Lessons Learnt – WellSouth 26 June 2019

Lessons Learnt Tauranga 26 July 2019

The Strategy: Vision and strategic goals The Southern health system is built on an overarching vision…

Better health, better lives, Whānau Ora The vision for primary and community care is…

Excellent primary and community care that empowers people in our diverse communities to live well, stay well, get well and die well, through integrated ways of working, rapid learning and effective use of technology

The strategic goals supporting this vision are…

1 Consumers, whānau and communities are empowered to drive and own their care

2 Primary and community care works in partnership to provide holistic, team-based care

3 Secondary and tertiary care is integrated into primary and community care models

4 The health system is technology-enabled

The best $20,000 of someone else’s money I’ve ever spent.

Programme summary • Tranche 1a: 4 practices started implementing HCH 1 November 2018 • Amity (Dunedin), Gore Health, Gore Medical, Queenstown Medical • 32,000 patients • Selected as early adopters to refine the model

• Tranche 1b: 4 practices started implementing HCH 22 March 2019

• Aspiring (Wanaka), Broadway (Dunedin), Junction (Cromwell), Waihopai (Invercargill), Wanaka Medical • 31,000 patients • Selected as progressive practices with committed teams

Tranche 2: 7 practices starting 1 July 2019

• Alexandra Medical, Clutha Health First, Invercargill Medical, North End (Oamaru), Mataora (Dunedin), Meridian (Dunedin), Mornington Health Centre

• EoI for tranche 3?

• Likely to target high-needs practices (Māori, Pasifika and Dep5 + ED rate) • 12 practices with ~60,000 patients

Practice Implementation Plan finalised HCH 101

Establishment Phase

July 2019

Workshops

Year 1 – Improve processes to free up time and capacity

Years 2 & 3 – Improve patient and system outcomes

Year 1

Year 2

July 2020

Health Care Home Collaborative Certification

Year 3

July 2021

End July 2022

Our principles for getting started are: 1.

2.

3.

4.

5.

that you trust us and each other that it’s clear what’s happening and in what order that you have the information you need to make HCH work that the next three years are well-planned and that, after all this, you go-live still excited.

Credentialing criteria At-Risk Target Implement GP triage and on the day appointment availability for triaged patients.

Alternatives to face to face appointments are investigated to ensure patients receive the most appropriate care.

Call management arrangements are in place

Extended hours

Patient portal – increased activated users

CLIC

Measure(s) of At-Risk Target

Credentialing criteria At-Risk Target Implement GP triage and on GP phone triage implemented five days a week by 30 the day appointment June 2019. availability for triaged patients.

Measure(s) of At-Risk Target 1. A project plan detailing the work needed to meet the At-Risk Target is agreed with the HCH Programme Team by 31 March 2019.

2. Each GP to have 2 acute appointments in each consulting session by 31 December 2018.

10

Tue 12/02/2019 Tue 19/02/2019 Wed 20/02/2019 Thu 21/02/2019 Fri 22/02/2019 Mon 25/02/2019 Tue 26/02/2019 Wed 27/02/2019 Thu 28/02/2019 Fri 01/03/2019 Mon 04/03/2019 Tue 05/03/2019 Wed 06/03/2019 Thu 07/03/2019 Fri 08/03/2019 Mon 11/03/2019 Tue 12/03/2019 Wed 13/03/2019 Thu 14/03/2019 Fri 15/03/2019 Mon 18/03/2019 Tue 19/03/2019 Wed 20/03/2019 Thu 21/03/2019 Fri 22/03/2019 Tue 26/03/2019 Wed 27/03/2019 Thu 28/03/2019 Fri 29/03/2019 Mon 01/04/2019 Tue 02/04/2019 Wed 03/04/2019 Thu 04/04/2019 Fri 05/04/2019 Mon 08/04/2019 Tue 09/04/2019 Wed 10/04/2019 Thu 11/04/2019 Fri 12/04/2019 Mon 15/04/2019 Tue 16/04/2019 Wed 17/04/2019 Thu 18/04/2019 Tue 23/04/2019 Wed 24/04/2019 Fri 26/04/2019 Mon 29/04/2019 Tue 30/04/2019 Wed 01/05/2019 Thu 02/05/2019 Fri 03/05/2019 Mon 06/05/2019 Tue 07/05/2019 Wed 08/05/2019 Thu 09/05/2019 Fri 10/05/2019 Mon 13/05/2019 Tue 14/05/2019 Wed 15/05/2019 Thu 16/05/2019 Fri 17/05/2019 Mon 20/05/2019 Tue 21/05/2019 Wed 22/05/2019 Thu 23/05/2019 Fri 24/05/2019 Mon 27/05/2019 Tue 28/05/2019 Wed 29/05/2019 Thu 30/05/2019 Fri 31/05/2019 Tue 04/06/2019 Wed 05/06/2019 Thu 06/06/2019 Fri 07/06/2019 Mon 10/06/2019 Tue 11/06/2019 Wed 12/06/2019 Thu 13/06/2019 Fri 14/06/2019 Mon 17/06/2019 Tue 18/06/2019 Wed 19/06/2019 Thu 20/06/2019 Fri 21/06/2019 Mon 24/06/2019

NUMBER OF GP TRIAGE CALLS

90

80 80

70 70

60

50 48

40 38

30 30

20 22 19 17 40 42

27 29 29

21 24 26 31

18 12 21 25

17 24

16 27 14 12 22 25

14 24

17 28 31

24 19 19 22 33 28

23 22 46

31 42

37 28 34

25 70

49 73 78

63 66

46 40 38 66 67

58 56 59

51 42 39

34 42 37 64

47 47 48 44 62 68

52 47 41 44

23 29 31

15

0 3 1

Credentialing criteria Alternatives to face to face appointments are investigated to ensure patients receive the most appropriate care.

At-Risk Target 1. By 30 June 2019, increase the number of e-consults by 20%.

2. By 31 December 2018, complete an options analysis for telephone consults.

Measure(s) of At-Risk Target 1. Patient portal emails for three months to 30 June 2019 are 20% higher than three months to 31 October 2018.

2. E-consult policy documented by 31 December 2018.

3. Options analysis for telephone consults completed by 31/12/2018.

Call management arrangements are in place

A plan is in place by 31 March 2019 to significantly reduce the dropped call rate by 30 June 2019.

1. By 31 January 2019, data is available showing dropped calls, call wait times, and peak demand times.

2. By 30/6/19, adequate reception staffing in place to ensure adequate staffing at peak times with “time to answer� standards in place.

Extended hours

1. Early morning and lunchtime consults offered by 30 June 2019.

2. Patient survey regarding evening consults complete by 30 June 2019.

1. Appointment templates show early morning and lunchtime consults by 30 June 2019.

2. Survey completed by 30 June 2019.

Credentialing criteria Patient portal – increased activated users

At-Risk Target 1. 70% of patients aged 18+ are registered by 30 June 2019.

2. 90% of MMH-registered patients are activated on MMH by 30 June 2019.

3. 10% of GP appts made online by 30/6/19.

Measure(s) of At-Risk Target 1 + 2. Patient portal reporting to HCH Programme Team.

3. 10% of appointments in three months to 30 June 2019.

Nurse phone calls per month

Credentialing criteria CLIC

At-Risk Target 70 Comprehensive Risk Assessments (CHAs) completed by 30 June 2019.

Measure(s) of At-Risk Target Report of completed CHAs to HCH Programme Team by 30 June 2019.

CLIC process overview 1. Practices (nurses) assess patients, assisted by a comprehensive health assessment on WellSouth portal 2. Patients are stratified into 1 of 3 levels 3. Funding is linked to the level 4. A package of care standardised for each level is delivered

5. Patients transfer off CarePlus funding

Lean in Year 1 Start with visual whiteboard, Kanban, huddles Practices are doing non-HCH improvements: script renewal, recalls, telephone management‌

Huddles continue daily, These were especially relevant and helpful during the measles outbreak as it enables us to get the message across to all staff in a timely manner and provide a space to discuss any implications easily.

I think this was a leaner process than prior similar situations, as consistent information was able to be given to everyone at the same time, reducing any confusion and allowing for cohesive discussion when required.

General Manager, Gore Medical

Lean mantras Spend time with problems first, don’t jump to the solution. You’ve got to fix problems, not implement solutions.

Put the problems into the right order: 1.

2.

3.

4.

Is this a problem?

Is this a problem that needs to be fixed?

Is this a problem that needs to be fixed right now?

Is this the most important problem that needs to be fixed right now?

There are three truths. We believe in the third.

1. What is written down. Like a policy.

2. What we think about what is written down. How we interpret the policy.

3. What actually happens. What we see.

What we’ve learnt…

• Use Slack • We make mistakes, so if something seems wrong just call us. Don’t waste time wondering.

• It takes effort and time to get the change team working and organised:

• Have clinical, admin and management on the change team. Make sure the same people are engaged throughout and give them to the time to do it.

• The GM/manager does a lot.

• The change team needs to meet weekly. Any less frequent and you lose momentum. Use the visual whiteboard.

• The wider practice might not be sure about what’s happening. Ask them.

• The connective tissue between the change team and the practice is gemba and data.

• The car trip to workshops is really useful.

• Learn from other practices: talk, visit, share, use VC • The establishment phase and the workshops will give you a lot of input. For some people it’s been challenging, but we’ve seen a real change in thinking over the course of the phase.

Health need

At-Risk Targets

Measurement(s) of At-Risk Targets

Accessibility

Improved accessibility to routine appointments.

Time to third next available appointment will average 2 days over three consecutive sample periods.

Polypharmacy

Working with WellSouth clinical pharmacists, we will Outcome of xx medication use reviews documented by 30 complete medication use reviews for xx >65 patients, with June 2020. outcomes of the reviews documented.

Angina pain

or

chest Work with Dunedin Hospital cardiology service to educate All GP and practice nurses have completed angina and chest our GPs and practice nurses in angina and chest pain pain management education by 30 June 2020. management.

Equity

Reduce the difference between the Māori ASH rate and the 10 fewer Māori ASH presentations in the 12 months to 30 All Patient ASH rate by reducing the number of Māori ASH June 2020 than the preceding 12 months. presentations by 10.

Mental health

Design, test and evaluate the xxxx programme.

ED AND/OR presentations

The evaluation of x is made available to the HCH Programme Team by 30 June 2020.

ASH ED AND/OR ASH presentations are 5% lower than baseline ED AND/OR ASH presentations to SDHB hospitals for our growth over the preceding 24 months predicts. enrolled patients in the 12 months to 30 June 2020 are 5% lower than baseline growth over the preceding 24 months predicts.

Southern Health Care Home Year 1 Credentialing Criteria Summary – May 2019 At Risk Target

Tranche 1a Oct 18- July 19

Amity Health Centre Gore Health Centre Gore Medical Centre Queenstown Medical Centre

Tranche 1b March 19 – Nov 19

Aspiring Medical Centre Broadway Medical Centre Junction Health Centre Waihopai Health Services Wanaka Medical Centre

GP Triage

Same day appointment availability for all triaged patients

Alternatives to F2F ie Telephone/ Video/Secure messaging

Monitoring call metrics + wait time reduction

Extended hours

Fully functioning patient portal

CLIC + proactive care planning

Measures

Effect of GP triage

Number of calls resolved on the phone / Number of same day appointments for triaged patients

As at 1 Nov 2018

1 Feb - 27 May 2019

PHO

Not provided

792/900

Amity Gore Health

Not provided Not provided

25/40 By 30 June 2019

Gore Medical

Not provided

166/169

M훮ori are 9.5% of total calls received and 9.9% of patients M훮ori are 6.6% of total calls received and 6% of patients From QMC: "Feedback from patients continues on the positive impact this is having for them.

Anecdotally we have noticed a reduction of the number of enrolled patients presenting to our walk in clinic following introduction of GP triage.

Data on enrolled vs non-enrolled vs accident presentations to A+M for early analysis pre vs post GP triage."

Queenstown

Not provided

469/625

M훮ori (all practices)

Not provided

52/71

792 people avoided an appointment (outcomes = largely advice only or script) 900 same day appointments were made for people (296 urgent and 667 non-urgent) M훮ori are 4% of total calls received and 3% of patients

Alternatives to face to face: telephone consults and portals are more convenient and efficient than face to face appointments 1-30 Nov 2018

1-31 May 2019

Amity

GP telephone consults = 0 GP telephone consults = 51 Secure portal messages = 763 Secure messages = >1,000 Portal script renewals = 141 Portal script renewals = 133

Gore Health

Number of nurse phone consults = 1,204 Secure portal messages = 42 Portal script renewals = 42

Gore Medical

GP telephone consults = 0 GP telephone consults = 0 Secure portal messages = 216 Secure portal messages = 676 Portal script renewals = 153 Portal script renewals = 220

Queenstown

GP telephone consults = 0 Secure portal messages = 0 Portal script renewals = 0

GP telephone consults = 0 Secure portal messages = 0 Portal script renewals = 0

By 10 June

MÄ ori (all practices)

Data not available

Data not available

Portal vendors can't report by ethnicity.

We are arranging a work around.

GP telephone consults should increase as an alternative to face to face

Number of nurse phone Nurse phone consults should decrease as non-clinical work consults = 1,058 is done via patient portals Secure portal messages = 133 Portal script renewals = 62

Call management arrangements in place including call metrics and patient wait times investigated Measure Abandoned call rate / Average time to answer

PHO Amity Gore Health Gore Medical Queenstown

1-30 Nov 2018 Data not available Data not available Data not available Data not available Data not available

1-31 May 2019 Data not available 2.4% / 11 seconds

Many practice telephony systems are not fit for purpose Updated telephony system by July These are excellent numbers. Some practices are >20%.

Updated telephony system by July Updated telephony system by July

Extended (routine) hours

As at 30 November 2018 Amity Gore Health

Open to 8pm Mondays

As at 31 May 2019 Open at 8am & lunch Open to 8pm Mondays

Surveying patients on extended hours by July

Gore Medical

Open to 7.30pm Mondays Open to 7.30pm Mondays Surveying patients on extended hours by July and Wednesdays and Wednesdays

Queenstown

A+M open 8am-8pm for out of routine hours

A+M open 8am-8pm for out of routine hours

Patient portal in place Target = activated users increasing Measure % patients 18+ with activated portal

PHO Amity Gore Health Gore Medical Queenstown MÄ ori (all practices)

As at 30 November 2018 7.84% 65.44% 4.95% 16.77% 0% Not available

As at 31 May 2019 14.76% 78.68% 39.20% 33.50% By 10 June Portal vendors can't report by Not available ethnicity.

We are arranging a work around.

Implement CLIC programme for at risk patients Measure # of Comprehensive Health Assessments completed HCH practices are 14% of all CHAs HCH practices cover 11% of all patients

PHO Amity Gore Health Gore Medical

As at 30 November 2018 Data not available 0 163 0

Queenstown

0

Māori (all practices)

Data not available

As at 31 May 2019 4015 56 1.5% of all Amity patients. Amity's CLIC target is 70 CHAs by 30 June 2019.

281 6% of all Gore Health patients. Gore has a CLIC test site. The target is 350 CHAs. 174 2% of all Gore Medical patients. The target is 100 CHAs. <1% of all QMC patients. QMC started CLIC in Nov 2018. They are making slow 42 progress but working closely with the CLIC team. The issue has been capacity.

6.4% of completed CHAs are for Māori 6.4% The practices are working to increase the rate of Māori in CLIC