1. Lessons from Study tour: Implications for Neighbourhood Healthcare Homes Nurses Hui 16.4.15 Jenni Moore

2. Synthesis

4. Key elements My distillery slide Support people to be healthier through providing better care Enhanced access Better patient experience Better patient experience Increased worker satisfaction Reduced costs Patient engagement, activation and experience Work with patients on all aspects of how you relate. They must have a good experience Work in a team, and make sure the patient knows the team: trust and relationships Technology : Use all technology to enhance access for patients, enable remote work, and monitoring Know your patients: stratify into high medium and low risk. Proactively manage medium and high, engage with low by email, phone, Skype etc. Appointment slots to reflect need. Post discharge follow up Implement lean processes. Consider ‘the flow’, reduce waiting, use the right workforce to do the right work, team huddles to coordinate Patient Centred Medical Home

5. What did we like and what didn’t we like Like: Patient centred: involvement of patients in co-design, prioritising patient experience Acknowledgment of need to include social and ‘behavioural’ dimension- whole of person Belief in need to link effectively with network of providers “improving health is a challenge that requires the engagement of partners across the community to address the broader determinants of health “ (IHI org) Innovative use of technology

6. …. Not so much Electronic tags Gouging out of middle level nursing roles, - replacing with lay workers Still more work to be done in linking more with external providers, but this is seen as essential

7. Paradigm shift TodayFuture Treating Sickness / EpisodicManaging Populations Fragmented CareCollaborative Care Specialty DrivenPrimary Care Driven Isolated Patient FilesIntegrated Electronic Records Utilisation ManagementEvidence-Based Medicine Fee for ServiceShared Risk/Reward Payment for VolumePayment for Value Adversarial Payer-Provider RelationsCooperative Payer-Provider Relations “Everyone For Themselves”Joint Contracting

8. Evidence Patient experience is positively associated with clinical effectiveness and patient safety Patients experiences should be included as one of the central pillars of quality in healthcare Clinicians should resist side-lining patients experience as too subjective, or mood oriented, divorced from the real work of measuring safety and effectiveness Doyle, C.;Lennox, L.; Bell, D. 2012 “A systematic review of the evidence on the links between patient experience and clinical safety and effectiveness”

9. Evidence https://www.pcpcc.org/ Reduction in Emergency department attendances Reduction in Ambulatory Sensitive Hospitalisations

10. So how does this line up with what we are doing in Northland?

12. Northland Health Services Plan Integrated Urgent Health Care (IUHC) Neighbourhood Health Care Homes (NHH) Patient and Family Centred Care Fit for Life First 2000 Days

13. Project manager for 12 months Andrew Miller Clinical Lead Rose and Chris sponsors The NHH project

14. Neighbourhood Healthcare Homes A network of providers connected up with General Practice and including consumers to provide accessible, comprehensive, coordinated patient centred proactive care. Relationships between patients and the extended team, and within the extended team are central to success.

15. Aligns to IHI triple aim framework

16. Te Tiriti o Waitangi

17. Foundations of Primary Healthcare Excellent accessibility Comprehensive Coordinated Continuity – relationship (Barbara Starfield) Compassion (Dr Harry Rea) Community (Ben Rosenstein)

18. Wagner’s Chronic Care Model

19. Elements of a Neighbourhood Healthcare Home

20. Painting a picture Intentional linking and issue management with consumer involvement Clarity around nursing roles and linkages, for the patients and the health providers Proactive management of medium and high need patients Accessibility for all: options

21. Difference is…. More than lip service to ‘patient centered’ Co design : listening and acting Leveraging off technological advances Focus on relationships

22. Its not rocket science:

23. “I was dropped through the service and support gap in the hospital systems and it has yet to be determined how far I have fallen” (Patient complaint NDHB 2014) “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). Why is this project needed?

24. To improve equity of access to health services and health status Fragmented diagnosis and treatment as different parts of the system fail to communicate effectively Patients miss out on care To develop a sustainable fit for purpose PHC system To take advantage of technological change Changing demographics and patterns of disease Increased demand for quality care by patients Patients not supported to manage their own health

25. “The patients perspective is at the heart of any discussion about integrated care. Achieving integrated care requires those involved with planning and providing services to impose the patients perspective as the organising principle of service delivery” ( Shaw et al cited on www.Kingsfund.org.UK ) Integrated care is centred around the needs of users

26. Your assistance Support the kaupapa: stronger primary care Nurses are central to the change Key potential expanded roles You are leaders in the health system Be the champion in your practice for NHH Help get the right people involved, including consumers