Figure 1
Conceptual framework of Integrated Care based on the integrative functions of PC [3].
Figure 2
The Aotearoa New Zealand health system and integration in 2008 and 2020.
Table 1
Local Integrated Care Initiatives.
| CANTERBURY | GREATER AUCKLAND | MID-CENTRAL | NATIONAL HAUORA COALITION | MIDLANDS | |
|---|---|---|---|---|---|
| Original Business Case Description | Canterbury Clinical Network – a consortium of PC providers covering half a million people. The proposal focused on evolving general practice into IFHCs, developing the wider team of primary health care professionals, and improving cooperation between primary and secondary care | Integrated Health Network – a consortium of 274 general practice teams, 11 PHOs and 3 DHBs delivering PC to a million Aucklanders. The consortium was committed to working together to achieve better health outcomes, better patient experience and better use of money, establishing up to 12 IFHCs over time | Four Mid-Central PHOs (Ōtaki, Horowhenua, Manawatu and Tararua) proposed five Integrated Family Health Centres s, collaboration across health and social organisations, mainstream and Iwi providers, more clinical leadership, management of long term conditions, focus on care of the elderly, care of the young and care of those with mental health issues | National Maori PHO Coalition – involved 11 PHOs from around the North Island. The proposal aimed to devolve services and government-held resources to Māori communities. The Coalition aimed to develop a national network of whānau ora models of care including IFHCs, new care pathways, health and social service integration | Midlands Network – involved 11 providers from Taranaki, Waikato, Tairawhiti and Lakes districts which cover an enrolled regional population of around half a million people. The proposal identified consolidating $66 million worth of services that were purchased and managed by four of the Midlands region’s DHBs and their provider arms that could be devolved into the community. The plan also involved developing nine IFHCs |
| Evolution | Evolved into a wider Canterbury System change management and leadership programme under a ‘one system, one budget’ message developing new models of integrated working and new forms of contracting to support this. After several large earthquakes (2010/11), changes accelerated to relieve the immediate strain on the health service [33] | Evolved into a Localities initiatives in one DHB (Counties Manukau) which started with ambitious budget-holding proposals which were then abandoned due to lack of agreement between parties [39]. Attention then turned to building local relationships and implementing a long-term condition case management programme | Evolved into a diversity of local initiatives centred around different partnerships, and the building of Integrated Family Health Centres | Evolved into many initiatives adopting a whānau ora model of care including Mana Tū. As a result of a codesign process for Māori living with complex long-term conditions Mana Tū started with a focus on those with type 2 diabetes | Evolved into a Health Care Home Initiative modelled on the United States Medical Home model developed by Group Health Cooperative (tailored to the New Zealand context) [40]. Led initially by the ‘Network 4’ PHOs, the model has been picked up by others and governed by a Health Care Home Collaborative [41] |
| Type of Integration | Multi-level system wide changes– covering many categories of Valentijn’s rainbow model of care. For example: Clinical Integration: Older people case management support programme (CREST) Professional Integration: Multi-disciplinary guidelines including Health pathways and Acute Demand Management Programme supporting patients with a range of acute services in their own home Functional Integration: HealthOne (electronic Shared Care Record Viewer) Normative Integration: Investment in staff training and co-design workshops Organisational Integration: new forms of alliance contracting | Attempted multi-level system-wide changes but reverted to focus on Clinical Integration (case management and Multi-Disciplinary team meetings) for those at risk of hospital admissions] and Functional Integration (involving shared electronic medical record) Some Normative Integration through outreach clinics | Attempted complex multi-level system changes but reverted to making small scale local progress on; Organisational Integration: Building IFHCs Professional Integration: Integrated nursing pilots and partnerships with Whānau ora commissioning agencies. | Started as case management support within wider interest in indigenous models of care. Initial emphasis on: Clinical Integration: i.e. diabetes case management. From this starting base also weaves in: Organisational Integration: Shared governance of the service and creation of Network Hub; and Professional Integration: New skill mix in Kaimanaaki case workers Functional Integration: New digital information systems (Mohio) Normative Integration: Investment in early co-design workshops | Changes only at the level of the PC system involving: Clinical Integration: Extended acute treatment options, multidisciplinary team meetings, and case findings and risk stratification Professional Integration: Increased capacity in general practice teams from Health Care Assistants and Clinical Pharmacists Functional Integration: Telephone assessment and triage, virtual consults, patient portals Organisational Integration: PC business change based on Lean processes |
| RESULTS FROM EVALUATIONS [21] | |||||
| User and professional experiences | Multiple evaluations and reviews highlighting the importance of leadership enablers including staff engagement, continuous quality improvement as well as technology able to drive a “one system one budget” approach [33, 34, 36] | Evaluation of what encouraged general practices to successfully implement more proactive care highlighted the importance of team approaches within practices which were prepared to change their organisational processes to support nurses to confidently take on new responsibilities for those with long-term conditions [40] | Evaluation found professionals ranked their perception of care coordination highly while patients rated their experience less highly. Success largely hinged on the enthusiasm of a small pool of frontline workers (champions) and their initial buy-into the idea of integrated care and a patient-centred approach(22] | Early assessments suggested user experiences were shaped by the way the Mana Tū programme was co-designed with whānau (patients and their families) to incorporate the experience of Māori experiencing long-term conditions. The philosophy of the Mana Tū programme is to support whānau to ‘mana tū’ (i.e., ‘to stand with authority’) [42] | Multiple evaluations highlighting the early energy and focus given to actions linked to improved business efficiency and sustainability of general practice. Staff generally rated the model higher than the traditional model of general practice [24], noting the changes heralded a call to action to move from a reactive PC model of care [24] |
| Care outcomes | Care outcomes limited to small studies. For example; integrated falls prevention strategies contributed to a reduction in harm from falls in the elderly population [34], and 78 per cent of a sample of clients who have been through the Community Rehabilitation programme (CREST) believed the service worked well with other health services in the home [36] | No specific data | No specific data | Early results found an average HbA1c decrease of 5mmol/mol for participants 3 months into the programme [43]. Cluster randomised controlled trial underway [42] | Population health targets (e.g. immunisations, smoking) were met. Patient portal use, and accessibility of appointments improved [44] |
| Utilisation of services | Findings related to bending the demand curve, “slowing – but not reversing – growth”. Results included: lower acute medical admission rates; lower acute readmission rates; shorter average length of stay; lower emergency department attendances [36] | An evaluation found no evidence of change that could be confidently attributed back to the Localities initiative from tracking secondary care demand across the Auckland region [40] | Analysis of routine date revealed that the desired 30% reduction in ASH rates were not realised. Data for ED presentations revealed a flat or slightly upwards trend [22] | No specific data | Early findings in one region have reported a significantly lower rate of ASHs (20% fewer) and a significantly lower rate of ED presentations (14% decrease) [24]. Another regional evaluation noted that while care was more accessible, timely, flexible and efficient, moves to more proactive care along with a focus on prevention and on patient centredness have not yet been strongly embedded [44] |
| Financial performance/Cost effectiveness | Compared with the rest of A/NZ, Canterbury has higher spending on community-based services; and lower spending on emergency hospital care | No specific data | No specific data | No specific data | The financial performance of Midlands-based Health Care Homes practices was reported to have been maintained or improved [24]. For Capital Coast-based Health Care Homes, an evaluation found initial funding to build capacity for change was useful but questions were raised as to whether funding now needs to be directed to support the capacity of communities to participate in a wider outreach stage [44] |