Locality clinical partnerships – principles for contracting & funding

Martin Hefford8 December 2011

Locality Clinical Partnership Objectives Deliver Better, Sooner, More Convenient

Healthcare Improve patient health outcomes Reduce avoidable hospitalisations Improve clinical governance Deliver more integrated healthcare Deliver better value healthcare

Locality clinical partnerships: overview

Locality Health Profile

• To identify health priorities

Models of Care

• To address health priorities

Enablers

• To achieve models of care

Locality Clinical Partnerships to commission and review the work

An opportunity to create a clinically led integrated healthcare system that bridges the divide between primary care, community health services and secondary care.

Enhancing primary care to make it more accessible, comprehensive and proactive.

Enrolled populations of CMDHB service localities, Q3 2011

Locality Total% of pop enrolled in CM

practices Rank by size

Eastern 102,590 23% 3Franklin 45,570 10% 4

Mangere/Otara 138,230 31% 2Manukau 156,870 35% 1

Grand Total 443,250 100%

Source: PHO enrolment register Quarter 3, 2011, analysed by CMDH, December 2011

Ethnicity of the service locality enrolled populations Eastern

Other Asian

IndianPacificMaaori

European/Other

Franklin

Other Asian

Indian

PacificMaaori

European/Other

Mangere&Otara

Other Asian

Indian

Pacific

Maaori

European/Other

Manukau

European/Other

Maaori

Pacific

IndianOther Asian

Proportion of locality population defined as ‘High Need’

Locality % High NeedEastern 7%Franklin 26%

Mangere/Otara 81%Manukau 53%

Total 48%

PHO funding and monitoring frameworks include proportion of enrolled population defined as ‘high need’ – Maaori, Pacific or living in area defined as high socioeconomic deprivation (NZDep, quintile 5)

Within each locality, practice age structures vary

Locality% of locality 0 –

14 yrs

% of locality 15 – 44

yrs

% of locality 45 – 64 yrs

% of locality 65+

yrs

Eastern 20% 40% 27% 13%

Franklin 25% 37% 25% 13%

Mangere/ Otara

30% 46% 18% 6%

Manukau 24% 42% 23% 10%

CMDHB 25% 42% 23% 10%

Size of practice enrolled populations

Locality 0-4,999 patients

5,000-9,999 patients

10,000+ patients Total

Eastern 21 6 1 28

Franklin 1 2 2 5

Mangere/ Otara

12 4 5 21

Manukau 38 6 1 45

CMDHB 72 18 9 99

How are the population distributed across practices

Total hospitalisations

Distribution of hospitalisations by ethnicity

Crude rates acute med-surg-EC MMH by practice

Note, crude rate not age standardised,

EC presentations

Percentage of EC presentations statistically admitted

Locality

Age Grp Eastern Franklin Mangere/ Otara Manukau

Total CMDHB localities

0-14 years 42% 50% 43% 43% 43%

15 years & over 70% 72% 63% 65% 66%

All ages Total 64% 67% 57% 59% 60%

Volume of specialist OP visits

INITIAL THINKING

Contracting for Locality Clinical Partnerships

DHB PHO 1, 2, 3

Clinical Leadership

Group

GPs, PNs, Pharmacy,

NASC, DNs,

home care

SMOs, allied health

NGOs, social

services

Management support – enablers, IS, reporting, project management

Agreement

Alli

ance

Agr

eem

ent

Alliance agreement mandates:

• Locality clinical network – broad interest based membership

• Leadership group – clinically lead, focused on service integration, better value healthcare, and quality improvement

• Risk and gain sharing and $ commitment

• Management support, incl analysis and reporting

Locality clinical network

GAIHN contracting guiding principles (subset) 

• Incentivise the achievement of outcomes not the provision of service

• Build collaborative trust-based systems and processes

• Keep contracting simple, collaborative and outcome focused

• Have transparency in all dealings• Use a broad ‘dashboard’ of measures to prevent the

manipulation of single measures

Locality Clinical Partnerships - commissioning Determine current use of primary and secondary

health resources by locality (shadow budgets) Allocate budget decision making rights to three

streams:1. We discuss, DHB decides (eg hospital services)2. We discuss, LCP decides (eg community services)3. We discuss, primary care decides (eg capitation) Move to equitable budgets, & increase LCP

decision making over time

Commissioning – evolution over timeDecision making Time

We discuss, DHB decides E.G. Hospital operations, IDFs.

We discuss, LCP decides

E.G. POAC, After hours, community and home based services, primary mental health, CCM, Careplus …

We discuss, Primary care decides

E.G. SIA, HP Capitation

Acute demand gain sharing - overview

Time

Acu

te d

eman

d co

sts

planned

P&C costsNet saving

Acute demand risk & gain sharing - principles Funds that would have been used for extra

hospital staff/resources will be invested in primary & community settings to buy additional services.

Net gains to be re-invested in extra primary / community services – locality clinical leadership groups to advise on use.

Risk of poor outcome to be shared between DHB and primary care partners (say 75:25).

Acute demand targets & gains to be allocated by locality.

Fitting the pieces together

Locality clinical partnership

•Alliance agreement•Locality leadership group,•Clinical network

BSM business

cases• ISG led business case

for service integration MOC and primary care development with emergent LCP.

• Evidence and collaborative support for acute demand management in localities

• Risk tool• Care pathways• POAC• Whanau ora

GAIHN / NHC / AH+

• IS - shared care, e-referrals,

• Auckland clinical networks (diabetes, CVD, etc)

REGIONAL Plan

Regional initiatives

Next steps Develop locality clinical leadership groups Use 20,000 better care days as an initial

programme for contracting Use Better Sooner More Convenient Business

cases to develop alternative models of care & service integration plans for localities

Develop shadow budgets Put in place partnership agreements Monitor performance, evaluate, and adjust

over time.

Discussion points for board members Do we want to share some risk with primary care? Do we agree to take the largest share of risk? Do we agree that LCPs should decide on the use of

any conserved resources? Locality Clinical Partnerships could be as an alliance

agreement or a formal joint venture – thoughts? Proposed that the agreement is with PCOs (or

PHOs?) but the network is wider. Thoughts? Do we consider that future employment of

community health staff could change?