1. Neighbourhood Health Care Homes (NHH)

2. North Island by Deprivation Index
NZ Census 2006

3. North Island by Deprivation Index
NZ Census 2006

4. Northland by Deprivation Index
NZ Census 2006

5. Northland by Deprivation Index
NZ Census 2006

6. Whangarei City by Deprivation Index
NZ Census 2006

13. The Democratisation of Medicine
“The Patient will see you now”
“Participatory Health Care”

14. Direction of Travel
Healthcare is "not a service industry, it's a collaboration"
"Healthcare cannot be successful unless both parties are involved in what's going on."
Among the conditions needed for successful provider-patient collaboration: open communication, shared decision-making, mutual respect, information sharing and engagement.
We need a fundamental rethinking of how patients interact with the healthcare industry, helping them "shift from being mere passengers to responsible drivers of their health.
“Patient engagement is a key enabler of better quality outcomes and more cost-efficient care – the "blockbuster drug of the 21st Century"

15. Not Breaking News
Renowned informatics specialist Warner Slack, MD, professor of medicine at Harvard Medical School. "The largest and least utilized healthcare resource is the patient him/herself."
He wrote this in 1976!!
We're just starting to have these conversations and make this a reality.

16. “I“ Statements
“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me”.
“We are sick of falling through gaps. We are tired of organisational barriers and boundaries that delay or prevent our access to care. We do not accept being discharged from a service into a void. We want services to be seamless and care to be continuous”.
National Voices UK

17. The wise words of Don Berwick
“ There needs to be a radical redesign to move the focus of health from a quality improvement health focus to a courageous pursuit of wellbeing”
(1) “The needs of the patient come first.”
(2) “Nothing about me without me.”
(3) “Every patient is the only patient.”

18. Typical Day in General Practice

19. Current CarePlus Model

20. Integrated Family Health Centre?

30. Neighbourhood HealthCare Homes
Vision
“Working together to improve health for people who need it the most”
Aim
That Northland Primary care becomes an exemplar of how a patient centred, equity based model of care can improve health outcomes for the population and attract a primary care workforce who feel passionate and excited about what they do.

31. Neighbourhood HealthCare Homes Programme
1. Integration with community
2. Internal General practice change
3. Primary secondary integration
10 themes underpinning the model

32. Approach The Programme includes two phases:
Health Care Home - Scoping the Gap
Health Care Home - Implementation
The Scoping the Gap phase is likely take 3-6 months and the HCH Development Team will work with Practices to complete this.
The Implementation phase will have key milestones for delivery of the MoC – to be agreed by the Steering Group

33. Modified Driver diagram : Neighbourhood Healthcare Homes
Drivers
Changes
Benefits
Inequity
Quality initiatives to reduce inequities , based on data
Inequities are reduced
Time is valued not wasted
Ageing population and Increase in people with long term conditions
High need/risk patients are identified and proactively managed
Capacity is released, in order to do things differently
Whanau Tahi shared care planning tool
Increase patient demand for quality
Long term conditions managed more effectively
Increased access, through call management, technology and extended hours.
Technology advances
Reduced pressure on secondary services
Ageing and stressed workforce
LEAN work
Increased workforce satisfaction
Increase social navigation linkage and referrals
Uncoordinated services
Care is coordinated and patients are linked with the services they need
Use the person with the right skill for the right job. Explore increase in lay roles
Too many people ending up in hospital who don’t need to.
Patient driven and designed changes more likely to be effective
Patients and consumers involved in designing change

34. Components of Care Equity management Call management
Dr triage of patients
Planned year of care
Clinical and administrative pre work
Extended hours
Patient and whanau centric appointments
Expanded use of roles and new roles
Applying lean principles to facility layout and practice processes
Telephone consultations for Dr and Nurse
Patient portals
Engagement with new nursing model of care
Consumer and community engagement
Social and health service integration
Quality and safety

35. Equity AIMS Reduce inequities
Improve access and provision of services to those who need it
Reduce secondary care presentations for high need patients
Mechanisms
Release capacity and then provide more intensive and targeted services to those with the greatest need
Maori engagement / collaboration / representation in innovation
Maori employment
Ensure all new service programmes reach all population equally
Community engagement and collaboration
Measures
Patient Feedback / Consumer Focus group feedback
GP information reports

36. Consumer and Community Engagement
AIMS
Innovation and MoC design to be patient led
Consumer engagement / feedback
Consumer co design
Patient led services
Equity – reaching all parts of society equally
Mechanisms
Consumer groups
Focus groups
Walk in my shoes
Consumer representation in improvement work teams
Social media / NGOs / partnership working
Baseline Measures
Patient Feedback / Consumer Focus group feedback

37. Chronic Care Management
AIMS
To provide intensive services to those who need it most
Use patient centred, inter disciplinary model of care to improve outcomes and reduce avoidable admissions
To support continuity of care
To implement patient centred care supported by self management
Mechanisms
Nursing model of care
Shared, integrated care planning process
Collaboration and integration (health and social care)
Community engagement
I.T. platforms (Whanau Tahi)
Risk Stratification- 3 methods for this in development
Baseline Measures
GP information report
Patient Feedback
Current CarePlus user list vs Risk Stratified list

38. Approach Team Visioning Form Practice Implementation Team
Develop Model of Care
Determine MOC impact
Implement Model of Care
Establish Governance and Systems
Access, Capacity and Continuity
Separate Acute and Chronic Patient Processes
Streamline Processes
LEAN
Form Practice Implementation Team
Agree Governance
Implementation Plan
Financial Analysis starts
Analysis
Phone Analysis
Task Analysis
Consultations
Acute Scheduling
IT Capacity enablers
Analyse and Stratify Consultation Load
Managing Acute Demand
Identify complex patients
Workforce
Team Approach
Professional Development
Standing Orders
Appointment Scheduling
Complex care planning and co ordination
Patient centred care

39. Timeline for first two practices
August Sept Oct Nov Dec Jan Feb S M M
Financial Analysis & Modelling M
Visioning
Patient Feedback
Current State Assessment
Draft Change Plan
ADKAR Assessment
Comms Plan
Gap Analysis
Impact Analysis
Change Plan Agreed
Contract Signed
Ready to proceed
Change Plan Created
Consumer engagement
GP Information Reports
Same day access
MedTech call and appointment analysis

40. Financial Modelling Consumer Engagement
Develop Model of Care
Determine MOC impact
Implementation
Access, Capacity and Continuity
Separate Acute and Chronic Patient Processes
Streamline Processes
LEAN
Huddles, Facilities
Analyse and Stratify Consultation Load
Analysis
Phone Analysis
Task Analysis
Consultations Types
Acute Scheduling
Portal Uptake
Patient Feedback / Consumer Focus Groups
Extended Hours
Identify complex patients
Nursing Model of care
Dr Triage
Complex care planning and co ordination
Patient centred care
Virtual Consults
Appointment Scheduling and pre work
Workforce
Team Approach
Professional Development
Standing Orders
Self Management
New Roles
Technology
Health and Social Care Integration
Consumer Engagement

41. Love without a budget is not true love
Good will is easy. It gets complicated when it’s about money and income.
Business Case to Treasury for HCH’s a compelling case for better outcomes

43. Light at the end of the tunnel