Towards more accessible, more connected care

Southern Primary & Community Care Strategy

Mihi

Karanga atu rā ki ngā tangata o te taitonga;Nei rā mātou, e mihi kau ana ki ā koutou

tīpuna kua wehe atu ki tua o Paerau.Tēnā koutou katoa!

_______________________________

We call to you, the people of the south;We greet and acknowledge all of our ancestors

who have passed beyond the veil. Greetings to you all!

Key areas we will cover:

1) Why do we need a Primary and Community Strategy?

2) How did we develop the plan?

3) What is the strategy and what are the goals (and what does it mean for you)?

4) How will we put the strategy into practice? (The Action Plan)

5) Questions.

Why do we need a Primary and Community Strategy?

Introducing Margaret

• 82 years old.

• Margaret is a widow who lives independently in her one bedroom flat. She has two children who live overseas.

• In her spare time she likes to read and plays bridge with her friends. She endeavours to take short walks daily for exercise.

• Margaret is supported by a small group of friends and neighbours.

• Margaret keeps in touch with her family via Skype although she prefers to use the phone.

Margaret’s Health

Margaret’s Health Profile: Margaret has high blood pressure, arthritis and is pre-diabetic. She also has recurring troublesome skin spots (a side effect of blood pressure medications) that require treatment and removal.

Healthcare providers & services Margaret sees regularly:• General Practitioner of 25 years, Dr Welby• Community laboratory, for specimen testing• Practice nurse – blood pressure readings etc• Community pharmacist• Physio – on occasion since a fall last winter• Specialists – cardiologist, rheumatologist, surgeon for

skin lesions, geriatrician• Dentist

Margaret’s Current Healthcare Experience

• Currently she feels like she is passed between services.

• She has to be on top of things herself and follow up on test results

and specialist appointments.

• The services she deals with do not talk to each other.

• She has to retell her history with each new health professional

she meets.

• Margaret doesn’t always know what she needs to tell them.

• Her health information doesn’t appear to be shared across any of

services she sees.

• While Margaret doesn’t like to complain, the best word she can

think of to describe her experience is ‘patchwork’.

Why? Because we face challenges ahead.

Our populations are changing, and ageing

In 2038, 25% of the Southern population will be 65+

There is a lot of variation in care

Māori aremore likely to die for reasons that can be addressed

Demand for health services is growing

2nd… highest aged residential care use of DHBs

Urgent care demand is increasing

33%… increase in ED presentations at our hospitals in 2014 - 2016

56… more ED attendances per day in 2016/17 than in 2013/14

Our workforce is ageing and under pressure

40%… of Southern GPs intend to retire in the next 10 years

73%… increase in GPs consults for 65+ with the current model by 2036

3x

Why? Because needs and expectations are changing

People and their whānau expect a more consistent care experience, in which they are at the centre and play a more active role.

Primary and community care

Secondary and tertiary care

Self-care

Why? Because needs and expectations are changing

New Zealanders are more willing to use digital tools to help manage their health in the same way they use technology and online services in other parts of their daily lives.

Why?

Public health Individual prevention

Long-term condition management

Avoiding hospital admissions

Hospital care Rehabilitation End of life

Because people want to receive care closer to home, and accordingly resource is being prioritised away from hospital and into community care settings.

Current Spend

Future Spend

Ref: Helen Bevan, NHS, 2011

Why? Because it is a timely opportunity

Investment in primary and community is necessary to support the new integrated Southern health system, and to help better link health services to keep our population healthy.

The rebuild of Dunedin Hospital is a major opportunity to optimise the mix of services across settings.

How was the strategy developed?

How? Key inputs

• Key national, regional and local strategies and plans

• Analytical profile of the Southern district

Research

Engagement

• Consumer focus groups, with 32 participants

• In-depth interviews with consumers with existing health and/or disability conditions

• Wānanga with approximately 50 Māori consumers

• Online forums for sector representatives, and follow-up in-depth interviews

• Roadshow of the initial strategic thinking in Dunedin, Invercargill and Central Otago, with more than 300 stakeholders providing feedback.

• Community Health Council input on steering committee

Introducing the strategy…

Strategy / Vision

The Southern health system is built on an overarching vision…

Better health, better lives, Whānau Ora

The vision for primary and community care is…

Primary and Community Care that empowers people to live well, stay well, get well and die well, through integrated ways of working and effective use of technology.

Strategy / Strategic Goals

Primary and community care

works in partnership to

provide holistic, team-based care

Secondary and tertiary care is integrated into

primary and community care

models

Technology-based health care system

Consumers, whānau and

communities are empowered to drive and own

their care

1 2 3 4

Strategy / Goal 1

Consumers, whānau and

communities are empowered to drive and own

their care

1This means you and your whānau will have:

• A health care system that enables a more personalised overall experience

• A shared care plan – which you and your family will contribute to

• Access to information to help you stay well

• Increased choice – with you in the driving seat

• Access to more culturally-appropriate services to help you manage long term and ongoing conditions

• A key contact in your healthcare team who can be contacted via your phone or computer

• The same key contact will be responsible for coordinating your services if your needs are long-term, or complex

• There will be more opportunities to connect with others in your local area who may have the same, or a similar condition.

Strategy / Goal 2

Primary and community care

works in partnership to

provide holistic, team-based care

2Introducing:

• Health Care Home (HCH)• The General Practice at the heart of a patient’s care experiences, optimised to deliver

appropriate services for its patients.• Proactive and comprehensive, with strong relationships with community, hospital and

specialist services.• Might include rehab, rapid response services and some outpatients.

• Community Hubs• Potential physical infrastructure to enable integrated ways of working.• Scale and scope of the Hub determined by population size and existing infrastructure.• Longer hours, shorter wait times, better planning coordination.

• Locality Networks• The network of providers and services in place to provide timely, responsive and

holistic care to patients and their families.

What will this mean for Margaret?

• Overall, Margaret has a greater say in how she wishes to receive care and plan for the future.

• Members of her primary care team have more time to spend with Margaret, even though she is actually in the practice less.

• Margaret is more in control of her care. She can phone or email her key worker if she has a question about her care.

• She can make appointments online at a time that suits her.

• She can access her own notes on the system and share them with her family elsewhere in the country if she is unsure about anything.

•

Strategy / Goal 2: A new Structure for Primary Care

Primary and community care

works in partnership to

provide holistic, team-based care

2

Kaupapa Māori

providers

Community Pharmacy

Other residential providers

Aged Residential

Care

Hospital services

St John’s

Hospice

Primary care & urgent

carePharmacy

Radiology

Blood labMinor

procedures

Visiting specialists

Community health

Social care

Specialist child health

Maternity services

Home-based support services

Mental health &

addictions

Community Health Hub

Locality network services

Health Care Home

Strategy / Goal 2: A new Structure for Primary Care

Primary and community care

works in partnership to

provide holistic, team-based care

2

Strategy / Goal 3 / Locality Networks

3

Strategy / Goal 2

Primary and community care

works in partnership to

provide holistic, team-based care

2

* Example care delivery team. Lead carer may vary.

What will Healthcare Homes mean for Margaret?

• More proactive outreach from the general practice team.

• Fewer tests and assessments as information is now shared

across all services involved in her care.

• Ability to access her practice team by phone or email if she

has a query that she is unsure about.

• More time spent with the Nurse working on goals to stay well,

rather than rushed appointments with the GP.

• More care provided closer to home. Fewer trips to the

hospital in Dunedin or Invercargill.

• An increased level of confidence thanks to online resources,

support groups and community-based care providers.

Strategy / Goal 3

Secondary and tertiary care is integrated into

primary and community care

models

3• Specialists will provide support to primary care team members to enable primary care to deliver a

higher level of care and treatment in the community

• Team members who are traditionally hospital based to form a key part of the extended primary care team and be based in health care hubs – such as long term condition nurses, Needs Assessment services for the elderly etc

• Specialists will deliver clinics into communities to minimise travel for patients – these may be in person, or virtual (via video link)

• There will be a single, clear point of access for primary and community care providers seeking rapid advice from specialist services

• In the event that a person does need admitting to hospital, this will be organised between the primary care team and the relevant specialty, to streamline the process

• Where possible, clinics will be tailored to the meet the needs of Māori

• Locality networks will influence future secondary services.

Secondary (hospital) and specialist care will support primary and community care teams, for example:

• Margaret may need hospital-based specialist care in the future. But it will be less frequent and her stay will be shorter.

• Required tests such as blood tests and X-rays, as well as follow up reviews, will all be undertaken by her primary care team and shared with the hospital.

• Depending on her health requirements, Margaret might:- See a Nurse Specialist in her local health hub if her GP becomes

concerned about her needing support to stay at home- Have a telehealth consult with a skin specialist in Dunedin from

her local health hub- Still travel to Dunedin or Southland occasionally to attend an

appointment, but she would have more say and flexibility withregard to her appointment time and a shorter wait.

• Coordinating with primary care and providing ongoing specialist input is much easier and seamless thanks to shared care plans and electronic health records.

What will this mean for Margaret?

Strategy / Goal 4

• An electronic shared health record accessible to you and members of your care team, accessible from any device

• More options for virtual consultations

• Care supported by new technologies e.g. in-home sensors for people with conditions such as heart disease or dementia. Real-time data is collected and acted on by care professionals

• Better behind-the-scenes technology systems to support shared planning, administration, health system intelligence, and professional development.

The health system is

technology-enabled

4 This means you will have:

Strategy / Goal 4

What does this mean for Margaret?

• Margaret regularly skypes her practice team in between face to face visits.

• She has an app on her phone that has been set up by her practice nurse encouraging her to do her falls prevention exercises.

• Telehealth appointments mean her skin lesions can be reviewed by her specialist in Dunedin via a camera and video link at her local health hub.

• Online booking of appointments and mobile phone text reminders mean Margaret has choices and is in control of her healthcare regime.

• With her permission, her daughter can log on to Margaret’s shared care plan and review her goals and latest results, helping Margaret understand anything that she is unclear about.

How? / Executing the Strategy: Next Steps

• Feedback? strategy@southerndhb.govt.nz

• By 28 February 2018

• Revise

• Adoption – a co-design approach

Next Steps:

Have we got it right?

The full Primary and Community Care Strategy can be viewed here:

www.southerndhb.govt.nz