1. Integrated Framework of Care Toolkit

2. Presentation Overview Drivers for change What is integration? Toolkit objectives Leutz Integrated framework Forms and types of service integration Lessons from the literature Leutz five laws Quality measures Summary Where to from here? 1

3. Drivers for Change 1.The Ministers expectations 2.Demographic changes - ageing 3.A range of providers supporting older adults with multiple long-term conditions 4.The need to improve the experience of our service users through well planned community services preventing avoidable hospital and residential care admissions 5.Regionalisation of services - increased movement of service users & clinicians 6.Requirement for the most productive use of our health and social support workforces “Although my inpatient care was very good, I had an overall bad experience because I was sent home without any knowledge of how to access the support services I needed” 2

4. The Toolkit Proposes a framework specifying the different degrees of integration intensity required to meet different levels of client need Provides information on the different forms and types of service integration Offers a guide to planning integrated services 3

5. What is Integrated Care? An organising principle for service delivery aiming to achieve improved patient care through better coordination of services provided. Integration is the combined set of methods, processes and models that seek to bring about this improved coordination. Done well, integration should lead to the outcome of integrated care. Nuffield Trust: 2011 4

6. All Integration is Local The design of integrated services will vary depending upon; -The particular issue creating difficulties for clients & service providers -The constraints and possibilities within the local environment 5

7. Leutz: First Law of Integration ‘You can integrate all of the services for some of the people, some of the services for all of the people, but you can’t integrate all of the services for all of the people’ 6

8. Levels of Integration Intensity full integration resources are pooled to create new services to meet the complex health/social needs of a targeted population group coordination bridges largely separate acute, long-term care, social support systems using case managers and agreed processes to help higher need clients manage transitions in and across care settings linkage people with mild to moderate health needs are cared for by systems which serve the whole population. No new services or care management required Full Integration Coordination Linkage 7

9. Operational Domains Matrix Design of integrated services varies depending upon the need of the client group/degree of integration intensity The ODI proposes operational domains which should be considered in service development demonstrating differences between the linkage, coordination and full integration levels Useful for development of new services or as an environmental scan on an existing suite of services to understand the intensity of integration across the services 8

10. Operational Dimension LinkageCoordinationFull Integration Enablers in the Central Region context ScreeningScreen population to identify emergent needs Individualised needs assessment triggered by screening tool Referral protocols to ensure that individuals who are screened and referred get to the service Screen flow at key points (e.g. ED and hospital discharge, primary care providers) to find those who need special attention Targeted selection of older adults for specific services designed to meet priority needs of service users and providers Agreement between primary and secondary health care as to screening priorities Agreement on common screening tools across Region, and access by service users, caregivers and professionals to those tools Screening processes for high risk within integrated healthcare networks, accident and medical centres and Emergency Departments Referral protocols and pathways locally and regionally Identifying poor use of primary care Reliable and common data extracts Agreed stratification criteria for targeted services Information regarding eligibility for services is easily locatable and contingencies to fund service gaps are available 9

11. Matching Client Need to Integration Levels Need DimensionsLinkageCoordinationFull Integration Illness SeverityMild/moderateModerate/severe Illness StabilityStable Unstable Illness DurationShort to long-term Long-term or terminal Urgency of careRoutine/non-urgentMostly routineFrequent urgency Scope of services needed Narrow/moderateModerate/broadBroad Self-direction of client Self-directed or strong informal care Varied levels of self direction and informal care May accommodate weak self-direction and informal care 10

12. Forms of Service Integration Forms of integration which should be considered when an integrated service is being designed. Horizontal integration Vertical integration Virtual integration 11

13. Types of Service Integration Organisational Integration Functional Integration Service Integration Clinical Integration Normative Integration Systemic Integration 12

14. Leutz Five Laws of Integration 1. You can’t integrate all the services for all the people 2. Integration costs before it pays 3. Your integration is my fragmentation 4. You can’t integrate a square peg into a round hole 5. The one who integrates calls the tune. 13

15. Quality Measures Evidence on the impact of integration is limited Measures for improvement should always be linked to the programme objectives and aims, and be able to demonstrate that a change is an improvement (and not just a change) The IHI model for improvement questions can help define measures Structural, process, patient outcome measures can all be utilised. 14

16. Summary 1.Integrated services are a means to an end 2. Service design can be highly variable 3.Leutz levels of integration intensity provide a global view of how much integration is required for people at different levels of need 4.The operational domains suggest activities that could be undertaken by services/providers at various levels in order to meet client need and support service provision at other levels 5. Service planners should review the activities proposed at each level and apply them or not or in a variety of different ways 6. The need dimension table can be used to plan care for individual clients or to broadly analyse the numbers of people with needs which could be met by a linked, coordinated or 'fully' integrated service 7. Quality measures should be based upon the objectives of the service development - organisational, process and client health outcomes. 8. Great integrated service development requires a well informed and collaborative planning process 15

17. Provides a brief understanding of the Integrated Framework of Care References to the Framework document 16

18. International literature identifies that planning integrated care is a complex task To assist the Central Region DHBs to plan integrated care, a Planning Integrated Care Guide has been developed The guide provides a high level list of considerations for those involved in planning integrated services The questions posed are designed to promote a shared understanding of what the integration project expects to achieve and assist in a robust planning process 17

19. Case studies following Maria and Franz as they experience health changes and require different types of assistance Three case studies with emphasis on clinical / service integration 1.Linked 2.Coordinated 3.Integrated care 18

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21. Where To From Here? You can access the tool kit by going to: www.centraltas.co.nz/RegionalGroupsNetworks/ Central Region Health of Older People Network Application in DHB planning processes As a framework it is applicable to other areas such as mental health Follow up in April / May 2013 with DHBs Report to the National Health Board in June 2013 20