1. Mental Health Transformational Service Change A Results Based Story Dr Sue Hallwright (MBChB, MBA) February 2012

2. Context CMDHB – Public Funder and Provider Funder and provider of clinical services (inpatient and community) Funder of NGO community support services Funder of residential care Funder of primary care

3. Context – Local Population Young Ethnically diverse High socio-economic deprivation Urban/rural mix Rapid growth

4. Context – Local Population Living in NZ-Dep Decile 9 and 10 areas: 34% of our population 43% of all children 57% of all Maaori 74% of all Pacific peoples

5. Christmas 2002: the story begins… 110% occupancy acute MH inpatient unit Mentally ill people in medical and surgical beds People waiting hours for a bed Christmas eve: staff have given notice they will walk out CMDHB takes out an injunction to stop this… and “wins”

6. CMDHB bed level 2002  Acute inpatient beds 2002 – ”x”

7. On further inquiry: Clinical staff say “unsafe – need more beds” Shortage of professional workforce, poor morale Fragmented, complex service configuration Hostility between DHB clinical services and NGO support services People with chronic conditions socially excluded

8. The results – 10 years on Managing acute demand Access improved Rapidly expanded workforce Cost growth constrained “Upstream” investment

9. The results – 10 years on High service acceptability for service users Increased social inclusion for people with chronic conditions Greatly enhanced cohesion and partnership Good staff morale Strong commitment to learning and innovating

10. Measures of success: “Hard” measures Bed numbers Workforce growth Access levels vs population-based funding “Soft” measures Qualitative evaluation findings Demand for innovative approaches (clinician and service user)

11. CMDHB bed level 2002  Acute inpatient beds 2002 – ”x”

12. CMDHB bed level 2002   Acute inpatient beds - planned

13.  Acute inpatient beds - actual

14. Other inpatient beds - actual

16. Savings (vs popn growth.) Bed days saved > 22,000 over 9 years > 4,800 per annum current (+ 490 each year) $ saved > $15M over 9 years > $3M per annum current (+$350K each yr)

17. Savings (vs national ave.) Bed days saved > 75,000 over 9 years > 8,400 per annum current (decreasing) $ saved > $55M over 9 years > $5.3M per annum current

18. So what did we do? Investigated the history Took a “system” view Questioned “conventional wisdom” Gained organisational commitment Built a partnership of leaders Established a “development” team

19. So what did we do? Identified the evidence Sought promising practice Engaged everyone in solution-finding Formed partnerships to guide implementation Started small, tested and then scaled up Evaluated and adapted

20. 3. NGO/DHB Alternatives to admissionInnovative system-wide change:Context – the challenges in 2002No outflow, unmet demand1. Clinician increase, changed model2. DHB/NGO/Housing NZ partnerships Acute Inpatient Alternative (Peer) Residential Crisis Respite Support Coordination Sub-Acute Day Prog Community Mental Health Centre Scheduled appointments: Clinical Local Clinical Response & Residential Rehabilitation Housing Community Support Work Inpatient Rehabilitation Flexible supports Home Based Treatment Acute Inpatient Beds Crisis Response 4. Peer Support – Self Management

21. Triple Aim (Adapted from IHI) Health CostExperience Our emphasis

22. Triple Aim (Adapted from IHI) Health Cost Experience

23. Triple Aim (Adapted from IHI) Health Cost Experience

24. Informed Choices Effective use Effective healthcare Efficient healthcare Acceptable healthcare best practice evidence business methodologies quality improvement workforce development Investment in service users:

25. Transformation Concepts Focus on people who use your services Strengthen people’s ability to manage their health and make informed choices Build staff ability to engage with patients, (as well as technical expertise) Take a system view and work to make the system more cohesive

26. Transformation Concepts Create a learning, innovating culture use information to improve investments and services communicate frequently and use every conversation to bring people with you foster creativity and innovation Dedicated resource to support change Start small and scale up when “demand” grows

28. The Health “System” (Network of Care) Continuity of care across the spectrum of services in the system Funding is available for investing ‘upstream’/elsewhere Outcomes for people If people are in charge of their own wellbeing and recovery then ….. Good information about the services No stigma People use less intensive services to get better If demand met, then… And also, if there is a mechanism to match people’s needs to service then ….. Population focused Individual focused If unmet demand, then increased access to service People use less services to get better And if the system responds well then… People are not afraid to use the service People’s past experience of services is a good one Health Promotion and Illness Prevention Wellness Education Primary Care Healthy/protected population People at risk/vulnerable People who are unwell KnownNew Person Fewer people become unwell Fewer people become unwell People become unwell (relapse) less often Unwell people get better quicker CMDHB Health System – A dynamic model Family/whanau & support people enhance wellbeing and recovery And if there is a full range of clinical and support services to enhance wellbeing and recovery …. People present earlier when unwell People are supported to be in charge of their own recovery and wellbeing Community Recovery and Support services Community - out of home Clinical services Recovery and Support services Hospital Clinical services Recovery and Support services Peer Support Services Peer Support Services Peer Support Services

30. NGO Benchmarking example Initiative to support NGOs to improve services NHI-Based Reporting to DHB Linked to DHB information in database Benchmarking Dashboards generated monthly Quarterly Provider Benchmarking Forum

31. Improving delivery of services Choosing the 17 reports Interviewed people about how they would choose a service: Do people like me get better using this service? Client groups – diagnosis, gender, ethnicity Outcomes for these client groups What range services/treatments will I be likely to access if I use this service? Service mix Does the service use force? Rates of compulsory care Will the service help stop me getting sick again? Relapse prevention How much does the service cost? cost per hour

32. Sample Report: Relapse (benchmark)

33. Team A Sample report: Relapse (Team A over time)

34. Improving delivery of services How does it work? DHB sends each team benchmarked dashboard individual dashboard (last 12 months) Quarterly forum offers an opportunity to To discuss interpretation of reports Provide the context/story behind them Learn from others about good practice Question one another

35. Improving delivery of services How does it work? Providers disseminate the reports within organisations and Educate staff about them Involve workforce in the change process Build team pride Celebrate change Encourage critical reflective practice

37. Linking components of a system across multiple providers to include people using services How can IT support transformation?

38. Providing information about: people using the service best practice choices outcomes (positive and negative) services, interventions costs How can IT support transformation?

39. Informing healthcare decisions by healthcare practitioners by people using services by communities How can IT support transformation?

40. Informing performance improvement by services by providers across systems Informing investment decisions (interventions, service mix, equipment) by policy-makers by planners and funders by service leaders How can IT support transformation?