetheirhealthliteracy,andtheself-managementskillsofthosewithalong-termcondition(s)

2. haveasinglepointofonlinecontactthroughaportaltoaccesstheirhealthinformation,includingsharedcareplansconnected totheirhealthcarerecords;initialdiagnosis,triagingandcareoptions;andotherreliablehealth-relatedinformation

3. beabletoparticipateinpeergroupsofconsumers(e.g.viasocialmedia,communitymeetings,andprofessional-ledsessions)

4. beabletoshapetheimprovementofprimaryandcommunitycarethroughregularfeedbackmechanisms,andaccesstoproviderperformanceresults

► Consumers,whānauandcommunitieswillbesupportedtohavegreaterinvolvementincaringforothersthroughtechnologysupport, accesstotime- andskill-sharingvolunteeropportunities,enhancingsocialparticipationandresilience.

Southernconsumers,whānauandcommunitiesaresupportedtodrivetheirowncareandwellbeing,andtheoverallperformanceofSouthernprimaryandcommunitycare

17

Goal2.Primaryandcommunitycareworksinpartnershiptoprovideholistic,team-basedcare

Primaryandcommunitycareisworkinginpartnershiptoprovideholisticcaretailoredtoindividualneeds,throughteam-basedwaysofworkingacrosshome,clinicandcommunitysettings

Whatthiswillmean:► Primaryandcommunitycarewillbe:

1. abletoproactivelymatchresourceswithcareneedsthroughnewwaysofworking(e.g.extendedconsultations;extendedhours;team-basedcare;virtualhealth),andnewteamroles(e.g.healthcareassistant,healthcoach;clinicalpharmacist;alliedhealthprofessionals)basedonaHCHmodelofcare

2. usingdiagnosticandvirtualhealthtechnologiestoprovideefficientandconvenientcare3. usingwhole-systemcarepathwaystailoredtotheSoutherncontext4. organisedintointegratedmulti-disciplinaryteamswrappedaroundgeneralpractice,whichprovide24/7holisticandculturally-appropriatestepped

care,withteammembershipbasedonskillsandcapabilitiesratherthanprofessionaldemarcation5. deliveredthroughintegratedprimaryandcommunitycarehubs thatfostercloseralignmentofDHBandNGOcommunityservices,and- wherecost-

effective- ambulatorysecondarycareservicesfromDunedinandInvercargillhospitals6. abletoeffectivelyrespondtoacutecrises(e.g.paramedicsandPRIME-trainedpractitionersinruralcommunities;accesstocommunitydiagnostics;

clinicalobservationinacentreorhub)7. equippedwithenhancedaccesstoclinicaladvicefromsecondaryandtertiarycare8. abletoprovideanincreasedscopeofclinicalinterventionsthroughdefinedclinicalprotocols9. deliveredinwaysthatrecognisetheimportanceofTeAoMāori(theMāoriworldview),tereoMāori,andinsettingsthatrecognisetheimportanceof

culturalsafetyandfamiliarity(e.g.marae;integratedMāorihealthserviceclinics)10. engagedinteachingandlearning

► Primaryandcommunitycarewillbeattheheartofruralhospitalcareprovision.Withinadistrict-wideplanningframework,theywillbeabletoprovideanexpandedscopeofdiagnostics,andstep-up/-downcarefortheircatchmentpopulations,withaworkforcedevelopedtodeliverthismodelofcare,withcapacitymatchedtopopulationneeds

► PrimaryandcommunitycarewillbeplannedtorespondeffectivelytotheneedsofMāori,Pacifica,ruralandremotepopulationgroups

► Communitypharmacy,agedcare,mentalhealth&addictions,andpalliativecarecommunityproviderswillbefullyintegratedintoteam-basedcaremodels

► Effectiveintersectoralpartnershipswillbeeffectivelyaddressingthesocialdeterminantsofhealth,includingintroducinganexplicitHealthinAllPolicies(HiAP)componenttoallpublicsectorpolicydevelopmentprocesses.

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Goal3.Secondaryandtertiarycareisintegratedintoprimaryandcommunitycaremodels

Whatthiswillmean:

► Secondaryandtertiarycarewill:

1. beactivesupportersofprimaryandcommunitycareteams,providingspecialistadvice,episodiccareforconsumerswithmorecomplexneedsvirtuallyandinclinic-basedsettings,andcontributingtothedevelopmentandimplementationofcarepathways

2. supportregulatedhealthcareprofessionalstoextendtheirscopesofpracticeandinter-professionalworking(e.g.developmentofnursepractitioner,GPandPNwithspecialinterestroles,andallied-nursinginter-professionalskills/competenciesforsharedtasks)

3. haveaclearunderstandingoftherangeofcommunityoptionsavailableforconsumers,andprioritisecommunitycarewhereclinicallyappropriate,includingstep-up/-downcare

4. haveasingleclearpointofaccessforprimaryandcommunitycareprovidersseekingrapidadvice

5. integratedteaching,learningandresearch

6. accommodatethedistinctneedsofruralcommunitiesthrough:

a) patient-determinedprimaryandcommunitycarebookings,andcoordinationofspecialistappointments*

b) localoutreachclinics(virtualorvisiting)

c) tailoringoutpatientclinicstotheneedsofMāori

d) preparednessforemergencytransferorretrieval

e) arrangementoftravelandaccommodationoptions.

Secondaryandtertiaryservicesjointheprimaryandcommunityteamtoprovidesupporttoenableconsumerswithcomplexneedstoaccesstimelycareclosetohome

*patient-determinedbookingswillbeacrossbothprimaryandsecondarycare,withprimarycarebookingsabletobeself-initiated,whilepatientsarepromptedtomakesecondarybookingsthroughaclearsinglepointofaccess

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Goal4.Thehealthsystemistechnologyenabled

Whatthiswillmean:

► Everyconsumerwillhaveanelectronichealthrecord(EHR)accessibletothemandmembersoftheircareteam,accessiblefromanydevice,andwithaconsumer-nominatedleadcarerascustodian

► Thehealthworkforcewillusedigitalplatformsforprofessionaldevelopmentandfosteringofpeersupportnetworks

► AnintegratedsetoftechnologysolutionswillenableasinglepointofcontacttotheSouthernhealthsystem,sharedcareplanningandefficientadministration.Itwillsupporte-orderingandinstantcommunicationregardlessofdevice,reducingbarrierstoaccessandsupportingtheprimaryandcommunityworkforcetooperateatthetopoftheirscopes

► Virtualhealthtechnologiessupportingthedeliveryofvirtualconsultationsbytheprimary,community,secondaryandtertiarycareworkforce

► Clearlyspecifiedprocessesfordatacollection,analysis,andperformanceimprovementinitiativesdrivenbyinsights,withtheuseofAItoaugmenthumaninput

► Newtechnologiestosupporthome-basedcareandremotemonitoringwillbecommonplace,includingin-homesensorsforpeoplewith relevantphysicaland/orcognitiveneeds(e.g.heartdisease;dementia),withreal-timedatabeingcollectedandactedonbycareprofessionals

► Consumergenomicinformationandhealthdatafrombothhome-basedandwearabletechnologieswillbeincorporatedintotheconsumer’sEHR,informingdiscussionsanddecisionswiththeircareteam

► Wherefeasible,cost-effectiveemergingtechnologieswillbeinusebyconsumers(e.g.home-basedsupportforolderpeople)andbyproviders(e.g.communitypharmacy)

► Theintroductionofemergingtechnologieswillhaveaclearprocessforprioritisation,seedfunding,structuredadoption,andevaluation(includingreturnoninvestment)

► Southernwillbeafast-followerofnationalandotherregionaltrends,adoptingothers’provensolutionswherepossibleandinnovatingasrequired,dependingonneedsandtechnologytrends.

Technologysolutionsaresystematicallydeployedtosupportseamlesscareandcontinuousimprovementofprimaryandcommunitycare

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Bringingitalltogether– theconsumerandwhānauexperience

Icangetasame-dayappointmentwhenmy

needsareurgent

Icangetholisticsupportfromarange

ofcarers

Consumer’shome

HCH

Hospital

Icanaccessallmyhealthinformationfromhome

includingcertifiedself-careresources

Icanaccesspeersupportgroupsonlineandinmy

community

Icanaccessreal-timeadvicefromhealth

professionals24/7byphone,emailorvideo

Homemonitoringandwraparoundsupportmakesmefeelsafeliving

athomewithadisabilityorsignificantlong-termcondition(s)

Ihaveatrustedcareproviderwhounderstandsmeandmy

whānau

Whenmyneedsarecomplex,mycarejourneyissmooth

andeasytounderstand

Icangetspecialisedassessmentandcare

closetohome

Icangetrapidaccessto

specialistcarewhenIreally

needit

Icanquicklyreturnhomeortomylocalhospitalthroughimprovedcommunicationandsupport

Ihaveaccesstoservicesinculturallysafesettings(e.g.

marae)

IcanfindtheinformationIneedtoseektherightcareat

therighttime

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Primaryandcommunitycare► Primarycareadviceto,andcoordinated

caredeliveryalongside,communitycareproviders

► Step-upcareoptionsavailable► Socialcareincorporatedintoteamcare

models

Communityandsecondarycare► Streamlinedaccesstospecialistadvice

forcommunityproviders► Step-downcareoptionsavailable► Remotemonitoringandrapidresponse

Primaryandsecondarycare► Primarypractitionerwithspecialist

interestsroles► Rapidaccesstoclinicalspecialistadvice► Virtualandvisitingspecialistclinics

Primary,communityandsecondarycare► Multi- andinter-disciplinarycareteams► Sharedcareplansandcarecoordination

forpeoplewithmorecomplexneeds► HCHstopromoteteamcareand

consumeraccess► Whole-systemcarepathways► Integratedinformationtechnologies

Bringingitalltogether- integrationofprimary,communityandsecondarycareThedeliveryofbettercoordinatedwaysofworkingacrossprimary,communityandsecondarycarewillimproveefficiencyandconsumerexperience.Corecomponentsareshownbelow.

Primarycare

Communitycare

Secondarycare

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TransformingprimaryandcommunitycareforMāoriWhilsttherehasbeenimprovementinMāorihealthoutcomesoverthepastthreedecades,thefactthatsignificantinequitiesremainisofgreatconcern.TransformingprimaryandcommunitycareforMāoriisthereforeapriorityinaddressingtheselong-termissues.WithinthecontextofthisStrategy,effortstoeliminatethesepersistentinequitieswillrequirefocusingonthesocialdeterminantsofhealth,liftingthecapabilityandperformanceofbothMāorihealthandmainstreamservices,andbuildingmoreeffectivewaysofworkingtheseservices.Thekeywaystoachievethiswillbeawillingnesstounderstandthosemeasuresthathaven’tworkedwellenough,andleadershipinrespectofapproachingandimplementingthosethatmay.Data,analysisandreportingwillbeusedtohelpdriveaconcertedfocusinthisregard.

AddressingthesocialdeterminantsofhealthwillincludeworkingwithhealthandsocialsectorsusingaHealthinAllPoliciesapproach,whichfocusesonaddressingthemajordeterminantsofhealthinequities.IwiwillbeactivelyengagedthroughthisprocesstohelpdesignandimplementeffectiveandinnovativeapproachesforconnectingwithMāoriwhānauandcommunities.

BuildingthecapabilityoftheMāoriprovidersectorwillinclude:

► StrengtheningthebreadthanddepthofdeliveryofcarefromMāorihealthclinicsthroughHCHdevelopment

► IntegrationofMāorihealthprovidersintolocalitynetworkssupportedbycarepathwaysalignedwiththesteppedcaremodel,allowingkaupapaMāorisupportforconsumerswithcomplexneeds

► Workforcedevelopment,includingincreasingMāoriparticipationandfosteringgreaterculturalinclusivity

► RecognisingtheroleofrongoāMāoriandothertraditionalMāorihealthcarepracticesincaremodels.

Liftingtheresponsivenessofmainstreamprimaryandcommunitycareserviceswillinclude:

► HCHmodelofcaredesigntoreducebarrierstoequityofaccessby(forexample)targetinghighriskpopulations,includingMāori, throughstratificationandsteppedcare

► LocalitynetworkmodelstoincludeexplicitkeyperformanceindicatorsforimprovingMāorihealthaccess,experienceandoutcomes

► Increasingworkforcecapability,particularlyinrelationtoculturalcompetency,andunderstandingandusingtereoMāoriandteaoMāorivalues.

Transparentequityanalysisandreportingwillinclude:

► HealthandbusinessintelligencetoquantifyandbenchmarkMāoriandnon-Māoriaccessandoutcomes

► LocalityhealthneedsandserviceprofileanalysistoincludeassessmentofcurrentandfutureMāorihealthneedsandservicegaps.

WithMāoriconsumerfeedbackspeakingclearlytofeelingsoflackofunderstandingandrespect(andconsequentlossofmana),geographicalisolationanddistancefromtheirtraditionalmethodsofhealthcare,effortstoaddresstheseissuesisvital.EnablingSouthernMāoritoregaintheiraspirationalhealthfocus,feelculturallysafeandrespected,andaccessprimaryandcommunityhealthserviceswithoutunduebarriersthroughtheHCHandimplementationofeffectivetechnologywillbegin(atleast)toaddresstheinequitiesinmeaningfulways.

23

Ruralmodelsofcarewillbeprogressivelybasedonadistrict-wideplanningframework,withtailoringfortheuniqueneedsofdifferentcommunities.TheplanningframeworkwillincludethetransformationofprimarycareintoHCHmodelsofcare,and,asappropriate,developmentofcommunitycarehubsthatco-locateabroaderrangeofservices.TherewillalsobeplanneddevelopmentofprimaryandcommunitycarepractitionerswithspecialintereststhatdelivercarefromandacrossHCHsandcommunitycarehubs.Ruralhospitalswillincreasinglyoperateinanintegratedwaywithprimaryandcommunityhealthservices,withmedicalstaffingbyruralhospitalmedicinespecialistswhoarepartoftheunifiedmedicalteamservingthecatchmentpopulation.Thiswillincludeensuringappropriatemedicalsupportforhealthcentresoperatinginmoreremotetowns.

Withineachlocality,deliveryofaminimumsetofserviceswillberequired,withfundingandcontractingarrangementstosupportbroadeningscopesofpractice,increasedaccesstocost-effectiveclinicaltechnologies,andlocallytailoredserviceinterventions.Therewillbeanexplicitfocusonreducingruralandremoteinequitiesrelatedtocost,transport,andotheraccessbarriers.Insomecases,morespecialisedserviceswilloperateacrossmultiplecommunitiesorHCHsinordertobecost-effective- whilestilldeliveringcareclosetohomeforconsumers.

Caremodelswillbebasedonasteppedcareapproach,supportedbycarepathways,sharedcareplanninganddelivery,EHRs,andotherkeyenablers.Thiswillnotonlysupporttheintegrationoftheruralhospitalwithotherprimarycareservices,butalsotheextensionofprimaryandcommunitycarethroughstrongerstrategicandoperationalconnectionswithlocalproviders,andlocalsupportservices(e.g.healthofolderpeople)andsocialcareservices(e.g.housing,MSD,education).

Aspartoftheprimaryandcommunityserviceforthecatchmentpopulation,theruralhospitalwillofferacutecareintegratedwithlocalprimarycareservices,extendeddiagnostics,andhavetheclinicalcapabilitytodelivercareatanappropriatelevelofacuity.

Theruralhospital’sclinicalcapabilitywillincreasewiththedistancefromabasehospital,andthesizeandstructureofitspopulation.

Otherconsiderationsindefiningtherangeofservicestobeofferedbyruralhospitalsinclude:

► Moderatelyspecialisedprocedurescouldbedeliveredlocally,suchaschemotherapyinfusionsunderthesupervisionoftheSouthernregionalbloodandcancerservice,minoroperationsforskinlesions,andinjectionsforwetmaculardegeneration(insomeinstances,HCHsmayprovidesomeoftheseservices)

► Expandeddiagnosticswouldsavetime,enhancelocalcare,andprovidevisitingorremotespecialistswithadditionalclinicalinformation.Electrocardiogramsfortestsofheartconditionsandspirometryforrespiratoryfunctioncouldbeavailable.Somelevelofimaging,suchasX-ray,CTscanning(wheretheworkforcepermits),andlesscomplexultrasoundisdesirable.Overtime,theabilitytoperformawiderrangeof‘scopes’islikely

► Closelocalmanagementofacutepresentations,alignedwithanintegratedEDnetworkacrossthedistrict,wouldreducetheneedfortransferandtransport,andensurepatientswhodoneedcarefromabasehospitalaresenttothecorrectdestination.RuralhospitalscouldofferprimarycareacutemanagementbackedupwithsupportfromInvercargillandDunedinhospitalEDs,closeon-siteintegrationwithStJohnparamediccapacity,andshort-stayobservation/assessmentbeds

► Dependingonlocalcircumstances,theacutecapabilityoftheruralhospitalcouldbecomplementedby:‘step-down’subacutecapacity,includingrehabilitationfollowinganacutemedicalorsurgicalinterventionatInvercargillandDunedinhospitals;agedresidentialcare;andprimarybirthing.Suchco-locationofservicescouldprovidethescaleneededtomeetclinicalandfinancialrequirements

► Anenhanced‘hospitalinthehome’communitynursingservicecouldprovideacute,sub-acuteandpost-acutecaretoadultsandchildrentoavoidtheneedforinpatientcareinarural(orbase)hospital

► Localityplanningwillalsoworkwithindistrict-wideparameterstodeterminetheavailabilityofspecialistclinics(visitingandvirtual)tomatchpopulationneeds.

Transformingprimaryandcommunitycareinruralcommunities

24

Wewillknowwe’vebeensuccessfulwhen…

Asaresultofconsumeraspirations,moreofourpopulationissupportedtoeffectivelyself-managetheirhealthandwellbeing

Wehaveimplementedproactiveriskstratificationandsteppedcaremodelsbasedonhealthandsocialneeds,includingcarecoordinationforpeoplewithcomplexconditions

Wehaveaplannedapproachtoworkforcedevelopmentthatisbasedonthedesiredmodelsofcare,newworkforcerolesandsystempriorities,andisstronglylinkedwitheducationandtrainingprovidersandprofessionalbodies

Wehavesignificantlyreducedinequitiesofaccessforruralandremotecommunities,Māoriandothervulnerablepopulations

Consumersandwhānausayitisquickerandeasiertogetthehealthcareandadvicetheyneedincommunitysettings

Ourinvestmentinprimaryandcommunitycarehassignificantlyreducedtherateofacutedemandforhospitalservices,andhasenabledagreaternumberofolderpeopletolivesafelyathome

Wewillbeabletosay…Ourpopulationhasequitableaccesstoprimaryandcommunitycare,andspecialistsupportwhenneeded

Ourhealthworkforceisworkingas‘oneteam’,withinanintegratedsystemofcare,andwithdeliverythroughteam-basedcare(includinghealthandbroadersocialservicerepresentation)

Wehavebettermatchedourworkforcecapacity,capabilityandmixtopopulationphysical,mental,andsocialneeds

Wehavebecomeanimbleandsustainablesystem,abletomakeeffectiveinvestmentdecisionsthatensureongoingimprovementinpopulationhealthoutcomesandcost-effectiveuseofresources

Ourconsumers,whānauandcommunitiesknowhowtolivewell,andareactivelyparticipatingincaringforthemselvesandothers

Virtualhealthcareapproacheshavebecomepervasiveacrossoursystem,supportingconsumerstogainfasterandmoreconvenientaccesstohealthinformation,adviceandcare

Strategicaspirationsandsuccessfactors

Ourprimaryandcommunitycareworkforceisculturallycompetent,andisaddressingtheneedsofMāoriinpartnershipwith(ratherthandependenton)Māoriandotherspecialisedcareproviders

PrimaryandcommunitycarerespondseffectivelytotheneedsofMāori

12

54

6

87

Ourprimaryandcommunitycareworkforceisculturallycompetent,andisaddressingtheneedsof,Pacificarural,remoteanddisabledpopulationgroupsinpartnershipwithspecialisedcareproviders

Primaryandcommunitycarerespondseffectivelytotheneedsofothervulnerablepopulationgroups(e.g.Pacifica,rural,remote,anddisabled)3

Wearerecognisedfortheresponsivedevelopmentofaworkforcematchedtopopulationneeds,andacommitmenttocontinuouslearning

Weareactivelyinvolvedintrainingourfutureworkforce,andresearchisactivelysupportedtoimprovehealthandoutcomes9

25

TheStrategydescribesourvisionandstrategicgoalsfortransformingprimaryandcommunitycareservices,withinthecontextoftheoverallSouthernhealthsystem.AnActionPlantodeliveronthevisionandgoalshasbeendeveloped.IndevelopingtheActionPlan,wehaveconsidered:► Howthesystemisbestconfigured► Theimportanceofconsumers,cliniciansandproviders

understandingtherationaleforchange,andsupportingitsdirection

► Howtobuildacriticalmassofinter-linkedactions► Actionsthatneedtobe:

► District-wide► Tailoredtolocalcommunityneeds► Targetedtospecificpopulationgroups

► LearningsfrompreviousplanningandactioninSouthern► Theexperiencesofotherhealthsystemsinimproving

primaryandcommunitycare.

ThreeactionareashavebeenidentifiedfordeliveringontheStrategy(seeright):caremodels;enablinginfrastructure;andsupportforadoption.TheseactionareasformthebasisoftheActionPlan.Theactionareaswillbeprogressedconcurrently,withsequencingofactivitiesandmilestones.Roll-outofnewcaremodelswillbeundertakenintranchestoenablemanageabledesign,adoptionandevaluation.

AroadmapforeachoftheactionareasfortheinitialphasesofexecutingtheStrategyhasbeendevelopedtoguideearlyprogressonachievingthevisionforprimaryandcommunitycareinSouthern(seethePrimary&CommunityCareActionPlan).

Governanceandleadership

DevelopHCHstoenhanceaccessto

primarycare

Empowerconsumers,whānauand

communitiestoself-care

Createlocalitynetworkstobettercoordinate

care

Workforcecapabilityandculture

Whole-systemhealthandbusinessintelligence

Fundingandcontracting

Caremodels

Enablinginfrastructure

Supportforadoption

Demonstration Communicationsandengagement

Providersupport

Informationandcaretechnologies

ExecutingtheStrategy:TheActionPlan

26

ExecutingtheStrategy:Ourcommitment

Alignincentives

Innovate

Innovateandbecourageous

Demonstrate

Evaluate

SpreadStopOperateasonesystem,makingthebestuseof

availableresources

Takeaninvestmentapproachthatprioritisesevidence-basedinterventionstoimprovelong-termoutcomes

Supportourpopulationtolivewellandself-care

Makealldecisionsinthebestinterestsofourpopulationandconsumers(usingthequadrupleaim)

Improveequityofoutcomes,particularlyforMāoriandruralcommunities

Makeourhealthsystemeasytouse

Movefromtraditionalwaysofworkingtobefit-for-the-future

Takeaprincipledapproach

Provideequitableaccesstoappropriate24/7careacrossthedistrict

Treateachotherwithtrustandrespect

Fundingandcontractingapproacheswill

progressivelyincentiviseprimary,communityandhospitalcaretowork

collaborativelytoachievetheoptimalmixofservicesacrosssettings,andto

improveaccess,outcomesandresourceuse

Utiliseoureducationpartnerstodevelopaworkforcematchedtopopulationneed

27

Appendix- Planningframework

28

Keynational,regionalandlocalstrategiesand

plans

Scanofinnovativemodelsofcareand

evidenceofwhatworks

Stakeholderengagementincluding

consumers

AnalyticalprofileoftheSoutherndistrict

AwiderangeofinformationinformedthedevelopmentoftheStrategyanditssupportingActionPlan.ThisinformationisincludedinthePlanningFrameworkthataccompaniestheStrategyandActionPlan.

Areviewofkeynational,regionalandlocalstrategiesandplanswasundertaken,withrelevantthemesfromthesedocumentsbeingusedtohelpidentifyfocusareasforStrategydevelopment.Inparticular,theNewZealandHealthStrategyandit’sfivepillars(‘people-powered’,‘closetohome’,‘valueandperformance’,‘oneteam’and‘smartsystem’)andtheHeKorowaiOrangaframework(overallaimof‘PaeOra’,supportedby‘WaiOra’,‘WhānauOra’,and‘MauriOra’)informedtheprioritiesoftheStrategy,alongsideserviceplanningworkundertakentoinformtheDunedinHospitalIndicativeBusinessCase.

Ascanoflocalandinternationalliteraturewasundertakentoidentifyinnovativemodelsofcareandevidenceforwhatworksinimprovingaccess,qualityandoutcomes,includinglearningsforhowtotransformmodelsofcareandsystemdesign.CasestudiesofinnovativecaremodelsfromNewZealand,Australia,theUnitedKingdomandtheUnitedStateswerealsodevelopedtoprovideapracticalsenseofwhatchangesotherlocalhealthsystemsandprovidersareundertaking.

AnanalyticalprofileoftheSoutherndistrictwasalsodeveloped,updatingrelevantpartsofthe2013SouthernHealthNeedsandServiceProfile.Theanalyticalprofileexamineddemographictrends,populationhealthriskfactors,andserviceuseacrossarangeofprimary,communityandhospitalservices.TheprofileinformedtheStrategyandActionPlanthroughsizingcurrentandfutureopportunitiesforimprovingsystemperformance,andmatchingcarewithpopulationneedsacrosstheSoutherndistrict.Asnapshotofkeyfindingsfromtheprofileisprovidedonpage34.

AkeypartofdevelopingtheStrategywasgainingtheperspectivesofstakeholdersonwhatismostimportantforfurtherdevelopingprimaryandcommunitycareinSouthern.Stakeholderengagementactivitiesincluded:

► Fourconsumerfocusgroups,with32participants

► Fourin-depthinterviewswithconsumerswithexistinghealthand/ordisabilityconditions

► Twowānangawithapproximately50Māoriconsumers

► Adirection-settingworkshopwithSouthernDHBCommissioners,WellSouthPHNBoard,SouthernDHBexecutiveteamandtheproject’sSteeringGroup

► Eightworkshopswithsectorrepresentatives

► Onlineforumforsectorrepresentatives,andfollow-upin-depthinterviews

► AroadshowoftheinitialstrategicthinkinginDunedin,InvercargillandCentralOtago,withmorethan300stakeholdersprovidingfeedback.

Keyinputs…

HowtheStrategywasdeveloped

29

TheNewZealandHealthStrategy(NZHS)andHeKorowaiOrangawereusedincombinationasakeyconceptualframeworkfortranslatingnationalandregionalaspirationsintolocalprioritiesforprimaryandcommunitycareinSouthern.

TheNZHSreflectsthegovernment’scommitmenttoaddressingthehealthsystemsustainabilitychallenge,andultimatelyshiftingtowardsabetterintegratedmodelofcarecentredonconsumersandtheirwhānau.It’svisionisthatallNew Zealanderslivewell,staywell,andgetwellinasystemthatispeople-powered,providesservicesclosertohome,isdesignedforvalueandhighperformance,andworksasoneteaminasmartsystem.

HeKorowaiOrangaisNewZealand’sMāoriHealthStrategy,settingtheoverarchingframeworkthatguidestheGovernmentandthehealthanddisabilitysectortoachievethebesthealthoutcomesforMāori.It’soverallaimisPaeOra,‘healthyfuturesforMāori’,recognisingthemultifacetedneedsofMāorithroughaholisticapproachandthreeinterconnectedelements:mauriora(healthyindividuals),whānauora(healthyfamilies),andwaiora(healthyenvironments).TheapproachreinforcestheneedtoensurethatMāoriareinvolvedinbothdecision-makingandservicedelivery.PaeOraguidedthinkingonhowtheStrategyneedstoaddresstheneedsofMāoriinSouthern.

TheNZHSandHeKorowaiOrangaprovidetheframeworkforarangeofmorespecificnationalstrategiesandplanssuchastheHealthyAgeingStrategy,PharmacyActionPlan,andtheMentalHealth&AddictionsServiceDevelopmentPlan.ThesestrategiesandplanswerealsoconsideredduringStrategydevelopment.

ThesocialservicessystemfunctionsreasonablywellformostNewZealanders…

…butthesystembadlyletsdownmanyofNewZealand’smostdisadvantagedpeople.

Thegovernment’ssocialinvestmentpolicyacknowledgesthattraditionalapproachesarenotmeetingtheneedsofthemostvulnerable– particularlychildrenandyouth.Inresponse,governmenthaschallengedagenciesto:• Prioritiseeffortsforimprovingthelivesofthemost

vulnerable• Takeadata- andevidence-ledapproachto

commissioningandcontractingforoutcomes• Joinupplanningandactionacrossagenciesand

sectorsincludingintegratedfundingandcontractingmodels

• Designnewmodelsofcarethatovercomebarrierstoaccessforpeoplewiththemostcomplexneeds

• Involveindividuals,whānauandcommunitiesinprioritysettingandservicedesign.

ThisthinkinghasbeenincorporatedintotheStrategythroughrecognisingthatsomemembersofourcommunitieswillrequiremoretime,effortandresourcesthanothers,tolifttheirhealthandsocialoutcomes.

Nationalstrategiesandplans

30

AllianceSouthisapartnershipbetweenSouthernDHBandWellSouthPHNtodrivecollaborationandprogressonkeyinitiativesacrosstheSouthernhealthsystem.TheAlliancehasdrivencollaborationandprogressthroughanumberofnetworksfocusedonparticularpartsoftheSouthernhealthsystem.Acrossthesenetworks,it’spriorityareasoffocushavebeen:careplanningandmanagementofcomplexconsumers,enablers,alocalityapproach,communication,andcareclosertohome.AllianceachievementsandlearningshavebeenfactoredintothedevelopmentoftheStrategyandActionPlan.

AnumberofstrategyandplanningdocumentshavebeendevelopedtoinformtherebuildofDunedinHospitalbusinesscaseprocess.Theseinclude:► AStrategicServicesPlan

► DetailedServicePlans(A&B)forDunedinHospitalservices

► AnIndicativeBusinessCasefortheHospitalrebuild

► Anumberofclinically-ledpositionpapersregardingpossiblefuturemodelsofcare.

ThesedocumentspointtothesignificantopportunitytherebuildpresentstoradicallyredesigncaremodelsbothwithintheDunedinHospitalsettingandinprimaryandcommunitycare.Fromastrategicperspective,theStrategicServicesPlanmadethefollowingrecommendationsrelatedtoprimaryandcommunitycare:

a) Activelysupportaggregationofgeneralpracticesintolargergroupingsandinvestinenhancedmodelsofprimarycare

b) Proactivelydeliverwell-organisedandconnectedprimarycarethroughthedevelopmentofleadershippositionsandnetworks

c) Considercomprehensivewraparoundservicesforhighlycomplexconsumers,includingpartnershipswithcommunityorhospital-basedpharmacy

d) Consideraclinically-ledreviewofhowHealthPathwaysaredetermined,marketedandutilised,andestablishnear-termprioritiesforfurtherexpansionofpathways.

TheStrategyandActionPlanhaveincorporatedthethinkingemergingfromthebusinesscaseprocess,whilealsoconsideringdistrict-wideissuesandopportunities,andtheparticularnuancesofSouthern’sdiversecommunities.

TheSouthernhealthsystemhasadoptedaQuadrupleAimframeworktoguideplanninganddecision-making.Thefourdimensionsoftheframeworkare:populationhealth;experienceofcare;costpercapita;andteachingandlearning.Thepurposeoftheframeworkistoensurethateachofthesedimensionsisconsideredsimultaneouslywhendecidingprioritiesandactions.TheframeworkhasbeenusedtohelpshapetheStrategyandActionPlan.

WithinthecontextoftheSouthernWay,theSouthernStrategicHealthPlandescribeshowhealthservicesinSouthernshouldevolvebetween2015and2025.Itdescribesasysteminwhichfamilydoctors,communityhealthanddisabilityproviders,andhospitalcareworktogetheraroundcommunityhealthanddisabilityneeds.ThePlanhassixpriorityareas,withthemostrelevantonesfortheStrategybeing:1. DevelopingacoherentSouthernsystemofcare2. Buildingthesystemonafoundationofpopulation

health,andprimaryandcommunitycare.

Localstrategiesandplans

31

Healthsystemsarefocusingonbetterintegratingcareacrossprofessions,servicesandsettings,withastrongfocusonmovinginvestment‘upstream’topreventionandstrengthenedprimaryandcommunitycaredelivery.Thereisalsoastrongemphasisonactiverehabilitationthatreducesriskofrecurrentacutepresentations,andend-of-lifecarethatprovidespeoplewithappropriatesupportstoenableadignifieddeath.Achievingthese outcomesrequiresprioritisingfutureinvestmentstowardspreventionandcommunity-basedmodelsofcare.

Rebalancingcapacitythroughreallocationacrossthesystem

Publichealth Individualprevention Long-termconditionmanagement

Avoidinghospitaladmissions

Hospitalcare Rehabilitation Endoflife

“Thecostofprovidinghealthservicesthroughthecurrentmodelisunsustainableinthelongterm.TheTreasuryestimatesthat, ifnothingweretochangeinthewaywefundanddeliverservices,governmenthealthspendingwouldrisefromabout7percentofGDPnow,toabout11percentofGDPin2060.Itisessentialthatwefindnewandsustainablewaystodeliverservices,investingresourcesinawaythatwillprovidethebestoutcomespossibleforpeoples’healthandwiderwellbeing.”

TheNewZealandHealthStrategy:FutureDirection(MinistryofHealth,2016)

Trendsinsystemdesign

32

► Simplifyingthesystemforbothconsumersandcarersthroughmechanismssuchasconsumerportals,singlepointsofaccess,andcarepathways

► Re-engineeringclinicalandbusinessprocessestostreamlineconsumerflow,releasingtimetocare

► Organisingservicesarounddefinedpopulations, includingonalocalitybasis.

Manyoftheseinnovativemodelsarenew.However,thereareearlysignsofsuccess,suchas:

► Improvedconsumersatisfactionwithaccessandexperienceofcare

► Improvedworkforcesatisfactionresultinginbetterrecruitmentandretention

► Increasedcapacitywithinprimaryandcommunitycareasevidencedbymoreconsumerinteractionswithinsimilarresources

► Someevidenceofreductionsin:

► Urgentcare

► Polypharmacy

► Acutehospitalisations

► Hospitalbed-days

► Entryintoaged-relatedresidentialcare.

TheseleadingpracticedesignfeaturesofcontemporarymodelsofcarehavebeenincorporatedintheStrategyandActionPlan.

InnovativecaremodelsareemerginginNewZealandandinternationally.Thesewerescannedtoseewhatothersystemshavebeingdoingoraretrialing,andtheirlessonsandlearnings.Somekeythemesemergedfromthescan,irrespectiveofjurisdictionorsystem.Thesethemesinclude:

► Activelyinvolvingconsumersandwhānauindeterminingcareneedsandapproaches

► Takingapopulationhealthfocusthatprioritiseswellness,prevention,healthliteracyandself-management

► Focusingonindividualsandpopulationsratherthanspecificconditionssuchasdiabetes,heartfailureordepression

► ReinforcingthepivotalroleofprimaryhealthcareinthehealthsystemthroughapproachessuchastheHCH

► Proactivelytargetingresourcestoindividualandpopulationneedsthroughriskstratification– ledfromprimaryhealthcare

► Buildingtheprimaryandcommunitycareworkforcethroughnewworkforceroles(e.g.,clinicalpharmacy;healthcoaches;kaiāwhina)andenablingpractitionerstoworkatthetopoftheirscopesofpractice

► Usingteam-basedapproachesforpeoplewithmorecomplexneeds,whichintegrateskillsandcapabilitiesfromacrossthehealthandsocialsectors

► Maximisingtheuseoftechnologytosupportconsumersandthewiderhealthandsocialcareteam

► Developingfit-for-purposefacilitiesthatenableintegratedwaysofworking

Trendsinmodelsofcare

33

Newandemergingtechnologiesarerapidlytransforminghowpeopleengagewitheachotherandtheservicestheyuse.Inhealthcare,thismeanshowpeopleaccesshealthinformation(includingtheirownrecords),howtheyengagewithservices,andthehealthchecks(likesimplediagnostics)theycandoforthemselves.Togetherthesetrends,andthefurtherpromiseofnewtechnologies,havethepotentialtoradicallychangeconsumerexperienceofcare.Thepromiseofthesetechnologiesisahealthsystemthatcanmoreefficientlyandeffectivelydeliverconsumer-centredcare,makingthebestuseofworkforceandinfrastructure.Someofthechangesthatnewtechnologypromisesareasfollows:

► Peoplearemoreactivelyinvolvedinmanagingtheirlifelonghealthandwellness.Theycandrivetheirhealthexperiencethroughuseoftoolslikewearabletechnologies,onlineaccesstotheirhealthandwellnessinformation,andgamesthatsupportmemoryfunction,painrelief,andself-managementoflong-termconditions

► Socialnetworkingmechanismsthatsupportpeer-to-peersharedexperiences,informationandmotivationalencouragement

► Encouragingastrengthenedrelationshipbetweenconsumersandthehealthworkforcethatenablesconsumerstobeco-producersoftheirwellness,withphysiciansasexpertadvisors

► Ataservicedeliverylevel,technologiessuchasclinicalanddecision-makingalgorithms,artificialintelligence(AI)diagnostics,andonlinepathwaysandservicedirectoriestosystematisecaredeliverysystemsandprocessesefficientlyandeffectively

► Peoplewithlong-termconditionsbeingabletomonitorclinicalmeasures(e.g.,temperature,bloodpressure)andrelaytheseinreal-timethroughsmartdevicestotheircareteam,withtheircareteambeingabletorespondwhenthereareclinicallymeaningfulchangesinaperson’shealthstatus.Thisfreesupbothconsumerandprovidertime

► The‘internetofthings’enablingsafeandeffectivehomemonitoringofpeoplewhohistoricallywouldhaveneededshort-termcareinahospitalsettingorlong-termcareinaresidentialsetting

Interested Interestinservice Notinterested

87% Makeanappointmentonlinetoseeadoctorororganiseahospitalservice/appointment 13%

83% Completedoctororhospitalregistrationdetailsonlinebeforeyourvisit 17%

74% Useanat–homediagnostictestkit(e.g.forstrepthroat,cholesterollevels)andsendtheinformationtoyourdoctor 26%

70% Communicateelectronicallywithadoctororotherhealthprofessional(e.g.email,text,socialmediasite) 30%

70% Orderprescriptiondrugrefillsusingmobileappsonyourphone 30%

66% Useadevicethatconnectstoyoursmartphone(e.g. temperature,bloodpressureorheartrate)andsendtheinformationtoyourdoctor 34%

61% Consultadoctorbyvideoonyourcomputerratherthanin-personinaclinic 39%

60% Sendaphotoofyourinjury/heathproblemtoadoctorusingyourcomputerormobiledevice 40%

Consumerinterestinusingnewtechnologies*

► Newrobotictechnologiesaremakingpossibleavastrangeofnewwaystoprovidecareanddeliversystemefficiencyimprovements.Thisincludesrobotsthatprovidecompanionshipforpeoplelivingalone,robotsthatsupportcaredelivery(e.g.helpingpeoplehavesafetransitionsoutofbedinagedcare),anddronesthatcandelivermedicinestoconsumers

► AIandmachinelearningofferthepromiseofanalysingvastamountsofdataquickly,improvinghealthandbusinessintelligence.

Newandemergingtechnologies

Seeformoreinformation:Healthcare:thecross-currentsofconvergencedeliverparticipatoryhealth:AsecondpaperintheHealthReimaginedseries,2017,EY.

34

ASouthernanalyticsprofilewasdevelopedtoinformprioritysettingfortheStrategy.ThisconsideredarangeofmeasuresacrossprimaryandcommunitycareintheSoutherndistrict,andalsobroadersystemmeasuresrelatedtouseofhospitalservices.Itshowsthatweperformwellonmanymeasures;however,thereremainsampleroomforimprovement,particularlyinthecontextofrisingdemandforservicesandemergingcapacityissues.Key findingsaresummarisedbelow.

Demographicchangewillbeunevenacrossthedistrict Urgentcaredemandisincreasing

Variationinaccessandoutcomesisevident Workforcecapacityissuesexist,andwillintensifyinthecontextofrisingdemand

Manysmall-scaleprimaryandcommunityprovidersexist,presentinganopportunityforconsolidationtobroadenthescaleandscopeofservicesUtilisationratesarehigherthanpeerdistrictsonsomekeymeasures

%populationchange2016-36

-50% 100%50%

%populationchange2016-36

-100% 400%200%

Totalpopulationgrowth 75+populationgrowth

56…morenon-admittedED

attendancesperdaythanin2013/14

…ofSouthernconsumersexperiencedanunmetprimarycareneedinthepast12months

29% 40%…ofSouthernGPs

intendedtoretireinthenext10yearsin2015

RuralGPvacancies

…percapita

Highestrateof…

In2016/17thereareapproximately…

…variationinmedical/surgicaldischargesbyenrolledgeneral

practicepopulations

3-fold 73%…increaseinGPconsultsfor65+populationwithcurrent

caremodelsby2036

11+medicationsaged85+years-

2014

*Darkershading=higherrateofuse

…highestagedresidentialcareuseof

peerDHBs

2nd

…increaseinnon-admittedEDattendancesatDunedin,

SouthlandandLakesHospitalsfrom2014- 2016

33%1

2

3

4

5

62nd…highestlowurgencyEDattendancerateof

peerDHBs

Southernanalyticsprofile:keyfindings

35

AwiderangeofstakeholderswereengagedduringthedevelopmentoftheStrategy,includingconsumers,healthprofessionals,non-governmentalorganisations(NGOs),andDHBandPHNstaff.Stakeholderssharedtheirperspectivesontheirexperienceofprimaryandcommunityservices,andopportunitiesforthefuture.AnumberofkeythemesemergedfromconversationswithSouthernstakeholders:

► Consumerscontinuetoexperiencebarrierstoaccessingservices,particularlythosewholiveinmoreruralsettings

► Consumersreportinconsistentexperiencesofcarefromsimilarproviders

► Māoriconsumerscontinuetoexperienceprejudiceanddisrespect,andwouldvaluegreateraccesstorongoāMāori/traditionalMāorimedicineandpractitioners

► OnesizedoesnotfitallforMāoriconsumers,andmanyfeelthatthecurrentmodelofcaredoesnotcatertotheirneeds

► Consumersdesiregreaterempowermentintheircare,andtheinformationandsupportneededtorealisethis

► Thereisageneralviewthathealthserviceshavebeenslowtoadapttochanginghealthneedsandconsumerpreferences

► Allstakeholdersareunitedintheirdesireforgreatersharingofclinicalinformationthroughmeanssuchasanelectronicheathrecord

► Thereisageneraldesiretodevelopamorecollaborativeandintegratedsystem,foundedonasharedpurposeandsetofvalues

► Whilegoodprogresshasbeenmadeonparticularserviceareas,thereremainsapressingneedtodescribetheoverarchingorganisationofcaredeliveryinprimaryandcommunitysettings,andtheirrelationshipwithhospitalservices

► Therearesignificantopportunitiestoimprovehowprimaryandcommunitycareprovidersandpractitionersworkintermsofclinicalandbusinessmodels

► Peopleareexcitedbythepromiseofnewtechnologies,andtheirabilitytoimproveaccesstoinformationandcare.

Usingtechnologytoenhancecurrentinteractions…

“HavingtodrivetoInvercargillfortwohoursforappointmentsthatcansometimesonlybe10minuteslongcanputyouatrisk.

I’dmuchpreferthis.”(Queenstown consumer)

Co-locatedservices…“IlikethisbutsomeservicescancostmoreattheGP– Iwenttohospitalforeyetestsanditwaswaycheaper,soaslongasthe

pricedoesn’tgoup…”(Dunedinconsumer)

“

”

Directionsettingworkshop

Wananga

Stakeholderperspectives

36

SteeringGroup,WorkingGroupandUniversityofOtagoThisprojectwasoverseenbyaSteeringGroupwithbroadrepresentationfromacrosstheSoutherndistrict.AWorkingGroupco-developedthedetailedactivitytablestosupportimplementationofthefirstthreeyearsoftheActionPlan.Toassistwithdemonstratingchange,theUniversityofOtagodevelopedfivecasestudiestosupportStrategyandActionPlandevelopment.

SteeringGroupTheSteeringGroupguideddevelopmentoftheStrategyandActionPlan,reviewingandprovidingfeedbackonkeydocumentation,meetingfive timesatkeypointsacrosstheproject.Membershipwasasfollows:

► ChrisFleming(SDHB,CEO)

► LisaGestro(SDHB,ExecutiveDirectorStrategy,PrimaryandCommunity)

► IanMacara(WSPHN,CEO)

► WendyFindlay(WSPHN,DON)

► ProfessorBarryTaylor(UniversityofOtago,DeanMedicalSchool)

► BronnieGrant(Consumerrepresentative)

► SueCrengle(Providerandiwirepresentative)

► KarlMetzler(RuralHospitalrepresentative)

► Dr.MurrayTilyard(GP)

► Dr.NigelMillar(SDHB,CMO)

WorkingGroupAWorkingGroupwasestablishedtosupportActionPlandevelopment,withrepresentationfromacrossprimary,communityandsecondarycare.Inparticular,thisgroupsupporteddevelopmentofthedetailedactivitytables.

UniversityofOtagoRepresentativesfromtheUniversityofOtagodevelopedfivecasestudiesaspartofthePlanningFramework,usedtosupportStrategyandActionPlandevelopment.

*LizDisney(SDHBEDP&F(Acting))wasaSteeringGroupmemberuntilleavinginOctober2017