Self-Management & Shared Care Evaluation Report · ProCare Self-Management & Shared Care Evaluation...

Self-Management & Shared Care Evaluation Report May 2016

ProCare Self-Management & Shared Care Evaluation Report Page 1


Table of Contents

1.0 EXECUTIVE SUMMARY ......................................................................................................... 5

2.0 INTRODUCTION ................................................................................................................... 7

2.1 Context ............................................................................................................................................... 7

2.2 Programme Objectives and Care Model Overview .............................................................................. 7

3.0 PROGRAMME METHODOLOGY ............................................................................................ 8

3.1 At Risk Individuals and Change Management ...................................................................................... 8

3.2 Programme Approach ......................................................................................................................... 9

3.3 Participating Practices ......................................................................................................................... 9

3.4 The Self-Management and Shared Care Programmes ....................................................................... 10

3.5 Programme requirements ................................................................................................................. 11 3.5.1 Programme requirements for patient enrolment ............................................................................... 11 3.5.2 Programme requirements for practices .............................................................................................. 11

3.6 Supporting the new model of care .................................................................................................... 12 3.6.1 Change Management Initiatives ......................................................................................................... 12 3.6.2 Funding Model Implications ................................................................................................................ 15

4.0 EVALUATION METHODOLOGY ........................................................................................... 17

4.1 Evaluation Framework ...................................................................................................................... 17

4.2 Data Sources ..................................................................................................................................... 18 4.2.1 Age Sex Register (ASR) .................................................................................................................... 18 4.2.2 ProExtra .......................................................................................................................................... 18 4.2.3 Collaborative Care Management Solution (CCMS) ......................................................................... 19 4.2.4 Partners in Health (PIH) .................................................................................................................. 19 4.2.5 Assessment of Primary Care Resources and Supports for Patient Self-Management (PCRS) ........ 19 4.2.6 Combined Predictive Risk Model Algorithm (CPRM) ...................................................................... 20 4.2.7 Patient Survey ................................................................................................................................. 20 4.2.8 Provider Interview .......................................................................................................................... 20 4.2.9 Secondary Care Utilisation Data ..................................................................................................... 20

5.0 RESULTS ............................................................................................................................. 21

5.1 Individual – improved quality, safety and experience of care ............................................................ 21 5.1.1 Programme Enrolment ................................................................................................................... 21 5.1.2 Partners in Health ........................................................................................................................... 22 5.1.3 Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS) .................. 23 5.1.4 Patient Survey quantitative ............................................................................................................ 27


5.1.5 Patient survey – qualitative feedback ............................................................................................. 29 5.1.6 Provider Interviews ......................................................................................................................... 30

5.2 Population – Improved clinical outcomes and equity for all populations .......................................... 30 5.2.1 Clinical outcomes ............................................................................................................................ 30 5.2.2 Demographic Information/Equity of Access ................................................................................... 32

5.3 System – Improved value for public health system resources ........................................................... 35 5.3.1 Existing Services .............................................................................................................................. 35 5.3.2 Sustainability – Primary care utilisation ......................................................................................... 35 5.3.3 Sustainability – Secondary care utilisation ..................................................................................... 36

5.4 Workforce – Improved workforce engagement and workforce skill .................................................. 37

6.0 DISCUSSION ....................................................................................................................... 38

6.1 Achievements ................................................................................................................................... 38

6.2 Challenges ......................................................................................................................................... 40

6.3 Future Development ......................................................................................................................... 41

7.0 Recommendations ............................................................................................................................ 41 7.1 Effective executive sponsorship ..................................................................................................... 41 7.2 Building relationships ..................................................................................................................... 41 7.3 Training and support ....................................................................................................................... 42 7.4 Care planning .................................................................................................................................. 42 7.5 Operational technology .................................................................................................................. 42 7.6 Intervention funding ....................................................................................................................... 42 7.7 Self-management review ................................................................................................................ 43

APPENDIX A – GLOSSARY .......................................................................................................... 44

APPENDIX B - HOUSE OF CARE MODEL ..................................................................................... 45

Putting the patient at the centre ..................................................................................................................... 45 The foundation ................................................................................................................................................. 45 The walls ........................................................................................................................................................... 45 The roof ............................................................................................................................................................ 45

APPENDIX C - PLANNED PROACTIVE MODEL OF CARE .............................................................. 48

APPENDIX D - PARTNERS IN HEALTH QUESTIONNAIRE .............................................................. 49

APPENDIX E - CHANGE MANAGER CASE STUDY OF PFHC .......................................................... 51

APPENDIX E1 - WELLNESS WHEEL PATIENT ASSESSMENT TOOL ............................................... 61

APPENDIX E2 - PFHC – OTHER PATIENT CASE STUDIES .............................................................. 62

Case 1 - DB........................................................................................................................................................ 62


Case 2 - MF ....................................................................................................................................................... 62 Case 3 - AB ........................................................................................................................................................ 63

APPENDIX F – PCRS PRIMARY CARE RESOURCES AND SUPPORTS FOR CHRONIC DISEASE SELF-

MANAGEMENT ......................................................................................................................... 65

APPENDIX G – PATIENT SURVEY ................................................................................................ 78

APPENDIX H – PROVIDER INTERVIEW ........................................................................................ 80

APPENDIX I – PROVIDER INTERVIEW ANALYSIS ......................................................................... 84


1.0 Executive Summary The Self-management and Shared Care (SMSC) pilot was carried out with two practices in the

Counties Manukau District Health Board from July 2014 until October 2015. The aim of the pilot was

to:

build a patient centric model of care for patients with long term conditions

integrate self-management, delivery system design, decision support, quality clinical

information systems and multidisciplinary teams

target a range of patient groups with long term conditions

develop a model of care that is applicable to general practice and can be established and

transferred across New Zealand

provide value for money

The pilot was rolled out in conjunction with the At Risk Individuals (ARI) programme being

implemented in Counties practices. Each patient enrolled on the programme was assigned a care

coordinator who helped them to create a care plan with goals that they would like to achieve. They

were supported by their practice to become self-managing as well as providing them with problem

solving skills.

A key difference between the SMSC pilot and the ARI programme was the more intensive change

management support offered to the two practices. ProCare provided training for the practice

executive sponsor and coached them in how to undertake their role, using the Prosci® methodology.

This pilot has received positive feedback from both patients and practice teams. The patients have

really appreciated having the support and guidance from their care coordinator and team to listen

and develop a care plan. Practice staff have enjoyed working closely with patients and having the

opportunity to spend more time with them to understand issues impacting on their health. Seeing

patients achieve their goals motivated them to continue with the programme despite the teething

issues of learning a new model of care and IT system. GPs also reported improved access to services

for patients. They also noted improved collaboration and communication with allied health workers,

including multi-disciplinary team meetings.


Figure 1 Summary of results from the SMSC pilot

Upon enrolment, each patient completed a Partners in Health assessment. This was again repeated at

an annual review. Significant changes were observed for many of the domains measured by the

assessment, and the average change in total score for the two practices was greater than those doing

ARI alone, suggesting the SMSC model of care provides additional benefit compared to the ARI model

alone.

The model of care is associated with improvement in HbA1c levels for patients with diabetes.

Practice processes for supporting self-management improved.

Both practices managed to enrol 3% of their enrolled population on the programme. Each patient was

assigned a name care coordinator and was supported to create a shared care plan. These care plans

were stored electronically on a secure website that was accessible to all care team members looking

after the patient.

This pilot has highlighted seven key recommendations to ensure success and sustainability of a

programme such as this. These are:

Effective executive sponsorship

Building relationships

Training and support


Care planning

Operational technology

Intervention funding

Self-management review

Practices will need support and coaching to ensure the success of a change of this complexity.

Releasing of clinical staff from a practice to attend training can often be a financial and human

resource barrier to small businesses, so consideration needs to be given to the financial model to

support this.

2.0 Introduction

2.1 Context

In 2014, the New Zealand Ministry of Health (MoH) released a Request for Proposal seeking to test a

model of care that enables healthcare providers to better coordinate care and promote patient self-

management. This model is based on the NHS Year of Care and would be adapted to the local context.

By applying intensive change management support to two practices we are able to develop a

comprehensive model of care and identify barriers and enablers that contribute to successful

implementation. This knowledge would support adoption of the model by other practices.

ProCare was successful in securing a contract and began the programme evaluation from October

2014.

Part of the evaluation process, was to identify the project outcomes and benefits that aligned to the

New Zealand Triple Aim focussing on:

Improving quality, safety and patients experience of care;

Improving health and equity for all populations and;

Maximising value for public health system resources.

The impact on health care professionals improved knowledge and satisfaction was also examined.

This final evaluation report provides an evaluation for the one year programme and aims to

consolidate findings and lessons learnt from the programme to feed back to the MoH as

considerations for future implementation.

2.2 Programme Objectives and Care Model Overview

The proposed new model of care was based on the ‘House of Care’ model originally developed by

National Health Service in UK. The model of care puts patients at the centre of the healthcare system

supporting them to develop a care plan with shared care and self-management initiatives to improve

health outcomes (Appendix B).

Evidence from the UK experience suggests that this model improves care for people with long term

conditions (LTC) delivering overall better health outcomes for patients, their families and the wider

healthcare system.

This programme sought to understand whether the positive outcomes demonstrated in the UK would

be realised when a comparable model was implemented in New Zealand. Recognising that the new

pilot model deviated significantly from the traditional model of care, the MoH was also keen to


understand the change management initiatives and the business model modifications required to

create a truly sustainable, long lasting care approach. This approach is outlined in Figure 2.

Figure 2 Practice process for Shared Care and Self-Management

Patients most likely to benefit from the programme are identified and invited to take part. Those that

agree are assessed using the Partners in Health (PIH) questionnaire (Appendix D) and a care plan is

developed with support from the health care professional at the practice. The plan is stored in a

shared repository to allow secure access by multiple health professionals across the health system

who are involved in the patients care. The patient can also access the care plan through a secure

patient portal. The clinicians can then apply resource to support the patient to achieve their goals.

There is a wide degree of autonomy in the application of resource. Depending on patient need this

resource could cover time with a doctor or nurse at the practice, home visits, and services not easily

available through existing programmes such as dentistry or health psychology. It can also be used to

help fund goods required for a patient to achieve their care plan goals, such as sneakers or scales.

In order to generate well-balanced insights from the programme evaluation, two practices from the ProCare network were selected with each representing general practice with different characteristics in terms of their location, demographics, care approach and business model. Setting up the programme this way also enabled ProCare to understand how differences in business and funding models would affect the programme implementation and consequently determine the benefits and outcomes realised from their shared care and self-management initiatives.

3.0 Programme Methodology

3.1 At Risk Individuals and Change Management This programme was rolled out in conjunction with the At Risk Individuals (ARI) project. The ARI

project commenced at the start of July 2014, and involves a three-stage patient journey:


Assessment and enrolment

Up to 12 months of coordinated care

Transition off ARI or reenrolment as needed

ARI recognises that primary care is the best place for patient-centred care and subsequently has a

broad criteria for patient selection. The programme utilises the Collaborative Care Management

Solution (CCMS) eShared Care tool which allows clinicians to develop and manage a patient-centred

care plan that can be accessed by other clinical specialties not necessarily linked to the practice.

Patients benefit from enhanced collaboration between primary, secondary and allied health care, as

well as a flexible funding model that allows funding to be spent in a way that helps a patient achieve

the goals. The ARI intervention funding ensures clinical autonomy to apply resources as appropriate

for each patient, to achieve the overall programme goal of keeping patients well in the community.

As part of implementation of the ARI programme, practices were supported through a change

management process to inform and upskill team members. The change management support for the

Self-Management and Shared Care (SMSC) project was significantly greater than for practices doing

ARI alone. The SMSC project offered a dedicated in practice change manager to work with the

practices, as well as offering funded practice meetings to support the change.

3.2 Programme Approach

To successfully conduct the one year programme and ensure outcomes of the new model of care

could be effectively captured, a three stage approach was followed:

Service Enablement

Service Rollout

Service/Pilot Evaluation

Service Enablement: This was the planning and organisation phase of the pilot when shared care and

self-management programmes were designed, supporting materials were developed and programme

resources were trained and recruited to ensure the initiatives could be smoothly run during the pilot

period.

Service Rollout: This was the rollout phase of the new care model when the shared care and self-

management initiatives commenced to be implemented and incorporated as part of the practices’

core offering. Enrolments for the shared care and self-management initiatives began during this

phase in a staggered fashion to facilitate data collection and administration processes.

Service/Pilot Evaluation: This was the evaluation phase at the end of the one year pilot period when

data collected were consolidated, analysed and presented back to the MoH and the participating

practices.

Data collection was carried out throughout the programme to ensure sufficient data were available to

support the evaluation of outcomes and benefits at the end of the pilot. These included collecting

data before the programme started as benchmark indicators, throughout and at the end of the

programme.

3.3 Participating Practices In order to evaluate the feasibility and scalability of the new model of care, two practices with very

distinct characteristics were selected from the ProCare network as the demonstrators for the one


year programme. Summarised below in Table 1 are some high level differences between the two

practices.

Table 1 SMSC practice descriptions

Practice CMC PFHC Business Type Ltd company with multiple

stakeholders Ltd company with multiple stakeholders

Geographic Classification Urban Rural

Enrolled Population (as at 29/10/15)

8644 19028

Business Model Partnership Very Low Cost Access (VLCA)

Salaried GPs Regular Fee-for Service

Demographics Pacific peoples are the most common ethnic group in CMC.

Mainly of European descent, with significant Māori and ethnic Indian and East Asian communities

Social-Economic Profile Social - high rates of poverty and complex health issues in the population.

Good mix of people from different social-economic classes.

3.4 The Self-Management and Shared Care Programmes To cater for differences in their target patient groups, existing business and funding models, each

practice has designed and tailored a unique wellness programme to meet their individual needs. The

different programmes are shown below.

Table 2 SMSC programme descriptions for both practices

CMC PFHC SMSC Programme Description

CMC was introduced to care planning as part of an earlier High Risk Individuals (HRI) project being trailed in Counties Manukau Health (CMH). Following implementation of SMSC, CMC’s programme highlighted how a patient centred care model delivered within the general practice can provide the tools and support for people with long term conditions to successfully manage their health. They achieved this by working in partnership with patients to develop care plans with mutually agreed health goals and providing patients with access to complimentary services and input from a multidisciplinary team.

PFHC had a more structured approach to managing the Chronic Care Management (CCM) programme which was transitioned through to ARI. This structure included scheduled quarterly recalls for patients enrolled on CCM. The PFHC SMSC programme piloted how a patient-centred care model delivered within the general practice can help patients better manage their chronic conditions. The practice established a working partnership with patients to develop care plans with mutually agreed health goals, introducing broader access to health services and coordinating social and other complimentary support to provide a more holistic primary health care approach.


Shared Care and Self-Management Initiatives (SMSC)

Implemented ARI

Onsite health psychologist

Community health coordinator / social worker

Group self-management education (‘my health my life’ course)

Mindfulness course

Implemented ARI

Health psychologist

Community health coordinator or social worker

Group self-management education (‘my health my life’ course)

Pharmacy medication support services

Palliative patient care

Member of the Locality Implementation Group

3.5 Programme requirements

3.5.1 Programme requirements for patient enrolment Patients were identified by members of the clinical team as being potential candidates for the SMSC

programme. The decision to invite patients to take part was made based on clinical judgement of risk

of a poor health outcome, the modifiability of the patient’s condition and likely amenability of the

patient to adopt the behaviour changes necessary to benefit from the programme. Consideration was

given to patients enrolled on the recently discontinued Chronic Care Management (CCM) programme.

A Combined Predictive Risk (CPRM) algorithm was developed to guide enrolment. See section 3.2.6.

This tool was not available for routine use due to challenges in its development. It was used

sporadically towards the end of the programme

For each patient enrolled the programme was required to meet set criteria. These criteria were:

Patient consent

A named care coordinator

An electronic shared care plan

A Partners in Health (PIH) assessment (Appendix D)

Each of these elements was recorded electronically, through either the ProCare ProExtra tool or the

CCMS Shared Care website.

The Partners in Health assessment is a tool was developed by Flinders University as part of The

Flinders Programme TM for Chronic Condition Management. Patients complete the questionnaire

which covers 13 areas such as knowledge of the condition, ability to take medication, and their ability

to navigate the health system. Upon completion of the programme, patients undertook a second PIH

assessment to understand how their understanding and management of their health care had

changed.

A patient’s care plan is a living document so is intended to remain current and up to date even though

they are no longer actively enrolled on the programme. The care plan can be updated as part of a

regular consult with their GP or nurse.

3.5.2 Programme requirements for practices During implementation, all clinicians within each practice undertook an Assessment of Primary Care

Resources and Supports for Chronic Disease Self-management (PCRS) questionnaire to understand


the level of self-management integration in the practice. This assessment was carried out again at the

end of the pilot period to demonstrate how practice had changed.

3.6 Supporting the new model of care

3.6.1 Change Management Initiatives A change manager was assigned to work one day per week at each practice to help facilitate and

implement change based on the Prosci® change management framework. The Prosci® framework

uses the ADKAR® model – Awareness, Desire, Knowledge, Ability, and Reinforcement to implement

change. A post evaluation case study of the change initiatives in PFHC is attached as Appendix E.

A description of the implemented change management strategies is shown below in Table 3.


Table 3 ADKAR Change management approach

ADKAR principle Challenges for successful change in general practice Activities implemented to drive change

Awareness of why change is needed

Dissemination of communication that is clear, simple, timely and understood by recipient as intended

Programme training initially focussed on nurses – gap in awareness for GPs and others (eg, practice managers, health care assistants and admin staff)

Time and ability required for general practice to capture regular patient feedback/input that can inform service design

Programme information evenings for practice staff

Practice presentations

ProCare practice engagement staff and on-site change manager

Sharing of patient case studies

Care planning process (allowing patients to work in partnership with health professionals to manage their health)

Desire to support and participate in the change

Size of practice – impact on communication/awareness across whole practice

Change in nursing role for no/minimal increase in remuneration

Perception of reduced capacity for nurses to support GPs as per previous operational processes (patient centred care model vs. business as usual)

Variation in ways of operating across clinical teams

Fee for service business model

History and perceptions of short-term programme approaches

Personal motivators of staff

Identify and engage the executive sponsor in practice

Assessment of Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS)

Group discussion based on the 10 Building Blocks of High Performing Primary Care

Engage respected clinical leaders (Dr Allan Moffitt, Dr Janine Bycroft, Dr Tim Hou)

Sharing of patient case studies

Team huddles to discuss patient centred care model as part of whole practice meetings

Nurse meetings without management staff to problem solve issues (resistance management)

Practice values and performance management

Knowledge on how to change

Understanding the training requirements of all stakeholders

Practice size – larger practices require more structure and processes and training resources

Variations in experience within clinical teams – training needs to be adaptable to the audiences targeted

Comprehensive one-on-one care planning training provided (ProCare + DHB)

Care coordination training (DHB)

Practice notice board for sharing resource information

Dedicated care coordinators employed to work with complex patients

Patient feedback/focus group

Ability to implement the change

Technology problems eg; Slow connectivity/timing out Data transfer between software

Dedicated time in practice meetings for new model of care

Paid time for clinical team huddles to identify patients and plan care

Paid time for staff to attend additional meetings

Change management resource (on-site change manager and funding allocated)


Rules around access to eShared Care for some practice staff (non-registered health professionals eg, health care assistants, practice managers not being able to access care plans)

Timely communication and resolution of issues – delay in solving problems can cause disengagement

Agreement within practice of processes that fit operationally with resources and structures available

Fee for service business model deters practice from accessing external services/intervention options for patients

Awareness of community partnerships and/or access to external resources – referral processes and feedback mechanisms not always clearly defined

Flexibility of the patient centred model (ARI) vs very structured CCM programme

Clinical leadership (executive sponsor) role established

Practice weekly ARI project team meeting to problem solve programme issues

Process mapping

Developing community partnerships and processes for referral (social work, mental health, district nurses, pharmacy)

Reinforcement to sustain the change

Size of the practice and change required

Time needed to implement change

Existing communication channels

Competition between clinical teams

Dedicated time for care planning peer review / coaching

Monthly whole practice meeting

Online nurse tasking system (Medtech)

Development of nursing pathways

Intranet forums


3.6.2 Funding Model Implications Due to the differences in funding and business models adopted by the practices, funding for the ARI/SMSC initiatives were allocated differently between the two

practices. Table 4 below summarises the difference in funding arrangement for each practice and its impacts to the workforce.

Table 4 Practice funding models

GP - CMC GP - PFHC Nurse - CMC Nurse - PFHC Funding Arrangement for ARI/SMSC Consultations

No patient co-payment Quarterly visit – funded through ARI interventions

Patient pays co-payment No patient co-payment Funded through ARI interventions

No patient co-payment Funded through ARI interventions

Cost to Patient Free Patient to pay Free Free

Impacts on Current Role

Increased workload from additional documentation and paper work.

Doctor consultation not funded, therefore patients will have to pay if required to see the doctor. For this reason, patients often reached out to their care coordinator directly when experiencing health related issues.

Initially no additional time was allocated for nurses to conduct consultation. They will often have to squeeze in their consultation time with the patients right before or after patients' regular GP visit. The care coordination responsibilities were considered additional work to their day-to-day job. Towards the later part the programme, nurses were given 2-3 hours per week to catch up on some of the outstanding paperwork related to the SMSC programme.

Nurses have been given additional time and resources at their discretion to facilitate shared care and self-management activities. This gave the nurses some degree of autonomy to organise their own work.

Benefits GP is able to provide regular consultation services without patients needing to worry about financial issues.

A nurse-led model provides additional support for GPs to deliver more holistic patient care by relieving the burden off GPs from some of the less clinical aspects of patient care e.g. administrative and care coordination activities.

Minimum additional expenses incurred for the practice to fund for extra nurse staff activities.

The fully funded nurse-led model increased the nurses' sense of ownership and accountability.


GP - CMC GP - PFHC Nurse - CMC Nurse - PFHC Risks No major changes to GPs’ routines -

minimal risk. GP unable to provide timely clinical input or interventions when patient circumvents them or when there is a lack of communication with the nurses.

Additional pressure placed on nurses to deliver more work with the same amount of time. This could lead to over utilisation of the nursing workforce.

Identification of health issues that need to be escalated to a GP with a robust escalation process in place.


4.0 Evaluation Methodology

4.1 Evaluation Framework The evaluation sought to measure outcomes from the application of a flexible model of patient

centred care planning, shared care and self-management. These outcomes were aligned to the Triple

Aim specified by the Health Quality & Safety Commission New Zealand, which are:

Individual - Improved quality, safety and experience of care

Population - Improved clinical outcomes and equity for all populations

System - Improved value for public health system resources

In addition, the evaluation also assessed the programme and its impact on workforce.

Workforce - Improved workforce engagement and workforce skills

To effectively assess the programme outcomes, each outcome was broken down further into

anticipated benefits that were measurable. The Evaluation Framework (Table 5) summarises the

anticipated benefits associated with each of the programme outcomes and demonstrates how these

benefits were measured.


Table 5 Evaluation framework

Outcomes Benefits Data source

INDIVIDUAL: Improved quality, safety and experience of care

Improved ability for patients to choose and access health services

ProExtra

CCMS

Patient survey

Provider interview

PIH

PCRS

Improved ability of patients to self-manage and educate themselves about their health

PIH

Patient survey

PCRS

Provider interview Increased quality and safety of health services

Patient survey

PCRS

Provider interview

Enhanced customer experience within the health system

Patient survey

POPULATION: Improved clinical outcomes and equity for all populations

Improved clinical outcomes TBD

Increased equity of healthcare services for all populations

Provider interview

ASR

ProExtra

SYSTEM: Improved value for public health system resources

Appropriate utilization of existing healthcare services

CPRM

CCMS

Provider interview

Increased sustainability of practices

TBD

Reduced unplanned hospitalisations

DHB data

Provider interview

Improved shared accountability with secondary care

Provider interview

WORKFORCE: Improved workforce engagement and workforce skills

Increased knowledge of the work force

Provider interview

Increased skills of the work force

Provider interview

Increased satisfaction and engagement of the workforce

Provider interview

4.2 Data Sources

4.2.1 Age Sex Register (ASR)

This refers to the practice register which was the source for demographic information for the practice

population and individuals enrolled on the programme.

4.2.2 ProExtra

ProExtra is a tool which assists with the provision of primary care services to eligible patients either

through general practice or through referral to other contracted providers. It effectively incorporates

clinical triage criteria, real time business intelligence, and manages demand and budget for the ARI


programme. The system allows sequential recording of PIH, enrolment numbers and dates,

supporting interventions ordered by clinicians.

4.2.3 Collaborative Care Management Solution (CCMS)

CCMS is the electronic shared care plan. It stores a shared health record and the patients plan. This

system records activity on the plan and who the patients assigned care coordinator is. This plan and

information can be shared with health care providers agreed to by the patient.

4.2.4 Partners in Health (PIH)

PIH is a generic measure of self-rated self-management knowledge and skills. It is primarily a care

planning tool that allows support and coordination to be targeted more appropriately but has also

been used sequentially as an outcome measure.

Flinders University Human Behaviour and Health Research Unit developed the tool which was based

on six principles of self-management:

1. Improved knowledge of their condition

2. Following a structured treatment plan agreed with the health provider

3. Actively share in decision making about their health

4. Monitor and manage signs and symptoms of the condition

5. Manage the impact of their condition on the physical, emotional and social aspects of life

6. Adopt behaviour that promotes healthy lifestyles

The tool has been confirmed to have construct validity and internal reliability.

4.2.5 Assessment of Primary Care Resources and Supports for Patient Self-

Management (PCRS)

The PCRS is a self-assessment tool for use in primary care settings. Its purpose is to provide a focus on

actions that can be taken to support patients with long term conditions.

The measure has two components:

Patient support. This assessment at the “micro system” level of the patient, provider and care

team addresses characteristics of service delivery found to enhance patient self-

management.

Organisational support. This assessment at a more “macro system” level addresses

characteristics of organisations that support delivery of self-management services.

Specifically the PCRS:

1. Defines characteristics and levels of capacity for patient and organizational

supports of self-management

2. Provides a way for patient care teams to assess current capacity in both areas –

patient support and organizational support

3. Helps identify specific gaps in capacity and/or lack of agreement about capacity

so that team members know where to focus their improvement efforts

4. Promotes discussion among patient care team members that can help build

consensus for change and plans for improvement

5. Gives teams a way to measure progress over time.

A baseline measure was taken just prior to commencement of the project and repeated as the project

ended.


4.2.6 Combined Predictive Risk Model Algorithm (CPRM)

Risk stratification is essentially a method of screening to identify a cohort of individuals who are more

likely to respond to a treatment or model of care. The combined predictive risk model (CPRM) is

designed to predict the risk of an individual having an unplanned hospital admission in the next six

months. The algorithm was developed by the Greater Auckland Integrated Health Network in

conjunction with Sapere Consulting Ltd.

CPRM takes a multi-morbidity approach rather than disease specific one and considers future risk

rather than only patients currently at risk. The model therefore allows a risk score to be calculated for

an entire enrolled population.

The variables included in the algorithm are listed in Table 7 below.

Table 6 CPRM variables and data sources

Variable Data source

Demographics Ethnicity Age Quintile Distance to nearest ED

Age sex register (ASR)

Secondary care utilisation

Inpatient admissions in the last 1,3,6,12 & 24 months ED attendance in the last 1,3,6,12 & 24 months

DHB

Primary care utilisation

GP consultations (not immunisations) in the last 1,3,6,12 & 24 months

Clinical performance indicator (CPI) extract from the practice management system (PMS)

It was intended that this tool would be available to clinicians to aid in the appropriate selection of

patients to be invited to enrol in the programme. Development challenges precluded the tool being

available. It has been used retrospectively to determine if patients have been enrolled in the

programme in proportion to their calculated risk.

4.2.7 Patient Survey

A short patient survey was developed to assess the patients’ experience of being in the programme

and also the perceived benefits. See Appendix G.

Patients were sampled opportunistically when they came to the practice in the last few months of the

programme.

4.2.8 Provider Interview

Provider interviews were carried out at the conclusion of the programme. Data came from 67

interviews from both practices consisting of 24 doctors, 25 practice nurses, 10 administration staff

and 8 healthcare assistants. The analysis was conducted by an independent qualitative researcher

who was blind to any other findings from the evaluation.

4.2.9 Secondary Care Utilisation Data

Counties Manukau Health supplied data for:

Emergency department Attendance

Acute inpatient medical admissions

Ambulatory Sensitive Hospitalisations

The date range was 1 July 2013 until 31 October 2015. This extended date range would allow seasonal

variation to be included in the analysis of use of secondary services.


Data was collected for both participating practices and at an aggregated level for the DHB.

5.0 Results

5.1 Individual – improved quality, safety and experience of care

5.1.1 Programme Enrolment

For patients to be enrolled in the programme the requirements outlined in 2.5.1 were met. The

enrolment numbers below represent patients who have formally consented to take part in the

programme, have completed the self-assessment PIH, have an assigned care coordinator and have a

personalised care plan created in partnership with the nurse or doctor.

Enrolment onto the SMSC/ARI programme was tracked through ProExtra. The SMSC/ARI programme

commenced July 2014 however, due to delays with the IT launch patients were not enrolled onto the

electronic system until September 2014. The ARI enrolment target to end of June 2015 was 3% of the

total enrolled population in each practice. There was a financial incentive to achieve this target.

Figure 3 Monthly enrolment progress - CMC

During the 16 month pilot 332 patients at CMC were enrolled into the programme. CMC achieved the

3% enrolment target June 2015 and 3.8% enrolment at the end of October 2015

Initial uptake was slower in this practice due to turnover of key clinical staff. This meant other staff

needed training and mentoring to fulfil these roles. This may have resulted in a longer period before

processes were sufficiently embedded in the practice workflow and the programme gained

momentum.


Figure 4 Monthly enrolment progress - PFHC

During the 16 month pilot 792 patients from PFHC were enrolled into the programme. PFHC achieved

the 3% enrolment target June 2015 and 4.1% enrolment at the end of October 2015. Due to the size

of this practice a more systematic implementation process was adopted which appears to have

resulted in a consistent and therefore more sustainable growth in enrolment numbers.

Both practices experienced challenges at the start of the programme with a less than optimal IT

platform for enrolment of patients.

5.1.2 Partners in Health

PIH was used to collect scores at the time of enrolment in the ARI programme and again in ten to

twelve months when individuals were either re-enrolled or graduated from the programme. Both the

change in total score and the change in individual questions was considered.

Table 7 Partners in Health results

Practice CMC PFHC

Average change per question score 10months - baseline

Average change in total score 10months - baseline

5.40 95%CI (0.41, 10.40)

4.29 95%CI (3.14, 6.69)

The average change in total score for all practices doing the ARI model of care (not the more

comprehensive SMSC programme) was 3.47 95%CI (2.43, 4.52), suggesting the more comprehensive

SMSC model of care provides additional benefit compared to the ARI model alone.

The observed changes in total PIH scores are statistically significant for each observed cohort. The

smaller numbers from CMC give rise to larger confidence intervals.


Both practices demonstrated an improvement in knowledge of health condition and knowledge of

medications (Q1&2)

Shared decision making (Q4) improved in both cohorts although did not quite achieve statistical

significance in CMC.

Knowledge of early warning signs of acute deterioration of long term conditions (Q7) and acting on

these signs (Q8) also improved in both sites.

The PFHC cohort also showed significant improvement in management of how the long term

conditions effected the patients’ emotions and spiritual wellbeing (Q10), social life and personal

relationships (Q11a). This was not seen in the CMC cohort.

Most individual questions showed statistically significant improvement and total scores improved.

5.1.3 Primary Care Resources and Supports for Chronic Disease Self-Management

(PCRS)

The Primary Care Resources and Supports for Chronic Disease Self-Management questionnaire

(Appendix F) was undertaken at the start of the programme and repeated upon conclusion of the

SMSC pilot.

At CMC four GPs and five nurses took part in the survey. At PFHC 12 GPs and 18 nurses took part in

the survey. The average of the before and after scores for each practice is shown below and further

broken down by professional group.

Both practices showed a general self-reported improvement in the characteristics of good self-

management processes at both the patient and clinical team (microsystem) and organisational

(macrosystem) levels.


Figure 5 PCRS scores for patient support – CMC

Both nurses and GPs at CMC perceived an improvement in practice processes that support patients

to better self-manage.


Figure 6 PCRS scores for organisational support – CMC

CMC clinicians reported an overall improvement in organisational processes that support self-

management. The greatest perceived change was from nurses with GPs reporting little or no change.


Figure 7 PCRS scores for patient support – PFHC

Practice processes that support patients improved in PHFC as reported by both nurses and doctors.

Doctors perceived little change in the level of patient involvement over the course of the pilot.


Figure 8 PCRS scores for organisational support – PFHC

5.1.4 Patient Survey - quantitative

Patients were given the option to feedback on the programme in each practice via a short

questionnaire. They were asked 10 questions relating to their overall experience, access to services,


quality of care and the impact of the programme on their wellbeing. There was also the option for a

free text comment after each question. Thirty six patients in CMC and 108 patients in PFHC chose to

complete the patient survey.

100% of CMC and 91% of PFHC respondents either agreed or strongly agreed that their care plans

have helped them change the way they care for themselves and become more organised.

95% of CMC and 94% of PFHC survey respondents agreed that the programme had improved their

health and well being

For all questions over 90% of responses indicated that the programme had a favourable impact.

At CMC, 14% of respondents had a negative experience on the programme. This represents five

patients. Of these three added a free text comment. Two patients had difficulty with the programme

because of language barriers.

“I want to do the programme but my English not very well but I can move on”

“It was in English and I cannot understand very well but I am slowly learning”

One patient felt the content of the care plan was too large and was more than they could cope with

“If I was to have done everything fully I would have focused on nothing else”

Of the four patients (3%) from PFHC who reported a negative experience two left supporting

comments. One did not like a support programme to which they were referred.

“Green prescription no good”

One probably did not feel engaged in the programme.

“Had not really got off the ground”

Figure 9 Figure 10

Figure 11 Figure 12


Figure 13 Figure 14

Figure 15 Figure 16

Figure 17 Figure 18

5.1.5 Patient survey – qualitative feedback

When participants were asked about what they thought the best part of the programme was, three

main theme responses were communicated:

Improved relationship and communication between the patient and their care team

“Being able to give feedback and be involved in brain storming”

“Being able to discuss my health issues, easier to carry out”

“The continual interest in my wellbeing, the fact that I am called to see how I am

coping’

Improved understanding and confidence to manage their health

“Made me conscious of how to better my health”


“A better understanding of my illness and medication”

Improved overall wellbeing

“Looking how far I have come with my illness in a positive way”

“I cannot remember all but I am in better shape than before”

When asked what they thought could be improved with the programme, overwhelmingly patients

endorsed this new model of care. The recommendations that were provided were:

Patients recognising they must be more motivated to achieve their goals

“More effort from me”

“Follow the plan whole heartedly”

More support and information from their care team

“To talk about my condition more”

More time with care coordinators for appointments and follow up

“Perhaps more general check-ups to make sure things are on track”

5.1.6 Provider Interviews

The provider interview report (Appendix H) suggested access for patients had improved from the

providers perspective. They also reported improved patient knowledge and confidence. These are

summarised here:

Doctors reported improved access to services and direct benefits to patients

Stronger relationships especially with nurses

Better access through longer consultation times

More opportunities to access care. Better access to a wider range of health services

Better access by removing payment barriers to some services

Better access to a wider range of social services

Inclusion of consideration of social determinants helps with attainment of medical goals

o Home visits and follow-up

o Psychological support

o Dietician

o Social support

Access to higher value services through training in areas such as motivational interviewing

Balancing factor may be access to some services that were previously funded such as

structured diabetes checks

Better patient knowledge about symptoms and conditions. Corroborated with PIH results

Greater confidence to self-manage. More empowered. More responsive

5.2 Population – Improved clinical outcomes and equity for all populations

5.2.1 Clinical outcomes

Clinical outcomes for a complex and broad programme are difficult to demonstrate. An analysis of

data on glycaemic control suggests a benefit associated with the ARI programme. Further analysis is

being done to determine if the benefit can be demonstrated to the practice level.


Patients enrolled in ProCare practices were identified using a data extract from the practice

management system. Patients were included if there was a record of a recent HbA1c at both

reference points. Current HbA1c results were compared to results recorded approximately one year

previous. We looked at the proportion of patients who had an HbA1c of 64mmol/mol or less at each

point.

The process for data extraction is new and more work needs to be done on data validation and

coding. These results should be treated as preliminary.

Figure 19 Change in HbA1c over 12 months WDHB and ADHB combined

Figure 20 Change in HbA1c over 12 months CMH


Figure 21 Change in HbA1c over 12 months all ARI patients

Table 8 Improvement in glycaemic control

Cohort Number of

patients

Good control previously %

(<64mmol/mol)

Good control currently %

(<64mmol/mol)

Change (%)

Average change (mmol/mol)

ADHB/WDHB 10928 71 73 2 0.74 95%CI (0.50, 0.97)

CMDHB all patients 6404 65 68 3 1.34 95%CI (0.98, 1.70)

CMDHB ARI patients 2168 50 56 6 2.49 95%CI (1.79, 3.81)

CMC non-ARI 248 69 70 1

CMC SMSC/ARI 120 43 46 3

PFHC non-ARI 292 84 83 -1

PFHC SMSC/ARI 202 51 56 5

ADHB and WDHB had a 2% increase in the number of patients with good control, as defined by an

HbA1c of less than 64mmol/mol. This represents a statistically significant reduction of 0.74

mmol/mol. Significant reductions were also observed in CMDHB, for patients enrolled on ARI and all

others. For ARI patients, there has been a threefold increase compared to ADHB/WDHB. The

confidence intervals show the three cohorts are significantly different from each other. The ARI

programme in CMDHB does not specifically target patients with diabetes and this cohort represents

only 24% of all ARI enrolled patients.

5.2.2 Demographic Information/Equity of Access

Enrolment into the programme was considered by deprivation, ethnicity and age. Deprivation was

measured using the Ministry of Health quintiles. Ethnicity considered Maori, Pacific and other.

Enrolment was compared to the practice demographics and also to the demographic profile of the

practice cohort with the highest predicted risk of acute hospitalisation. This was calculated using the

CPRM. This algorithm is weighted towards higher quintile, age below 5 years, age over 75 years and

Maori or Pacific ethnicity. A higher risk score is calculated for individuals in these cohorts.


Deprivation

Figure 22 Social Deprivation for CMC

CMC has high numbers of quintile 5 patients and enrolled in proportion to practice demographics and

calculated risk. There was a slightly greater enrolment of patients from the most deprived areas (Q5)

Figure 23 Social Deprivation for PFHC

PFHC serves a less deprived population. Their enrolment profile matched their higher calculated risk

profile albeit with a tendency to enrol more individuals from more deprived areas

Ethnicity


Figure 24 Ethnicity for CMC

CMC enrolled a proportion of Maori patients that matched the practice demographics and the

demographics of the highest risk cohort. They enrolled marginally more Pacific and marginally less

other patients.

Figure 25 Ethnicity for PFHC

PFHC had higher enrolment of both Maori and Pacific people. They enrolled less ‘Other’ when

considering both practice demographics and calculated risk.

Age

Figure 26 Age Distribution for CMC


Figure 27 Age Distribution for PFHC

Both practices showed strong enrolment in the 45 to 75 year age group with patients in this age band

being over represented when compared to practice demographics or calculated risk. The CPRM

predicts greater risk for patients under 5 years or over 75 years. Patients in the younger age group

were under represented. Patients in the older age group 75+ were enrolled in greater proportion than

the demographics of the practice but the profile of the high risk group contains more patients in this

age band.

5.3 System – Improved value for public health system resources

5.3.1 Existing Services

Figure 28 Interventions for SMSC patients

Both practices showed a high rate of utilisation for follow up consults.

5.3.2 Sustainability – Primary care utilisation

Analysis is being conducted on the change in utilisation of primary care health providers caring for

SMSC patients over the course of the trial. This will be available at a later date


5.3.3 Sustainability – Secondary care utilisation

Emergency department (ED) attendances and in-patient admissions show seasonal variation as

indicated in figures 25 - 27 below. There has been no discernible change in ED usage or acute

admission including those for ambulatory sensitive conditions. Seasonal variation appears consistent

for the three cohorts below.

Figure 29 Rate of emergency department attendances

Figure 30 Rate of acute medical inpatient admissions

Figure 31 Rate of ambulatory sensitive hospitalisations (ASH)


5.4 Workforce – Improved workforce engagement and workforce skill Question 8 in the provider interviews looked at increased knowledge of health care providers and

found the programme built knowledge of community resources. These were of benefit to patients

and whanau. The training provided to both GPs and nurses was useful and gave greater confidence

for referring to external providers.

Question 9 examined effective utilisation by various health care providers. It showed that the

providers successfully interacted with a greater range of external health care providers and social

services. Some findings suggest the programme could be strengthened by further focus on patient

centeredness and cultural competence training.

Multidisciplinary team meetings were found to be beneficial and strengthened relationships with

secondary care and community providers. The findings highlight the potential to increase the

efficiency of the meetings.

Question 10 explored the level of job satisfaction. The majority of nurses agreed they had a higher

level of job satisfaction despite the increased work load and were motivated by patient success and

achieving goals.

Nurses have adopted this new programme despite the challenges of a changing role and additional

administrative burden. Processes and IT were reported as being a barrier by nurses and GPs.


6.0 Discussion

6.1 Achievements SMSC has been a beneficial programme for patients and primary care providers despite the

challenges involved with implementation of a new model of care in a complex environment. The

programme has reported measureable benefits for patients and improved job satisfaction for practice

staff.

A 3% enrolment target by the end of year 1 was set for each practice. This was an ambitious target

given the training and education that was required for this change. Practices needed to learn new IT

systems and processes as well as implementing a new model of care. If a higher enrolment target had

been set, this would have been at the expense of programme quality.

The observed changes in total PIH scores are statistically significant for each observed cohort. The

SMSC practices both achieved a greater overall shift in PIH scores compared to other practices

implementing ARI. Most individual questions showed statistically significant improvement and total

scores improved suggesting that people felt better able to manage their health conditions. A recent

study showed significant association between PIH scores and mental health quality of life, self-

efficacy, energy levels and health distress (Battersby, Harris, Smith, Reed, & Woodman, 2015).

The lack of a matched control group or randomised sample means we cannot conclude that the

observed improvement is due to interventions from the ARI programme. It is possible that the

Hawthorne effect where individuals may modify their behaviour in response to their awareness of

being observed may have contributed to the observed improvement. These issues highlight the

importance of a study with more robust design to test for outcomes for patients enrolled in the SMSC

programme.

Both nurses and GPs at CMC perceived an improvement in practice processes that support patients to

better self-manage. The SMSC programme is a nurse led process to enable patients to become better

at self-managing. Differences in some PCRS results between GPs and nurses reflects this changing role

in care delivery.

At PFHC GPs perceived that patients were much more involved about decisions relating to their care

at the start of the pilot compared with nurses. As nurses became more involved with care planning,

patient involvement became much more integral to the system of care. GPs felt they were already

actively involving patients in their care, therefore did not perceive as great a shift PCRS score.

At CMC, only the nurses perceived a change in organisational support. This may have been more to

do with feeling enabled to perform their roles or having permission to spend the time needed with a

targeted group of patients, hence allowing the patients to express their wishes rather than just ‘being

done to’. In effect the care planning process was a tool that enabled patients to have more control of

their care. This may have been perceived as organisational support whereas GPs may have believed

that this was happening anyway, when it may not have been.

The Wellness programme at PFHC was implemented as a team based approach. Patients were

allocated to care teams which included GPs and nurses. This team approach may reflect the

difference in results for organisational support.

Patients were invited to make comments on the programme. Because patients were identified

opportunistically, sampling methodology could be more robust in order to provide a more

generalizable result. Despite this, the overwhelming response from patients for the programme has


been positive and those who provided comments would like to see it continue. This favourable

response from patients is consistent with the provider interviews which indicated better relationships

with patients and better access to services.

In the provider interviews, providers indicated that patients had a better understanding of their

conditions and symptoms. This was also reflected in the patient PIH results which indicated significant

improvement in these domains. Both practices are enrolling large numbers of patients in the 45-65

age group. This may reflect enrolment of long term conditions on the programme. The model of care

utilised may still reflect a strongly medical approach. It is anticipated that as practices gain experience

with the care planning and goal setting model of care that they will shift to a more holistic view. The

PIH results for domains 1 and 2 reflect this, as patients are seeing improvement in knowledge of their

conditions and treatment including medications. Domains highlighting a holistic approach are 11a,

11b and 12 so these may be points for practices to focus on in the future.

Due to delays in developing the CPRM reports, practices were not able to utilise these to identify

patients to enrol on the programme. Clinical judgement therefore drove enrolment. Results indicate

that practices enrolled patients at least in proportion to the demographics of their practice when

considering social deprivation. This pattern was also seem for the high needs ethnicities of Maori and

Pacific patients for both practices. When considering a cohort of patients with the highest predicted

risk of acute hospitalisation those from deprived areas as well as Maori and Pacific patients were well

represented.

Previous LTC programmes have not included patients under 18 years of age, so practices may not

have experience working with these age groups. This is reflected in the small numbers of patients

aged 0 to 5 years who are enrolled, despite the high calculated risk of acute hospital admission.

Routine use of the CPRM reports may result in further improvements in targeting resources to this

high risk group.

It is too early to show whether or not there has been a decrease in the use of secondary services for

these patients as a results of the programme. A separate preliminary analysis of the data shows both

seasonal and all cause variation with no discernible increase or decrease in Emergency Department

utilisation or acute medical admission. Further detailed analysis is warranted.

To implement a change project with the degree of complexity, scale and pace of the SMSC pilot,

effective visible executive sponsorship is essential for the practice. This key person is responsible for

on boarding the team to the change, removing barriers and championing the new way of doing

things.

A common theme from the provider interviews, patient surveys and the onsite change manager is the

enhanced relationship that has been built between patients and their care team. Nurses noted the

hour of dedicated time for the initial care plan helped to develop this relationship.

PFHC piloted having an onsite health psychologist and community health coordinator (CHC). The

health psychologist was considered one of the most valuable interventions available to help support

patient goals, and both GPs and nurses reported positive patient feedback as well as a positive change

in the patients themselves. This was also noted by patients in the patient surveys. The CHC was

another successful initiative, and the practice team felt that having someone onsite led to greater

understanding and better communication. CHCs were better placed to connect patients with social

services. The practice undertook MDT meetings with both the health psychologist and the CHC to

feedback on patient progress. It was noted that these conversations added greater value and

understanding than relying on patient notes and progress reports alone.


PFHC also implemented MDT meetings with external providers and within their practice teams. They

noted that meeting with external health practitioners helped to build relationships and trust, while

the in practice meetings helped to develop the team based approach to caring for their patients.

The programme has strengthened relationships with external providers. Historically, PFHC would

provide patients with information on providers they could contact. Following introduction of SMSC,

the practice now facilitates the relationship between the patient and provider. This was the case for

health and psycho-social needs. The SMSC pilot did highlight for the practice that there was a need to

have an up to date source of current community providers that the practice could use.

This programme saw a significant change in the scope and breadth of nurse practice which highlights

the importance of appropriate training in both delivery of care and required skill set. Practices were

allocated funding to release time for this training which included care coordination, motivational

interviewing and care planning and goal setting. Recognition of the need for and sufficient resourcing

of this training is critical to the success of a programme such as this. Some nurses reported the

programme highlighted areas for professional development, as they came across conditions they

wanted to know more about. This led to self-directed learning. A process for nurse peer review was

established at PFHC to improve the quality of care plans. Although GPs regularly undertake peer

review, this was a new skill for nurses.

Patient achievements are an important factor in the initial stages of the programme. PFHC shared

these outcomes which helped to engage staff that had not yet brought into the change. As the

programme progressed personal satisfaction from working with patients to help them achieve their

goals increased motivation and job satisfaction. One frustration for the practice teams was being

unable to prove quantitatively that they had made a difference, as the goal they wanted to achieve

may not have been directly health related, instead laying the foundation for future health

improvements.

6.2 Challenges SMSC provided a very flexible means to fund patient care. Because of its size, PFHC found it difficult to

budget for the care that would be required for patients as this approach was so new. To help alleviate

budget issues, the practice had strict guidelines on what could and could not be claimed through the

funding. This programme also had a practice level budget to manage rather than a patient level one

historically used under other programmes. Systems needed to be established for the finance team to

monitor how claim choices affected the overall practice budget.

Each practice had a different approach to what they would and wouldn’t fund for patients. PFHC

chose to charge patients each time they saw a GP, and on reflection felt that patients were side

stepping them for clinical concerns and going straight to their care coordinator. They felt this posed a

clinical risk if the nurse did not escalate issues when appropriate. Clear communication between

nurses and GPs as well as guidelines on escalation of issues needs to be discussed with teams to

ensure this isn’t a risk for quality of care. CMC did not charge for GP visits and it remains yet to be

seen if this impacts on patients’ behaviour.

There was great value in being able to use external providers (including services funded by the DHB

and NGOs). In order to do this however, there needs to be a process to identify local providers, a

means to keep a list of providers up to date, certainty of funding to ensure the service is available

ongoing, clear processes to report back to the clinical team (which raises issues around

confidentiality). Feedback needs to be timely with appropriate content to support patient care.

Understanding what community resources were available has been a challenge for practices. They


have expressed frustration at not knowing who provided funded services, as a provider may only be

funded for a short period of time. PFHC set up regular meetings with social work providers to

establish regular information sharing. A significant learning for the practice team was around what

community support was actually available for patients.

One practice viewed the programme as being nurse driven and therefore did not involve GPs in the

training. As a result, GPs were slower to adopt the change. In order to overcome this, it was necessary

to run combined workshops to raise awareness, followed by one on one training for GPs.

IT infrastructure and associated software was a big challenge for practices. As the CCMS tool works

across a secure health network, practices experience a delay in the sending of information which has

resulted in frustration. Close attention for this type of pilot needs to be paid to effective IT including

internal practice systems and external shared tools. Broadband capability played a significant role in

the frustration of one practice as it resulted in a slow claims process and care planning. This added to

the administrative burden reported by the practices.

6.3 Future Development Some nurses felt patients were dissatisfied if they couldn’t contact their care coordinator. In order to

alleviate this, they have recommended having two nurses sharing the care coordination role for each

patient. This is particularly useful when a nurse only works part time.

Both practices had a target of enrolling 3% of their population on the programme within twelve

months of starting the pilot. The onsite change manager observed that having a target helped to drive

the change within the practice, although noted that reducing the target slightly may help to optimise

enrolment. This highlights the need for balance between a manageable work load and achieving

sufficient numbers to embed this model.

7.0 Recommendations This pilot has highlighted seven key recommendations when implementing a change of this nature.

7.1 Effective executive sponsorship

In order for change to be embraced and adopted by a practice, the practice team needs to have an

executive sponsor who champions the change. This person needs to be someone with the authority

to make decisions on what will happen and have the ability to secure necessary resource. The

nominated executive sponsor will need coaching and support from their PHO to understand what

their role entails.

PHO understanding of change management and the ability to support practices with complex change

programmes is essential for success.

7.2 Building relationships

Building relationships both within the practice team and with external providers was noted by

practice staff as being a real highlight from the programme.

Having an onsite health psychologist and community health coordinator was highly valued by the

practice that trialed it. The positive feedback was also reflected by the patients that were referred to

them. The community health coordinators also provide an invaluable role in navigating social services


for patients. Nurses recognized their specialist skills in this area. Practices need to be able to

commission these services for those patients most at need.

This pilot has highlighted the need to know what external providers are available in the practices

community and what services are offered and funded.

It is important to have an understanding of all allied health providers that are available to a patient.

Practices need to understand the benefit that each provider can offer and to have processes for

referral and feedback as well as being able to keep the list current. They need certainty of funding to

ensure a service be able to provide the care they referred for. In order to manage this, practices could

develop a community directory within their team to advise of providers used and services available.

Forming links and introducing multi-disciplinary team meetings with these providers gave a greater

understanding of patient progress with the service.

This pilot strengthens the relationship between a patient and their care coordinator. In order to

successfully build this, practice teams needing training on motivational interviewing and building

rapport to understand the patient perspective.

7.3 Training and support

As part of the pilot practices were provided funding to release staff for training courses and fund

training needs as appropriate. A one day care coordinator course was delivered by Counties Manukau

Health which was free of charge. Although this was initially intended to be a train the train approach,

many practices have sent multiple staff members to the training as it covers the essentials for care

planning.

Releasing of clinical staff from a practice to attend training can often be a financial and human

resource barrier to small businesses, so consideration needs to be given to the financial model to

support this.

7.4 Care planning

Providing funded time to understand the patients concerns and develop a care plan with them was an

essential way of building the relationship between the patient and their care team. It also allowed the

practice to understand other issues and concerns that the patient was facing that may be impacting

on the health. This pilot funded approximately an hours’ worth of nurse time to undertake the initial

review and development of the care plan. Dedicated nurse time and minimizing payment barriers for

patients is an important enabler for this model of care.

7.5 Operational technology

The technology for this programme initially faced many challenges. The shared care tool used to

create and manage the care plans underwent many changes in the first year to make it fit for purpose

which frustrated practices. Due to the security measures in place with the shared care tool, the

system can be slow with all the checks it has in place. This led to care plans taking a couple of minutes

to load in some instances. Internal practice infrastructure is also an important consideration. One

practice had issues with their internet speed which further slowed down their IT processes.

A fit for practice tool needs to be accessible to the patient and their extended care team. Future

consideration needs to be given to integrating allied health and secondary care to ensure all are using

the same shared platform and templates.

7.6 Intervention funding

An intervention fund that can be spent as necessary to help a patient achieve their care plan goals has

been essential. The flexibility of the funding was a challenge initially for practices as they were used to


prescriptive long term condition programmes that only funded quarterly visits. The practices were

given autonomy to apply resource according to need.

Clinicians need the autonomy to direct resources to the areas of greatest need and greatest benefit.

The practice team needs to develop capability and capacity to best utilize available resource.

7.7 Self-management review

Neither practice were regularly referring patients to self-management courses. It is unclear why this

service is not utilized given positive feedback from patients. We recommend undertaking a review of

the service, including both patients and practices to understand the barriers to referral.


Appendix A – Glossary Concept Definition

ASR Age Sex Register

PCRS Primary Care Resources and Supports for Chronic Disease Self-Management questionnaire

CCMS Collaborative Care Management Solution

CHC Community Health Coordinator

ProExtra

ARI At Risk Individuals programme

HRI High Risk Individuals Programme

PIH Partners in Health questionnaire

CPRM Combined Predictive Risk Model

CMH Counties Manukau Health

SMSC Shared Care and Self Management project

LTCs Long Term Conditions

HCA Health Care Assisstant

MDT Multidisciplinary Team

CCM Chronic Care Management

PMS Practice Management System


Appendix B - House of Care Model The UK model uses the metaphor of a house to explain the approach to the care of people with LTCs. To build the House of Care, we have extended the model to include a toolkit for practices to use to

bring about organisational change. The toolkit is transferable, to be used during the change

management process, and then moved to other contexts as needed.

Putting the patient at the centre Each Care Plan is developed in conjunction with a multidisciplinary team for a specific individual at a defined place in time. Goals are set by the patient in conjunction with their Care Coordinator. The Care Plan will provide each participant in the pilot project with a Year of Care, identifying the services and support needed to keep the patient well.

The foundation Defining services to be included and how they will be funded is the foundation of the House of Care. In our implementation, we are recognising funding streams which are already in place in the region.

The walls The walls of the house are made up of the multidisciplinary team (MDT) and the patient. We will look to build the skills, capability, attitudes and approaches for the practices to enable them to work within the model. We will build on the communication and coordination links already existing in PFHC, and we will build on our existing relationships and capability to further develop the team in CMC, using virtual resources and consults where necessary. We will place each patient firmly at the centre of their care, informing and engaging them in their Year of Care. We will provide them with the knowledge, skills and support to participate in the implementation and development of their Care Plan to the level of their capability. Self-management, communication and problem solving skills will be enhanced, promoting patient resilience.

The roof The organisational processes of the practice make up the roof of the house. The project will provide each practice with the knowledge, skills and tools to make long term changes to the way they do business.


Description – Current approach Description – The House of Care

Locus of control GP-centric process The GP: • is in charge of the Care Plan • assesses progress • holds the patient record in their PMS • shares information with other service providers • shares information with patient • refers patient to Secondary Services and Allied Health as appropriate

Patient-centric process The patient: • is jointly responsible for their Care Plan • has joint control of who has access to their e-shared Care Plan • accesses Secondary Services Allied Health as specified in their Care Plan • is a part of the progress assessment process

Care plans The GP: • defines Care Plan and goals using a medical model • assesses progress

• Care Plan and SMARTER goals are defined by patient and Care Coordinator • A Biopsychosocial model is used • Progress is assessed by patient and MDT as well as the GP

GP/Practice Nurse Consults

Each GP or Practice Nurse visits is 15 minutes • Last test results are reviewed • Health checks are completed • Discussion about progress and self-care • Prescriptions are written, potentially including a ‘green prescription’ • New tests are ordered

• Tests are ordered before the visit, a letter is sent to the patient with results, questions and prompts for patient to consider • Health checks are done by Practice Nurse /assistant before GP session • Extended GP or Practice Nurse consults • Other MDT members may be present

External support Patients may seek support from: • MoH programmes • Patient support groups • Helplines/websites

Patients may seek support from: • Allied Health • NGOs and voluntary groups • MoH programmes • Patient support groups • Helplines/websites

Education resources

Resources available to the patient may include: • A discussion with the Practice Nurse about self-care • Access to information about their condition • LTC Websites and online chatrooms

Resources available to the patient may include: • Local support groups, shared sessions with other LTC patients, evening meetings • Education sessions with MDT members, some group sessions • Access to information about their condition • LTC Websites and online chatrooms

Allied Health The patient may be referred by GP to an Allied Health practitioner e.g. physiotherapist, counsellor.

Allied Health professionals are part of MDT, involved in care planning and assessments as required.

Secondary care Following GP referral, the DHB: • Manages acute conditions • Sends records to GP

The DHB: • Provides improved access to secondary care and supports and participates in MDT meetings


• Monitors use of acute resources by LTC patients

Resource stewardship

Patients who arrive at the practice are provided with episodic care.

An ability to proactively manage patients depending on their need. The capacity to view both a patient-based and practiced-based budget allows allocation of resource to those most in need and recognises the impact that these decisions have on the ability to care for other patients in the population.


Appendix C - Planned Proactive Model of Care


Appendix D - Partners in Health Questionnaire


Appendix E - Change Manager Case Study of PFHC

Qualitative Findings: A Case Study on Pukekohe Family Health Centre’s implementation approach

and findings

The following outlines the implementation approach and key findings as identified through onsite

observation and provider interviews.

Roles and responsibilities: GP/Nurse

The programme was driven as a nurse-led initiative and communication, training and processes were

driven around nursing teams. GP communication and involvement across the practice was initially

minimal. A combined GP/Nurse full practice meeting was instigated after a few months which

started the inclusion process. In reality the Doctors did not fully engage until the 12 month

graduation process which provided paid involvement for the GP, Nurse and Patient to review the

year of care received and determine the plan for the future.

Nurses took on responsibility for patient’s holistic care (medical and wider psych-social needs). This

was seen by many as a stretch beyond general nursing competencies, even for senior nurses. Nurses

were provided with significant one-on-one training, mostly around the care planning process and

how to use the technology that supported the shared-care approach. Later training supported the

needed growth in capabilities around motivational interviewing, understanding and building health

literacy skills, and caseload management. On-the-job training and sharing was key for nurse

development.

Feedback from both GPs and Nurses indicated that the balance of involvement could be improved.

Patient’s increased involvement with nurses was seen by many as favourable and provided patients

with another ‘go to’ person in the practice, beyond ‘their GP’. However the unlimited support from

their nurse led some patients to rely on nurses for clinical advice that perhaps would be more

appropriate to gain from their GP. The funding model implemented (i.e. free Nurse visits, paid Dr

visits) potential exacerbated this situation. Providing guidance so staff and patients are clear on

which practitioner (i.e. GP, Nurse, HCA) is the best person to provide for their various needs is key to

optimal patient outcomes. This role clarity and role division applies equally to externally sourced

services (e.g. social services, mental health services) and seems a valid part of patient and

practitioner education when operating in a patient-led environment and in helping patients become

self-managing.

One interesting phenomenon identified by some staff was that the trusted relationship built

between a care coordinator and their patient created an expectation for Nursing continuity of care

that previously only existed for Doctors. If the patient’s nurse was then not available it sometimes

created greater patient dissatisfaction. A number of nurses recommended that having two nurses

within a team sharing the care coordination role for a patient might alleviate this, particularly when

there is a number of part-time staff in a practice.

Assessment, Care Coordination and Graduation


Time was provided to allow for a comprehensive initial assessment (~1 hour between nurse and

patient). A process and templates were established to guide areas for discussion with patients. This

approach was perceived positively by many patients who valued that ‘someone took the time to

listen to them’. This was the basis for developing a trusted relationship between the patient and

their assigned care coordinator. At this assessment the patient completed a Partners in Health (PIH)

assessment form, and worked with the care coordinator to set goals and some actions to work

towards achieving them.

The care coordinator then liaised with the patient at a frequency and using the method agreed

between them. This ranged from daily phone calls through to three monthly visits and anything in

between, including home visits. Some patients also used a ‘wellness wheel’ assessment to help

identify their most pressing social and psychological issues (refer to Appendix E1). Nurses reported

that this holistic approach to care, responding to patients broader needs in a proactive manner, was

valued by patients and professionally and personally satisfying for care coordinators.

Follow up sessions between patients and their care coordinator centred around supporting the

patient’s progress towards their goals, establishing new goals, and balancing that support with the

arising health and psycho-social issues that patients were dealing with at the time of the

appointment. Nurses were strongly encouraged to include an Action Plan to self-manage health

exacerbations and an Advanced Care Plan within the shared care plan.

The care coordinator documented the assessment details, patient goals and actions, progress and

any follow ups within the patient’s medical record (as per normal practice), and within an electronic

shared care plan that was written from the patient’s perspective. This care plan was accessible by

the patients, but early technology challenges meant many did not go through the process to register

to have access to the care plan. Other health professionals were added to the patient’s care team,

and some had electronic access to the care plan. Access depended on the healthcare organisation

and whether they had the required IT and privacy set ups, and the motivation of the providers.

Where direct access wasn’t utilised, some form of reports were typically provided to General

Practice and scanned into patient’s medical records and general referred to on the e-shared care

plan.

The care coordinator facilitated support for the patient to achieve their goals. This may have

involved contacting other healthcare or psycho-social service providers to get information, providing

and following up on referrals, facilitating support services, reviewing provider reports and feedback,

and ongoing liaison with the patients themselves. Sometimes there was considerable time spent

facilitating support and the variation in patient needs meant significant variation in care

coordination requirements. Unavailability of patients and healthcare providers at times of contact

meant this care coordination process could be time consuming and was perceived at times as an

‘administrative burden’ by nurses, when they’d rather be spending their time with patients. Some

nurses raised the future potential for using Healthcare Assistants (HCAs) for some of this

coordination work.

Over time, as the general practice staff became more informed on available services in the local

community, good quality providers, operational/referral processes, and the clinical and/or psycho-

social outcomes of different interventions, this care coordination process became more efficient and

effective.

After 10-11 months on the programme a 15 minute graduation appointment was made involving the

patient, their GP and their care coordinator. GP’s were paid for 15 minutes of preparation time prior

to this appointment so the time with the patient was best utilised. A checklist was used to guide the


discussion around the patient’s progress and whether they were ready to graduate and return to

normal care or whether they would benefit from re-enrolment to achieve their goals. Patients also

completed a PIH assessment and were provided with a patient survey. Patients who were graduating

kept an active care plan to support ongoing self-management.

Both GP’s and Nurses found significant value in this approach and for many Doctors it was the

strongest (and sometimes first) real engagement with the patient’s journey. A number of staff

recommended an additional shared appointment at the beginning and/or after six months could be

of benefit to the patient and would allow a more focused team approach to the patient’s proactive

care.

Further efforts to ensure a team approach to patient care would further improve patient outcomes,

ensure GP’s do not feel their clinical input is missed, and ensure nurses feel well-supported by GPs in

their care planning. For this practice GPs are paid for patient contact time, so time spent liaising with

nurses is unpaid so not often considered a priority. The business model of a practice is a key aspect

in how engagement in a team approach is driven and made financially viable.

Process-based Approach

The practice mapped out the many steps in the process of providing assessment, care coordination

and graduation. This captured key steps and accountabilities, and was revised and updated as

changes were agreed. Some nurses reported frustration at the feeling of constant change during the

first 6-9 months as process iterations were rolled out. This was unavoidable as the practice grappled

with operationally managing such a flexible approach to care, and as new information was provided

to them on a regular basis that required them to be agile and adaptable in their decision-making.

The formality of documenting processes was critical for a large practice that needed to ensure all

staff understood and could deliver a consistent service. It would seem a smaller practice may be less

likely to choose to do this but would equally benefit from the clarity this provides for staff

communication and role accountability.

Training

Training for nurses was a significant focus when rolling out this changing model of care. All nurses

received group and one-on-one training around care planning and how to utilise the electronic care

plan technology. The two nurses working full-time with complex patients built the greatest

experience fastest so were used as ‘super-users’ to support other nurses where time permitted. A

number of nurses reflected that having an ongoing training go-to person for the life of the

programme was important to respond to questions, as was training for new nurses that arrive after

the initial roll-out of training.

GP training was initially considered a lesser priority as they had a smaller role in this model of care.

However staff recognised this lack of training meant they adapted more slowly to the change. This

was addressed through a combined GP/Nurse workshop initially to raise awareness, then group and

one-on-one training for GPs for knowledge-building. Ultimately, having a task to complete (i.e.

patient graduation appointment) prompted the desire for GPs to want training.

As the programme progressed nurses reported being driven towards self-improvement as they

encountered patients with particular medical conditions or issues that nurses wanted to better


understand and support them with. A number reported accessing research, spending time with

specialists, or selecting professional development that aligned to their patient needs.

Financial Management

The care coordinator had to also follow internal practice processes to document time spent with and

for patients to ensure their practice could manage and analyse the finances associated with the

programme. Technology challenges meant this could be very time consuming (up to 7 minutes to

process one ‘claim’ for services) so this combined with the care coordination heightened the

administrative burden for nurses, sometimes overshadowing the patient-contact time and value.

The practice chose to fund unlimited nurse time for patients. They did not fund GP visits (which was

a change for patients with long term conditions who previously received four funded GP visits each

year). They funded health psychology and community health worker support for targeted patients.

Beyond this, they did not fund any services outside of the practice. Referrals were however

encouraged to free or community-funded services. Practice staff identified that having a pool of

money available to fund external services would provide an important level of flexibility for meeting

patient needs in future.

Tracking the detailed costs per patient under this type of programme when a patient or their care

coordinator may undertake a range of interventions in a single day can be complicated. The practice

already had a focus on using service codes to capture and therefore analyse the types and volumes

of services provided to patients. They improved on this over time with a system established and

rolled out to staff to document service type and timeframe using pre-determined codes within

specific fields within the practice management system (i.e. Medtech). Capturing this accurately is

critical to back-analyse service patterns to prepare forecasts and budgets for the future (as well as to

identify possible staff training needs where service provision between nurses may show abnormal

variability).

The practice had an overall budget assigned across this patient cohort which had complete flexibility

for individual patients (i.e. while this could be allocated as an ‘average amount’ per patient, in reality

individual patients were funded to a greater or lesser extent dependent on their needs). This

flexibility was highly valued compared to other programmes which are typically restricted to a set

number/type of services. However it was financially challenging to budget for this level of flexibility

when the services and costs of patient-centred programmes were largely unknown. It was equally

philosophically challenging for Nurses and GPs to adapt to operating within this flexible environment

because having no restrictions allowed a level of service choice previously not experienced which

created uncertainty.

For example, moving from an environment where funding supported one patient visit per quarter to

one where patients could be contacted at a frequency that best their needs was a significant change

for Nurses who had to then determine what that frequency should be (and for finance staff who had

to monitor how those choices across the whole nursing team were impacting financially).

Community-based Services

The process to refer to community health providers improved over time. Prior practice had been to

provide pamphlets for patients to access local services (where available), or for Doctors to complete


referrals relating to clinical needs. The changed approach was for nurses to facilitate connections

between the patient and the community service providers, both from a health perspective (e.g.

district nursing support, NASC reviews etc) but also for the broader psycho-social needs.

The practice broadened their use of community-based services, with a focus on those that were free

or already funded for target groups of patients. Anecdotally the most utilised of these included

green prescription fitness services, self-management group courses, budgeting services, family-

centred programmes (e.g. triple P parenting), local whanau ora Maori support services, podiatry for

diabetics, some counselling, and pharmacy services.

Understanding what services were available within the local community was challenging. Previously

GPs and Nurses would refer using pamphlets obtained from service providers, often with limited

knowledge on the actual service, the quality, and sometimes even the cost. Community services

were typically described by the practice as being funded for short periods, so just when a

practitioner has learnt about the service and started to refer their patients with confidence the

funding ended and the service was no longer available. This pattern has led to a tentativeness

towards referring to new community services.

Efforts were made initially to connect with social workers across the community because as well as

providing an important service, they are seen as being a source of information on other community

services. Regular meetings between some practice nurses and staff from key social work providers

created an environment for regular information sharing. The foundational practice learning was

around what actual services currently existed across the local community, what patient groups they

were funded for and/or what costs to patients, and how to refer. The shared learning between

community providers and the practice was an important journey so nurses could understand the

specific services that could benefit specific patient needs, and could gain trust that providers would

deliver those services to an appropriate standard. Similarly for social services agencies to learn

operationally how to interact with GP practices and the importance of reporting back.

The practice internally shared information on social work and wider community services by holding a

structured GP/Nurse/HCA sharing workshop for the whole practice. This pooled and shared the

knowledge of all existing staff at that point in time and captured it for internal communication

purposes. Nurses and GPs reflected that services recently referred to remain front of mind, but they

needed information to help prompt them on what services might help meet patient’s needs and

where/how that service can be obtained in the local community.

It was recognised that it was critically important to have a source of up-to-date information available

to guide the practice on community-based services, their costs and how to refer to them. A central

provider in the community outside the practice was deemed to be most appropriate to maintain this

type of information in future as it’s not specific to a single general practice but rather a geographical

area (e.g. the DHB Locality Group or similar).

The challenging aspect with any of the community-based services was providing appropriate

reporting back to enable the care coordinator to remain over the top of the patient’s care. Having a

process and structure for reporting back was identified by Nurses as being critical. Ideally enabling

the community service provider to have access to the patient’s electronic shared-care record would

allow reporting to be made directly. This has implications around patient confidentiality and what is

appropriate to report back. Some community practitioners provide reports to GPs, but internal

communication processes in a practice will determine whether or not such reports are seen by

Nurses in a timely fashion to support active care coordination.


Health Psychology

The funding of health psychology sessions was reflected by many nurses and GPs to be one of the

most valuable interventions to support patient goals and help them understand and have the

attitude to become self-managing with their health. This was piloted as a 3 + 1 hour session package

for any patients (i.e. regardless of quintile or ethnicity) with guidance around likely patient groups

(e.g. recent cardiac incident, recent major health diagnosis, ongoing and undetermined stomach

pain, general anxiety presentation). GPs and Nurses reported positive patient feedback and

observed positive change in patients that utilised this service.

Community Health Coordinator

Support of a Community Health Coordinator (CHC) was another successful initiative. The practice

initially tried to manage social support by channelling patients through a community social work

provider external to the practice for triaging and service delivery, supported by onsite weekly

meetings to discuss referrals. This wasn’t effective. So an on-site community health worker was

sought from the PHO to channel and manage social services referrals. This proved highly successful.

Nurses reflected that having someone onsite enabled a greater common understanding and better

communication and a CHC was seen to have the appropriate mix of skills to meet patient needs. This

included providing patient advocacy at WINZ/Housing NZ; knowledge of and networking with local

community service providers; case managing a patient’s social services’ needs; and working

alongside complex patients to hand-hold initially until gradually empowering them to become self-

managing.

Self-management Group Education

Six week long group self-management courses were initiated in the local area. These courses were

targeted for people with diabetes, those requiring pain management, and a general course for

patients with any long term condition.

Secondary Care Services

The electronic shared care plan was made available to secondary care (as well as community

providers that had the IT capability and financial resources to implement it). The practice strongly

supported the concept of patients having an up-to-date care plan when presenting at hospital. In

reality secondary care has been slow to change so staff reported little understanding or access of

patient care plans by the hospital.

In particular the practice focused on patients having action plans to raise their awareness of their

health condition so they could take the appropriate steps. This was seen by nurses anecdotally as

supporting a reduction in patients presenting at hospital in avoidable situations.

Caseload Management

Almost all nurses were Care Coordinators for a caseload of patients. Two experienced nurses were

assigned fulltime to manage the most complex patients. Floor nurses managed their own caseload of

patients within and alongside their day-to-day nursing duties. Specialist nurses took on board a

caseload of patients aligned to their area of specialisation (e.g. respiratory, diabetes, youth,

children). Balancing care coordination of patients with long term conditions alongside business as


usual was challenging for many. Particularly given the broader nursing skill expectations (i.e. psycho-

social), ongoing technology issues, and the variation in normal nursing duties (i.e. many part-time

nurses; and rostering between specialist clinics, floor nursing, an Accident & Medical department

and a secondary general practice site).

After an initial period of managing the service within business as usual, nurses were given separate

templates for the ARI service, so had allocated time for appointments and care coordination for this

group of patients. This was perceived by many as a more manageable approach, creating a greater

sense of control around caseload management, and allowing focused attention to keep patients

progressing towards their goals.

The approach for almost all nurses to become care coordinators was strategic so all staff could

become embedded in what the practice sees as the future model for primary healthcare delivery.

Some nurses reflected they personally enjoyed the depth and breadth of proactive long term care,

while others indicated that their personality was better suited to short-term responsive care. Finding

the best balance in future will be important. There are greater succession planning risks when a

practice has fewer staff committed to this approach, however there are benefits in matching staff

skillsets with the role.

Patient enrolments were driven by District Health Board targets for 3% of the patient population.

This volume was a challenging mandate for a practice of this size which meant the choice of which

patients to enrol was not as targeted as the practice would have preferred. Many patients with long

term conditions were supported under a previous funding scheme where they received quarterly

funded GP visits, and had done so for many years. The motivation levels to understand and self-

manage their conditions varied across these patients.

The drive for enrolments meant that a number of patients’ were personally unmotivated to be

involved in an approach to care supporting them beyond their purely clinical needs and with a focus

toward them to become self-managing. Each nurse typically had a proportion of their patients who

were not motivated to set and achieve health goals which caused frustration given the time and

effort put into care coordination. The majority of Doctors and Nurses reflected in hindsight the

critical importance of a patient’s motivation as a factor when engaging them into this type of

approach to care. It raises the potential for providing a level of care that maintains stable clinical

outcomes for disinterested patients with long term conditions, without driving an unwanted level of

additional care and support. Such a model of care would sit alongside the current quality approach

to flexible patient goal-driven care that supports a patient to becoming self-managing with respect

to their long term condition.

It should be noted from observation that having a target to drive patient enrolments seems an

important impetus to drive general practice to change their patient management approach. The

target for enrolments might be slightly reduced to optimise enrolment behaviour.

Patient Outcomes

Positive patient outcomes were a significant motivating factor for nurses. In the early stages, sharing

these outcomes helped engage nurses and doctors who had not bought into the changed approach.

Later on in the programme the personal satisfaction for healthcare staff who had supported a

patient’s change was a factor in motivation and job satisfaction (although the overall balance


between good patient outcomes vs demotivated patient frustrations determined overall nurse

satisfaction levels).

Patient outcomes were perceived in many different ways so typically can only be described

qualitatively rather than in any quantitative, health-targets fashion. As patient goals were unique to

the individual, so were patient outcomes. In many cases, the broader approach beyond purely

medical to psych-social needs, meant patients were achieving goals that did not yet have an impact

on their health outcomes. These could be life-changing achievements for patients which may have

been critical foundations to support future health improvements, yet are difficult to measure

clinically. Nurses and Doctors have been able to see and appreciate these positive changes in their

patients, but many noted frustration in not being able to ‘prove’ quantitatively the difference that

had been made. Case studies are the best way to reflect the impact of this approach to care.

For example a patient with uncontrolled diabetes who didn’t attend appointments. It was identified

they were living in a car and kept their insulin in the glove box. With care coordination to facilitate

community health worker (social work) support to get the appropriate help from WINZ and Housing

NZ this patient now has accommodation and a fridge. This was combined with education about their

health condition and its impacts/management and the development of a trusted relationship with

their primary care practice. These factors are likely to improve their insulin adherence, appointment

DNA rate, and diabetes outcomes in future. Yet when measured on a pure health measures basis at

this time results may appear unchanged or even negative. (refer to Appendix E2 for other patient

case studies)

The patients with the best outcomes were reported as those with the most intrinsic motivation to

change. Those reported as least likely to achieve good outcomes were unmotivated patients or

those who were working full-time (as they were typically to have less time to attend appointments

and/or address their health and psycho-social issues).

The most commonly reported difference this model of care has made is the time nurses spend

listening to and working with patients. The fact someone cares enough to spend the time, and that

alone, has a memorable patient impact. It builds a trusted relationship that is not impacted by the

barrier of cost. The ongoing motivation role that health professionals can provide as patient’s move

along the self-management continuum was valued by patients i.e. having someone that’s going to

follow up on their progress.

Multi-Disciplinary Teams

The practice approached MDTs in three ways. Firstly they had regular meetings between identified

nurses and social workers, and similarly with between nurses and the health psychologist. These

were targeted around discussing referrals and sharing around patient needs and outcomes. For the

nurses involved these were a valuable and integral part of good care coordination. Nurses with

patients referred to those services but not involved in the MDTs felt they lacked communication on

patient progress. There were reflections that value gained from MDT conversations could not be

replicated within formal patient notes and reporting.

Secondly they engaged in more typical MDT meetings. This included converting an existing

bimonthly GP training session with a gerontologist into an MDT format to focus on elderly and

palliative patient cases. And having Nurses or GPs either attend or phone in to District Nursing MDTs

hosted by the DHB. These were useful mechanisms to enable GPs and Nurses to experience the


value of MDTs without the commonly raised concerns of time wasting. A number of staff reflected

that technology could better support these MDTs, although having met in person was still key to

relationship building and trust.

Thirdly they instigated internal team MDT meetings with all GPs, Nurses and HCAs. This was

logistically challenging for a large practice to roster for each of their three large teams. However

many staff reported it as a valuable time to share patient needs and successes to gain input from

other staff and to develop a team-based approach to patient care. Some staff recognised the future

value in bringing other relevant health practitioners in on these internal MDTs (specifically

mentioning the CHC, psychologist and pharmacist).

Internal Communication

The name “Wellness Programme” was established to give this approach to care an identity within

the practice and for communication purposes.

A project team was established with the Executive Sponsor, Management staff and selected GP’s

and Nurses to drive the Wellness Programme. This was key to maintaining the impetus of roll-out,

sharing and addressing issues and opportunities arising along the way, and driving the change.

This practice already had a management team in place that held weekly management meetings.

They had a schedule of monthly GP meetings and Nurse meetings. Weekly Practice meetings were

also held with variations in format and focus across a month to support staff training and team

communication. These existing formats provided an important foundation for ongoing

communication about this shared care approach.

The practice also had a regular internal newsletter which was used for sharing important updates,

and created a noticeboard targeted at the programme. They utilised their intranet as the central

source of information. These methods were developed and improved throughout the programme,

particularly the intranet.

Staff feedback indicated that despite the extensive efforts even more communication would have

been valued. There was a sense that communicating the reasons (the ‘why’) for iterations and

change along the journey might have reduced some of the staff anxiety.

Sharing success stories, providing documented operational processes and information, and making

patient feedback available for staff, and were the key strands of communication.

Peer review

A process for peer review was established to understand and improve the quality of care planning. A

simple checklist was developed for use in self-assessment or peer-assessment of care plans.

Lunchtime and after-hours forums were provided to support nurse-sharing and feedback.

Although there is an existing peer review expectation for GPs this is uncommon for Nursing staff. So

building the approach and the level of trust for nurses to openly share and learn from each other

was a considerable change. Nurses, as well as Healthcare Assistants, reflected positively on these

learning opportunities.


The approach to peer review iteratively changed over time but in all formats the feedback was used

to inform staff training and programme improvements.

Executive Sponsorship

The CEO, one of the GP Owners, was observed to be fully supportive of this philosophical change to

patient care and assumed the mantle as active driver for change. She was supported by the

management team who worked together to give ongoing consideration to the many implications of

this change (i.e. operational, financial, staffing, organisational structure, training etc).

Having an active executive sponsor was key to the successful implementation of a care change of

this significance. This was particularly during the first six months when the change was challenging -

individuals and teams were being pushed outside their comfort zones; workloads were high; there

was financial uncertainty; technology was inefficient or ineffective; the patient outcomes were not

yet strongly evident; and staff morale was low. The CEO’s leadership demonstrated a steady and

positive approach to continually communicate the importance of this change, a willingness to listen

and take action, and consistency of conviction and support for the team.

The visibility of a leader who has the courage of their convictions and gives appropriate priority and

makes decisions aligned to the necessary change was clearly crucial for the magnitude of this

change.


Appendix E1 - Wellness Wheel Patient Assessment Tool


Appendix E2 - PFHC – Other patient Case Studies Case 1 - DB DB is a 51 year old lady with type one diabetes and depression.

When enrolled onto ARI/SMSC DB was taking her insulin sporadically, not testing her blood sugars,

or oral medication and had a very low mood. She had actively attempted suicide and also saw her

poor diabetic management as a slow form of suicide.

DB was enrolled onto the Wellness Programme 9 months ago and a full assessment was completed.

Upon completing her care plan, DB identified that her goal was to be able to spend more time with

her grandchildren, but she recognized that in order for her to be able to be comfortable doing this,

she needed to be able to manage her diabetes and to feel happier.

DB was offered assistance from the health psychologist for ARI, provided a green script and referred

to a self-management group.

Working with the health psychologist, DB now understands that she has control over her diabetes

rather than the other way round and has some coping mechanisms in place to manage her mood.

DB is now taking her oral and insulin medication daily and testing at least once a day. She has also

undertaking other screening programmes and has completed her smear, as she now wants to be

proactive about with her health

Her mood has improved greatly with DB now making plans for the future and is enjoying life again.

DB has developed skills to cope with difficulties in life.

Case 2 - MF A 64 year old with type two diabetes, heart disease and COPD.

MF was referred to be enrolled onto ARI/SMSC due to a climbing HBA1c which was 93.

It was felt by her care coordinator that a home visit would be the best place to undertake her full

assessment as it was felt there may be some concerns with her home. MF identified her goal as

wanting to be able to visit her sister, which she has been too fearful to do, due to her diabetes.

Following the home visit, her home was noted to be both cold and damp. Issues around medications

were discussed and resolved, as MF was able to chow the care coordinator all the medications she

currently had (and adherence issues were identified and discussed).

MF was offered self management, health psychology and was referred for insulation for her home.

By working with the health psychologist and her care coordinator, MF now understands how to

manage her diabetes and how to take control of it. She was due to visit her sister for Christmas.

After a year MFs HBa1chas reduced to 60 and she has lost 3kg. She has insulation in her home. Part

way through her year, MF identified a new goal of wanting to be able to help her son look after his

new baby, who is due in the new year. Working with the health psychologist has helped her to

understand the need to be proactive with her health to ensure she is around to help him. She has

now completed her mammogram and attends specialist appointments.


MF felt she was able to be involved in all the discussions and decisions around her health and well

being. Working with the health psychologist had empowered her to become an active member of

care team and gave her the confidence to take control of achieving her goals.

Case 3 - AB 18 month old European toddler was referred to me by her GP for assessment of delayed

developmental milestones.

Parents were keen to engage and I started with a home visit to assess her living environment for

child safety and also to establish how the child interacted in her familiar environment alongside her

parents.

Background History was Molly was born prematurely at 31+6/40 due to complications with mum,

she had had a difficult pregnancy with several bleeds before 20/40 weeks. On delivery of booked C-

section, she required ventilation for 3 days then high flow oxygen which was weaned within a week.

Molly is the 3rd daughter and she is well loved and cared for by her doting parents, due to being

premature they often carried her around and allowed her to sleep for extended periods of time.

Developmental Assessment

Gross Motor It was evident immediately that Molly had gross developmental delay she was unable

to roll over from back to front and if she ever was on her front she protested with a high pitch cry.

She was unable to sit up or pull herself up onto her knees.

Fine motor skills were OK she had a pincer grip but was unable to build 3 block tower or put toys

through holes (that may have been due to loss of opportunity).

Communication Molly had no comprehensible words or even baby babble. She was smiling certainly

no pointing and had a high pitch cry. Eating she was unable to tolerate solid finger foods (parents

stated she gag on it no episodes of choking or cyanosis. She couldn’t hold a cup and still drinking out

of a bottle being totally dependent for feeding.

Social Molly was very smiley girl, had an aversion to strangers, where she would be inconsolable

even in her parents arms. She was often kept in her pushchair which mum caused her “safe and

comfortable place”.

Goal Setting (by parents)

1) For Molly to walk so she could attend kindy by 3 yrs old.

2) Wanted answers why Molly was not progressing like their other 2 daughters the only

difference was Molly was premature.

What I did as the healthcare professional.

1) Discussed my concerns with the GP and write and urgent referral to the Paediatric

developmental team for assessment of gross developmental delay and severe plagiocephaly

(occipital flathead).

2) Referral to Neurodevelopmental therapist to assist with her lack of mobility.

3) Referral to special education for assistance with severe delay in all areas of development.

4) Referral to speech and language therapist for food aversion with solid lumpy foods.

5) Commenced her on fortini supplement drink as weight/ weight 10 percentile.


6) Reassurance and support to parents, giving them verbal and written material on the

Wellness programme, goals and expectations from myself and caregivers.

7) Offered community support worker for carer hours for respite and a support parenting

assessment.

8) Fortnightly clinic visits initially to assess progress and growth and development.

9) Encouraged parents and siblings to increase tummy time and standing to strengthen legs.

10) Encourage meal time eating together at a table to demonstrate eating habits and solid food

consumption.

What the parents did

1) Attended all appointments and referrals

2) Tummy time and leg strengthening before every meal or snack.

3) Communicate any concerns or worries to Claire if they did not understand a service or

referral.

4) Meal times together as a family encouraging finger food and drinking independence.

Summary

Molly was seen by the Paediatric developmental team and confirmation with MRI diagnosed gross

developmental delay with sensory issues. All above services are involved in her care and she is now

attending day care that specializes in children with developmental delays. She has made amazing

progress and is now pulling herself to standing. She has great fine motor skills and 5 comprehensible

words. She is now drinking out of a sipper cut and eating solid foods she picks up by herself.

Even though this is a long hard journey for Molly and her family they are overwhelmed by the

support and services that were quickly initiated due to her engaging in the Paediatric Wellness Clinic

otherwise known as the ARI/SMSC programme.


Appendix F – PCRS Primary Care Resources and Supports for Chronic Disease Self-management

Assessment of Primary Care Resources and Supports for Chronic

Disease Self Management (PCRS)

Individuals interested in using the PCRS in quality improvement work or research are free to do so. We request that you not change

the wording or content of the questions and that attribution to the Robert Wood Johnson Foundation Diabetes Initiative appears

prominently on all pages. We would appreciate an email or phone call from users of the tool, so we can track its dissemination. We

also ask that users be willing to share results and feedback about the instrument with us so that we can continually update our

work. If you need written documentation from us verifying permission to use the PCRS, please contact:

Robert Wood Johnson Foundation Diabetes Initiative National Program Office Washington University in St. Louis School of Medicine Division of Health Behavior Research 4444 Forest Park Avenue Suite 6700 St. Louis, MO 631082212 Phone: 3142861900 Email: [email protected]

This product was developed by the Robert Wood Johnson Foundation Diabetes Initiative. Support for this product was provided by a grant from the Robert Wood Johnson Foundation® in Princeton, New Jersey.

Developed by the Robert Wood Johnson Foundation Diabetes Initiative, March 2006 www.diabetesinitiative.org

Copyright © 2006 Washington University in St. Louis School of Medicine

Assessment of Primary Care Resources and Supports for Chronic Disease Self management (PCRS)


Background and Rationale

Purpose

This survey was developed by the Advancing Diabetes Self management Program of the Robert Wood Johnson Foundation Diabetes Initiative. The

grantees wanted an instrument that would be congruent with the Chronic Care Model, and which would be an expansion of the self management

component. Its purpose is to help primary care settings focus on actions that can be taken to support self management by patients with diabetes

and other chronic diseases. Specific goals are that it:

1. Function as a selfassessment, feedback and quality improvement tool to help build consensus for change

2 Identify optimal performance of providers and systems as well as gaps in resources, services and supports

3. Help teams integrate changes into their system by identifying areas where self management support is needed

Who should use this tool?

This tool is for providers in primary health care settings that are interested in or working on changes consistent with the Chronic Care Model. It is to

be used with multidisciplinary teams representing front line staff, clinicians and administrative personnel. We suggest that teams use it periodically

(e.g., quarterly, semiannually) as a way to guide the integration of self management into their system of health care.

Why another assessment tool?

This tool can be used along with other tools such as the Assessment of Chronic Illness Care (ACIC) (Bonomi, Wagner et al. 2002). It focuses on key

characteristics of good patient self management at the process level (how well the system is performing) and at the structural level (what systems

need to be in place). When appropriate, it looks at these characteristics at the patient, clinical team (microsystem) and organizational

(macrosystem) levels. The changes suggested should lead to improved patient and staff competence in self management processes and improved

behavioral and clinical outcomes.

How is it used?

This tool is intended for use by teams interested in improving the quality of their self management support systems and service delivery. Each

member of the team should fill out the assessment independently over an agreed upon timeframe (e.g., last quarter). When all members have

completed the tool, it is recommended that the team meet to discuss their scores and any discrepancies among scores. Discrepancies in scores

offer an important opportunity for discussion that can lead to improved communication and team function. The value of this tool is not in the number

each member assigns, but in the improvement process that is initiated by discovery of discrepancies or improvements warranted.



Definitions and Scoring

This tool will help clinics assess the level to which self management is integrated into their practice. It is divided into two components (Patient

Support and Organizational Support) followed by a score sheet.

Patient Support: The first section includes eight characteristics of service delivery found to enhance patient self management in the areas of

physical activity, healthy eating, emotional health, medication management, and managing daily activities and roles.

Organizational Support: The second section includes eight system design issues that primary care organizations must address in their planning,

resource allocation, and evaluation to support the delivery of self management services.

Both components are needed. Just as tools must be in place to assess individuals’ self management needs and work with them to achieve their

goals, the infrastructure must be in place to document and monitor progress in meeting those needs. The following diagram lists the characteristics

of each of the two components and reflects their interface.

Patient Support

Organizational Support

Individualized assessment Self management education

Goal setting Problemsolving skills

Emotional health Patient involvement in decisionmaking

Social support Links to community resources

Continuity of care Coordination of referrals

Ongoing quality improvement System for documentation

Patient input Integration into primary care Patient

care team Staff education and training

Ratings: Each characteristic listed has 4 levels of performance, from a low level of development (D) to a level that reflects strong systems

integration (A). The levels are progressive. In general, the following criteria were used in listing activities in each of the AD levels.

Level D: structure and/or process nonexistent or inadequate

Level C: patient/ provider level = addresses issues related to patientprovider interaction



Level B: microsystem level = addresses issues related to health care teams/ coordination of services of that particular office Level A: system

level = addresses issues in levels B plus the health care system, polices, and environmental and/or community supports

With the exception of the D level, each level has a range of 3 numbers from which to select. This allows you to consider to what degree your team is

meeting the criteria described for that level and score accordingly. Similar to Likert scales, this is somewhat subjective. Within each level, you can

adjust your score up or down depending on how much of the criteria you meet and/ or how consistently you meet it. Respondents should circle one

number (not a letter) for each of the 16 characteristics in the survey.

As in school, the best grade is an “A”. In general, to get an Alevel rating (8, 9 or 10), clinics should be consistently using systematic, integrated

approaches that incorporate follow up support and are sustainable. It is important to note that the highest level, the system level (A), assumes the

microsystem components in B plus the items specifically listed.

Scoring: There is an optional Individual score sheet attached to each survey. You/ the team may also want to devise a sheet on which to aggregate

scores for ease of comparison and to facilitate discussion among team members.

Bonomi, A. E., E. H. Wagner, et al. (2002). "Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement." Health Serv Res 37(3): 791820.


Individual Instructions for Completing the Survey

Although the survey can be answered regarding any of a number of chronic illness conditions, for today we would like

you to rate the care your team provides for your panel of patients only.

Please rate your care team or ‘microsystem’ on the extent to which it does each of the activities listed for those

patients under your care. By patient care team we mean the clinical staff that work together to manage a panel of

patients. This often, but not always, involves a physician and the nurse(s), technician(s), and possibly educators

and front office staff who work with that physician.

When considering your responses to each characteristic, use the previous 3 months as the timeframe.

Using the 1 – 10 scale in each row, give one numeric rating for each of the 16 characteristics. If you are unsure or

do not know, please give your best guess, and indicate to the side (or in the comment section of the score sheet)

any comments or feedback you would like to give regarding that item. NOTE: There are no right or wrong answers

and each members of the team’s perspective is different and important. For this reason, please first rate each item

without talking with or discussing your rating with other team members.

After team members have completed their surveys individually, have one team member collect scores from all respondents and

aggregate the scores for discussion (it may help to write scores on a chalk board or flip chart for each question). Meet and share

comments, insights and rationale for scores. Discussion should NOT be focused on who is right or wrong, but rather why

various ratings were given. If time permits, it may also be valuable to discuss ideas about specific actions that the team could

take to enact strategies described at the higher levels.

If your team uses this method, please answer these “group discussion questions” on a separate sheet and submit responses

with the surveys.

a. How was the discussion useful?

b. What items did you spend most time on?

c. Was there anything about which the group was confused?

d. Were the examples under the various levels helpful for generating improvement ideas? If yes, can you share an

example?

Teams can also opt to complete the group discussion on their own after the surveys have been submitted.

Return the survey and the score sheet (or copy of both) to the survey administrator by ______________.


Please make sure your team designation and role on the team are filled in on the front page.

If you have any questions, need assistance or clarification, please contact your survey administrator

_______________________________ (name) at ____________________________ (contact info)

Thank you!


To be filled in by your survey administrator:

Site/ Location: ___________________________________________________ Team: _________________

Focus of assessment or patient population under consideration (e.g., those with specific condition, those seen by certain patient care teams):

___________________________________________________________________

Has this team had past experience in systematic QI initiatives, e.g., collaboratives? Yes_____ No_____

To be completed by respondent: My role in team: _____________________________My profession: ______________________

I: PATIENT SUPPORT (circle one NUMBER for each characteristic)

Characteristic

Quality Levels

D C B A (=all of B plus these)

1. Individualized Assessment of Patient’s Self management Educational Needs

…is not done

1

…is not standardized and or does not consistently include most self management components*

2 3 4

…is standardized, fairly comprehensive and documented

prior to initial goal setting; takes into account language, literacy and culture; assesses patient’s self management knowledge, behaviors, confidence, barriers, resources, and learning preferences

5 6 7

…is an integral part of planned care for chronic disease patients; results are documented, systematically reassessed, and utilized for planning with patient

8 9 10

2. Patient Self management Education

…does not occur

1

…occurs sporadically or without tailoring to patient’s skills, culture, educational needs, learning styles or resources

2 3 4

…plan is developed with patient (and family if appropriate) based on individualized assessment, is documented in the patient’s chart, and all team members generally reinforce same key messages

5 6 7

…is documented in patients’ charts, is an integral part of the care plan for patients with chronic diseases; involves family and community resources; and is systematically evaluated for effectiveness

8 9 10

*e.g., for diabetes: physical activity, healthy eating, emotional health, medication management, monitoring, reducing risks and managing daily roles and activities



Characteristic

Quality Levels


3. Goal Setting …is not done

1

…occurs but goals are established primarily by member(s) of the health care team rather than developed collaboratively with patients

2 3 4

…is done collaboratively with all patients/ families and their provider(s) or member of healthcare team; goals are specific, documented and available to anyone on the team; goals are reviewed and modified periodically

5 6 7

…is an integral part of care for patients with chronic disease; goals are systematically reassessed and discussed with the patient; progress is documented in the patient’s chart

8 9 10

4. ProblemSolving Skills (i.e., problem identification, listing of possible solutions, selection of one to try, assessment of the results)

…are not taught or practiced with patients

1

…are taught and practiced sporadically or used by only a few team members

2 3 4

… are routinely taught and practiced using evidence based approaches and reinforced by members of the health care team

5 6 7

…. is an integral part of care for people with chronic disease; takes into account family, community and environmental factors; results are documented and routinely used for planning with patient

8 9 10

5. Emotional Health (e.g., depression, anxiety, stress, family

conflicts)

…is not assessed

1

…is not routinely assessed; screening and treatment protocols are not standardized or are nonexistent

2 3 4

…assessment is integrated into practice and pathways established for treatment and referral; patients are actively involved in goal setting and treatment choices; team members reinforce consistent goals

5 6 7

…systems are in place to assess, intervene, follow up and monitor patient progress and coordinate among providers; standardized screening and treatment protocols are used

8 9 10



Characteristic

Quality Levels


6. Patient Involvement …does not occur

1

…is passive; clinician or

educator directs care with occasional patient input

2 3 4

…is central to decisions about self

management goals and treatment options and encouraged by health care team and office staff

5 6 7

… is an integral part of the

system of care; is explicit to patients; is accomplished through collaboration among patient, team members and physician, and takes into account environmental, family, work or community barriers and resources

8 9 10

7. Patient Social Support

…is not

addressed

1

…is discussed in

general terms, not based on an assessment of patient’s individual needs or resources

2 3 4

…is encouraged through

collaborative exploration of resources available, (e.g., significant others, education groups, support groups) to meet individual needs

5 6 7

… systems are in place to assess needs, link patients with services and follow up on social support plans using household, community, or other resources

8 9 10

8. Linking to Community Resources

…does not

occur

1

…is limited to a list or

pamphlet of contact information for relevant resources

2 3 4

…occurs through a referral system;

team discusses patient needs, barriers and resources before making referral

5 6 7

…system in place for

coordinated referrals, referral follow up and communication among practices, resource organizations and patients

8 9 10


II. ORGANIZATIONAL SUPPORT (Circle one NUMBER for each characteristic)

Characteristic

Quality Levels


1. Continuity of Care …does not

exist

1

…is limited; some patients

have an assigned primary care provider (PCP); planned visits and routine lab work occur on a sporadic basis

2 3 4

…is achieved through assignment of

patients to a PCP, scheduling routine planned visits with appropriate members of the team, and involvement of most team members in ensuring patients meet care guidelines

5 6 7

…systems are in place to

support continuity of care, to assure all patients are assigned to a provider, to schedule planned visits and to track and follow up on all patient visits and labs

8 9 10

2. Coordination of Referrals

...does not exist

1

... is sporadic, lacking

systematic followup, review or incorporation into the patient's plan of care

2 3 4

…occurs through team and office staff

working together to document, completed referrals and coordinate with specialists in adjusting the patient’s care plan

5 6 7

…is accomplished by having

systems in place to track incomplete referrals and followup with patient and/ or specialist to complete referral

8 9 10


3. Ongoing Quality Improvement (QI)

… does not exist

1

...is possible because organized data are available, but practice has not initiated specific QI projects in this area

2 3 4

…is accomplished by a patient care

team that uses data to identify trends and launches QI projects to achieve measurable goals

5 6 7

… uses a registry or EMR to routinely track key indicators of measurable outcomes; is done through a structured and standardized process with administrative support and accountability to management

8 9 10


Characteristic

Quality Levels


4. System for Documentation of Self management Support Services

…does not exist

1

…is incomplete or does not promote documentation (e.g., no forms in place)

2 3 4

…includes charting of care plan and self management goals; is used by the team to guide patient care

5 6 7

... is an integral part of the patient’s medical record; is easily accessible to all team members and organized to see progression; charting includes care provided by all care team members and referral specialists

8 9 10


5. Patient Input ... does not occur

1

... mechanisms exist, but are not promoted; input solicited sporadically

2 3 4

.... is solicited through focus groups, surveys, suggestion boxes, etc. for both service and service delivery improvements under consideration; patients are made aware of mechanisms for input and invited or encouraged to participate

5 6 7

…is considered an essential part of management’s decisionmaking process; systems are in place to ensure consumer input regarding practice policies and service delivery and evidence that management acts on the information

8 9 10

6. Integration of Self management Support into Primary Care

…. does not exist

1

…is limited to special projects or to select teams

2 3 4

…is routine throughout the practice; team members reinforce consistent strategies

5 6 7

...is built into the practice’s strategic plan, is routinely monitored for quality improvement and visibly supported by leadership

8 9 10


Characteristic

Quality Levels



7. Patient Care Team (internal to the practice)

… does not exist

1

…exists but little cohesiveness among team members

2 3 4

...is well defined, each member has defined roles and responsibilities; good communication and cohesiveness among members; members are crosstrained, have complementary skills

5 6 7

...is a concept embraced, supported and rewarded by the senior leadership; “teamness” is part of the system culture; case conferences are regularly scheduled

8 9 10

8. Physician, Team and Staff Self management Education & Training

… does not occur

1

...occurs on a limited basis without routine follow up or monitoring

2 3 4

…is provided for some team members using established and standardized curricula; practice assesses and monitors performance

5 6 7

...is supported and incentivized by the practice for all key team members; continuing education is routinely provided to maintain knowledge and skills; job descriptions reflect skills and orientation to self management

8 9 10

Site/ Location: ___________________________________________________ Team: _________________

Focus of assessment or patient population under consideration (e.g., those with specific condition, those seen by certain patient care teams):

___________________________________________________________________

Has this team had past experience in systematic QI initiatives, e.g., collaboratives? Yes_____ No_____

Score Sheet (Optional)

If you plan to meet as a group to discuss your results, you may elect to transfer the rating (110) that you gave each characteristic onto this

sheet. If you use this option, please make sure the survey and this score sheet are attached when turned in to the survey administrator.


Appendix G – Patient Survey

The SMSC/ARI Programme

Patient Survey

We would l ike to know how being involved in the ARI programme has been for you. Your responses are anonymous and will be used to improve this programme and contribute to learnings that will improve future programmes. Thank you for your time. Date: ___________________

Quality of the programme SELECT ONE

Strongly disagree

Disagree Agree Strongly

agree

1. Being involved in the ARI programme has made the quality of my care even better

Please comment on your answer if you wish

2. Being involved in the programme has improved my health and wellbeing


Impact of the programme SELECT ONE

How much impact has the ARI programme had for you in:

No Impact Small Impact Large

Impact Very Large

Impact

3. Helping you to identify when you may have been getting sick earlier?


Care coordinator and care plan SELECT ONE

Strongly disagree


agree

4. I was actively involved in setting the goals in my care plan


5. My care plan reflects what is important to me



Strongly disagree


agree

6. My care plan helps me to change the way I care for myself


7. My care plan has made my care better organised


8. I have been given access to my care plan or been offered a copy of my care plan


Overall experience Yes No Please provide comments on your answer

9. Do you feel being involved in this programme gave you better access to services you need?

Did you have any negative experiences from being involved in this programme?

10. What were the best parts of being involved in the ARI programme?

11. What would you suggest to improve the ARI programme?

Thanks again for your time in giving feedback to help us improve the ARI programme.


Appendix H – Provider Interview SMSC Qualitative Survey Interview - Provider

Practice/Organisation:

Name:

Role:

Date: Start time: End Time:

# Question Response

Pilot 1 Please describe how having the ARI Programme has changed the care you provide to patients with long term conditions?

1 What benefits do you think the Long Term Care programme has had for your patients?

1a Are patients more aware and educated about their own health and do they better understand how to manage their own care?

1b Are patients better educated in how they can engage healthcare professionals?

1c Are patients more confident about themselves?

1d Does this service impact how patients interact with other primary and secondary care? (E.g Impact on hospitalisations etc…)

2 What benefits do you think the Long Term Care programme has had for you as a care coordinator/ GP/ Allied Health and other healthcare stakeholders?

2a Do you think care-coordination improves the way healthcare services can enhance patient care?

2b Does care-coordination provide a mechanism to identify health exacerbations early?

2c How does care-coordination impact the way healthcare stakeholders interact with each other and with patients?


3 What types of people do you think the programme has had the most and least benefits for? Please state why?

3a Specific chronic conditions

3b Gender, demographic and ethnicity

7 What aspects of the service could be improved in the future and how could the service be made more sustainable?

7a How can technology play a part in better sustaining this service?

7b What are the implications to business models and funding that need to be addressed for this service to be sustainable?

7c What policies, regulations and guidelines need to be in place to support this service? (E.g. a coherent funding policy that reimburses GP’s etc…)

7d Is there a specific set of skills and workforce model that are required to enhance this type of service? Please describe

7e What are the governance implications of this type of service? (E.g. who is now accountable for care etc…)

7f What are the key messages that need to be communicated to patient, provider and business stakeholders?

10 Do you think this type of service results in a higher level of job satisfaction?

10a Does working in a coordinated manner improve your overall job satisfaction?

10b Do you feel that you have developed new skills through this trial and has this provided you more clarity in how you operate in an MDT?

4 Do you feel that the new model of care better improves the access to care and increases equity of care to all patients? Discuss the following:

4a Does care coordination better allow different cultural needs and sensitivities to be addressed?


4b Does gender, demographic and ethnic differences affect the way coordinated care services are delivered?

5 What was your experience in working as part of a multi-disciplinary team?

5a Discuss the highlights and the difficulties in working as part of a coordinated team

5b Was there significant change effort required to work in a multi-disciplinary team? Share experiences.

5c What are you perceptions about other health stakeholders who were involved in coordinated care (e.g. GP’s, Allied Health etc…)

5d Could technology play a part to enhance how providers better coordinate with each other?

6 Were there any particular groups of stakeholders who you found challenging to deal with?

6a What are you perceptions about other health stakeholders who were involved in coordinated care (e.g. GP’s, Allied Health etc…)

6b What challenges did you find when you engaged and coordinated with health stakeholders?

8 Does this new model of care better equip the healthcare sector and increase the knowledge base of healthcare stakeholders?

8a Does this service improve the knowledge capacity of the health sector? (E.g. increased knowledge of community services, increased knowledge of care planning benefits, increased competency of e-Shared Care Plans, increased knowledge of clinical guidelines etc…)

8b Does this service improve the level of engagement between providers and increase the satisfaction of health care providers?

8c Does this type of service improve the skills of the healthcare workforce?


9 Do you think this service effectively utilized the various services offered by different healthcare providers

9a How effective were the MDT in delivering services to patients on a care plan?

9b Do you feel that the care plan allowed healthcare providers to be more effective with their time and resources to help provide an optimized service?

9c Did MDT’s regularly meet/ discuss the needs of the patient?

9d Was there a right balance between primary and secondary care services provided to the patient?

9e Do you feel that the service resulted in a noticeable reduction in the use of hospital services?

Admn What specific feedback do you have from the interaction you’ve had with ARI patients/programme in your Admin/Reception/Finance role?

A1 What has helped you in your Admin/Reception/Finance role engage with the ARI programme and ARI patients?

A2 What needs to improve for Admin/Fin/Reception staff to be more effective in supporting the ARI programme and ARI patients?

A3 Do you know who the patient's Care coordinator is and how to contact them?

Pilot 2 A

What has been the most valuable part of the ARI from an Administrator/Receptionist perspective?

Pilot 3 A

What’s the biggest thing you’d improve with ARI from an Administrator’s/Receptionists perspective?


Appendix I – Provider Interview Analysis

Qualitative Survey of Providers

ProCare Health Limited

Nicolette Sheridan and Timothy Kenealy

14 March 2016

Contents Summary and recommendations ........................................................................................ 86

Evaluation findings .............................................................................................................. 86

Recommendations ............................................................................................................... 87

SMSC Qualitative Survey Evaluation ................................................................................... 87

Question 1. What benefits do you think the Long Term Care programme has had for your

patients? their own care? .................................................................................................... 88

Patient’s understandings about their own health and care ............................................ 90

Patient engagement with healthcare professionals........................................................ 91

Patient confidence ........................................................................................................... 92

Service impact on patient interaction with primary and secondary care services ......... 93

Question 2. What benefits do you think the LTC programme has had for you as a care

coordinator/GP/allied health professional or other stakeholder? ..................................... 94

Question 3. What types of people do you think the programme most or least benefits? . 95

Most benefit .................................................................................................................... 96

Least benefit .................................................................................................................... 97

Question 4. Do you feel that the new model of care better improves the access to care

and increases equity of care to all patients? ....................................................................... 98

Gender, demography, ethnicity and coordinated care ................................................... 99

Question 5. What was your experience in working as part of a multi-disciplinary team? . 99


Question 6. Were there any particular groups of stakeholders who you found challenging

to deal with? ...................................................................................................................... 100

Question 7. What aspects of the service could be improved in the future and how could

the service be made more sustainable?............................................................................ 101

Technology ......................................................................................................................... 102

Policies and guidelines ....................................................................................................... 103

Specific skills ...................................................................................................................... 104

Accountability .................................................................................................................... 105

Key messages ..................................................................................................................... 105

Question 8. Does this new model of care better equip the healthcare sector and increase

the knowledge base of healthcare stakeholders? ............................................................ 105

Question 9. Do you think this service effectively utilizes the various services offered by

different healthcare providers? ........................................................................................ 106

Multidisciplinary team meetings and care planning ......................................................... 107

Question 10. Do you think this type of service results in a higher level of job

satisfaction? ....................................................................................................................... 108

Feedback on administration, reception and finance ......................................................... 109

Knowledge of the patient's care coordinator .................................................................... 110


Summary and recommendations

Background and purpose

This evaluation was conducted as one output for reporting requirements from ProCare

Health Limited to the Ministry of Health with respect to a contract to deliver the SMSC

programme.

Data sources

Data came from 67 interviews conducted with staff in two general practices in Clendon and

Pukekohe, consisting of 24 doctors, 25 practice nurses, 10 administration staff and 8 health

care assistants. Interview notes were typed during the interview.

The findings in context

The analysis was conducted by a senior qualitative researcher (NS) who was blind to any

other findings from the evaluation. The findings reported below need to be interpreted in

the context of other findings from the evaluation. To the author’s knowledge, the only data

collected directly from participating patients were answers to a quantitative questionnaire.

Detailed interview data collected from health professionals, as reported below, has been

offered without the balancing view of patients. Health professional interviews can report on

their own interpretations of events, but are arguably less reliable in reporting their own, and

are even less reliable in reporting patient thoughts and actions.

Evaluation findings

Staff attitudes to SMSC ranged from a small number of people who were neutral to the

great majority who were variably enthusiastic about the benefits to patients, themselves

and their practice. Some enthusiasm from nurses and health care assistants was unstinting.

Some enthusiasm from nurses and especially administrators was tempered by recognition

there was a great deal of time and opportunity cost dedicated to ARI, but nevertheless there

was worthwhile net benefit.

Doctors universally reported improved access to services and more direct benefit to patients

on ARI as a result of increased nurse time. Many doctors and nurses thought that patients

would benefit from some ARI-funded doctor consultations for medical reviews. Doctor

funded consultations were also associated with acceptability, and therefore sustainability,

of the ARI programme. Neutral comments mostly came from a small number of doctors who

had limited contact with ARI but thought the programme had not been running long enough

to adequately judge it.

The most frequently cited benefit to patients was free access to nurse services and health

care assistants, and a reduced cost or free access to transport, repeat medications, blister

packs, and gym services.

The other main benefit to patients was seen to be developing strong relationships with the

nurses and health care assistants due to free access, extended consultation time and


extended services such as home visiting. Nurses in particular were also seen as able to offer

higher-value services to patients due to increased training that came with the ARI

programme.

Strengthening of relationships with patients and new skills from training, particularly in care

planning, Advance Care Planning (ACP) and motivational interviewing were seen as value

added by nurses. Multidisciplinary team (MDT) meetings, knowledge of community

resources, home visiting and deeper insights into patient’s lives increased nurses’

confidence and increased job satisfaction. Doctors consistently and actively supported the

expanded role for nurses. Doctors and administrators considered the financial impact of ARI

was either neutral or positive for the practice.

All groups of participants were inclined to dichotomise patients into those who were

motivated and those who weren’t. There was no great subtlety or empathy, at least as

captured in the typed notes, with hints of blaming patients and considering them

undeserving, and one or two interviewees appeared actively hostile to unengaged patients.

ARI was seen as more flexible than the Chronic Care Management programme, which in

contrast had less dialogue between patient and practice staff and fewer referrals to social

services and community resources. ARI was seen favourably by all except for a small number

of nurses who commented that the benefits of a systematic approach to diabetes care, as

dictated by the diabetes template, had been lost.

Recommendations

Overall, the health care providers from these two practices strongly support the ARI

programme continuing.

They want faster computing, which may be a local issue rather than an ARI issue.

They want reduced workload associated with administering the programme.

Provide patient funding for doctor consultations, which may be a local issue rather than an

ARI issue, if not already provided.

Consider using some systematic data collection templates for routine use for common

conditions, such as diabetes.

SMSC Qualitative Survey Evaluation

Of the 67 general practice staff interviewed, 16 were from the Clendon general practice (6

doctors, 5 practice nurses, 1 administration staff and 8 health care assistants) and 51 were

from the Pukekohe general practice (18 doctors, 20 practice nurses, 6 administration staff

and 7 health care assistants).


Interviews were typically 20 to 30 minutes. Interviews were not recorded but detailed notes

were typed during the interviews. The interview questionnaire comprised ten main

questions with sub-questions under each and additional specific questions about pilot

projects.

Data are reported under the ten main questions with data on pilots integrated into text.

Themes are reported together for Clendon and Pukekohe, and for all staff, unless there

appears to be differences between groups.

Question 1. What benefits do you think the Long Term Care programme has

had for your patients? their own care?

Main patient benefits: (1) no cost for nurses time, no cost for repeat prescriptions, blister

packs, transport, gym; (2) referrals to a wider range of health and social services; (3)

improved coordination of services; (4) better knowledge of their symptoms and conditions;

(5) confidence to self-manage; (5) a focus on their own needs; and (6) nurse home visiting

and follow-up.

“One-to-one intensive nursing time, without them having to pay for it has been a

huge benefit” (PD).

“once they are on palliative and need morphine top ups, wiping the prescription

charge has helped them a lot” (CN).

“A lot more time… a focus on a problem that the patient thinks is a problem” (PD).

“they’re getting cared for and listened to, that’s the big one” (CN).

“having that ‘go to’ person… someone they can contact to discuss any issues… before

it would be that you see any nurse… that’s one of the differences” (CN).

“Easy access to a nurse… there have been some health benefits as well, weight loss,

better blood pressure control” (PD).

“It’s been beneficial for some… that want to lose weight they’re slowly progressing

towards that goal. Elderly patients who want to remain at home are still at home or

have fewer hospital admissions” (PN).

“more knowledgeable now and getting more help from nurses and doctors” (CN).

“Giving them the confidence to actually change things and see how change can affect

their health in a positive manner” (PN).

Doctors described the LTC programme as supporting patients with “better access” (PD);

improving “knowledge of their condition” (PD); allowing “insights into their illness and the


effects on their daily activities” (PD); becoming “involved in goal setting” (PD); and

independence in self-care activities that showed “a higher level of ability” (CD).

Nurses said the ARI programme enabled “better access to nurses” (Pt1n7); time and

“personal attention” (PD); “a named coordinator… one person they can contact” (PN) and

“targets to achieve… keeps them up to speed with their health” (PD).

Nurses described developing a more empathetic patient-provider relationship. They

perceived this was related to increased time and home visiting, which built trust because

there were more chances for patients to tell nurses about their needs and preferences.

Nurses saw this as directly leading to better patient care. In addition, if the family of the ARI

patient were identified as needing help it was offered. Removing the cost to patients and

facilitating access to different services was repeatedly reported as making an enormous

impact on care, especially for those with LTCs, such as diabetes and heart failure.

Doctors, nurses and health care assistants often referred to the motivation and compliance

of some patients in comparison to others who were “not that keen on things” (CD).

Main provider benefits were: (1) time to assess patients and coordinate care; (2) training in

care planning and Advance Care Planning, motivational interviewing; (3) MDT meetings,

shared information and teamwork; (4) greater knowledge of health, clinical, cultural, social

and community services and resources; and (5) income to general practice.

“not being in fixed structures of 3 monthly visits… being able to decide and see them

more often… sometimes they deteriorate because you’ve lengthened out the visits

and they fall off the wagon” (PN).

“initial one hour enrolment. Good time period for a really broad assessment” (PN).

“we’re able to pull from different resources and think outside the box [pause] we can

look at social issues, something we’ve never had to look at before” (CA).

“having continuity with that one patient. Being able to access all these services they

weren’t able to before….motivated ones get a lot out of it” (PN).

“Self-management group course also helps… one-to-one nurse as care coordinator

helps in large practice” (PD).

Health care assistants saw their care coordination role and relationship with patients as

central, in the same way that nurses saw this role.

“most of my patients they prefer coming and looking for me. If you’re not here, the

nurses will see them if they feel like they can’t satisfy my patients they leave a

message for me to call them. I’ll follow up and call them and apologise I wasn’t

there” (CH).

All doctors were aware of the broader programme reach and several commented that social

determinants were no longer barriers to health care, “non-medical related things that will

help with medical goals” (CD) and were part of the broader focus of general practice staff

who were more likely to refer to primary health care and community services.


“We deal with medical stuff first… other support stuff, probably just as important for

patient’s health, gets left behind... (ARI is) definitely useful” (PD).

“allied health, accessing social work, mental health… for my palliative patients it was

the care coordination and the support the family got” (PD).

One doctor said it “has made things better in a financial sense” (CD) for the practice, further

commenting on benefits, such as, the expanded range of services and improved

coordination of care. Consultations were seen as “more affordable” (CD). “Lots of patients

want to have more appointments because of that… funding is a big thing” (PD).

The newness of the programme was commented on by several doctors who were trying to

understand it and thought it too soon to be assessing whether goals had been met.

Nurse consultations lasting between 45 and 60 minutes were seen as time consuming but

they appeared to recognise a net benefit. Nurses commented on increased workload and

this quote reflects the feelings of many nurses, “As annoying as it is sometimes because it

takes up all our time, its’ good” (CN).

Patient’s understandings about their own health and care

Overall, providers thought that the majority of patients had more opportunities to engage as

a result of the programme and some were increasing knowledge about their health and

were getting better at managing their care. They recognised that patients too, were still

learning about how to use the programme

“Health literacy has improved” (PD).

“Mums of young kids are more aware of allergies, what to avoid and how to manage

kids well” (PD).

“most of them have a better gauge of what their condition is... with goals customised

to their condition they’ll be able to manage better” (PD).

“They seem to be more aware of what they don’t know…. less flippant” (PD).

“At least we’re paying more attention to that part of their illness” (PD).

“(programme) gives patients more time to ask more questions... assuming that the

nurse goes to their level so patients open up more” (CA).

Examples were given of improved adherence to medications as a result of blister packs;

knowledge of their medicines, in particular when being admitted to hospital; and carrying

medicine cards in their wallets. “Generally they know more about diabetes” (CN).

“for some patients their health has just improved greatly. They’re taking their meds

now because they know what it’s for, their diets are better, they’re exercising, they’re

involved in their families and their families health is improving” (PD).


The ability to individualise the programme was seen as being of high value. Patients engaged

in mindfulness, small group education about their condition and how to manage it, and

often had access to a dietitian for hypertension and obesity issues, or a psychologist.

Attitudes reflected perceptions of patients as good or bad, “The good ones yeah [pause] the

ones that actually turn up” (CN). Those that were not engaged were perceived as going to

be difficult to engage.

“Very mixed feelings… we’ve been enrolling our hardest to manage patients first, so

they’ve had years of CCM input without success so they’re a bit hard wired anyway...

to say it’s made a big difference there, probably not yet” (PD).

“some come and say they’re willing and in next few months they don’t come. They

say they want to do it but end up not wanting to. We still haven’t figured out why

they’re not engaging again. Some of them I’ve noticed have engaged, then

disengaged, then come back and re-engaged”(CN).

“Probably 60 (yes):40 (no). 60% respond quite well and are more informed and aware

of their health” (PN).

Patient engagement with healthcare professionals

Providers were acknowledged as playing a part in assisting patients become more familiar

with health services. Most providers, particularly nurses, thought patients were engaging

better with health professionals because of the opportunities the new programme offered.

“Some had embraced it enthusiastically” while others were “still finding their feet” (CD).

Engaging with providers online was considered more difficult for some populations, “our

patients are a lot older patients and they don’t know how to use IT” (CN). Linkages with

pharmacists and others reflected horizontal integration within primary care.

Nurses were seen as pivotal. “I’m not running it (doctor), the nurses they run it” (CD). “Here

the nurses have worked really hard to make this work” (PD). Another said “more than I have

(nurses)… have interacted with patients… (with) some satisfaction” (CD). System changes

were evident when nurses reported patients knew who, and how, to make contact.

“Most of the patient’s know our names, know who to contact, what numbers to call.

We’re the main contact now instead of the doctor… we triage and see if they really

need to see the doctor” (CN).

“they know… who they’d go to and how to engage with us” (CN).

Nurses were engaging with patients to address problems, previously managed by doctors,

which was mostly seen as useful. Nurses described difficult conversations, such as, with a

woman who had a fear of needles but needed to take insulin. Upon home visiting it was

found that she was caring for her sister who had Alzheimer’s. “At first she said she was

really anxious but the way I talked to her…” (CN).

ARI was attributed with improving engagement with patients and strengthening the team

approach within the practice.


“engagement of patients with their condition, getting involved and understanding the

chronicity of their condition, getting involved in treatment... all that increased patient

awareness... it’s improved the team approach within the practice” (CD).

Some doctors and nurses were seeing patients in joint consultations. Continuity of care was

considered in some settings to be more achievable if a person or doctor/nurse team

followed the patient over time. This contrasts with the view that more nurses need to be

engaged in patients care and care planning.

“I see the patients with the nurse. We do it as a team so that she knows what I’m

doing and I know that what she’s doing. It’s a consultation jointly with the practice

nurse. I find it good I’d like the same nurse to be following the patient... designated

nurse for the patient” (CD).

“Maybe have multiple nurses involved with every patient, rather than one nurse and

one patient. I’ve added team nurses on to my patients in my care team. Some have

taken it on and added to the patient’s care plan… others haven’t” (PN).

Patient confidence

Overwhelmingly, providers perceived patient confidence had grown.

“Yes I do. I think its empowering the patient. I found that the chronic programme

didn’t empower the patient but ARI did. I think it’s because we spend more time…

having a better understanding of their health they took ownership. The chronic care

programme didn’t do that. It was more there’s funding, come and see the doctor and

get your foot checked” (PD).

“They seem to be more confident in certain areas. Diabetics are more confident about

managing their condition… more specific confidence” (PD).

“Definitely with their health conditions, action plans, asthma or bronchiectasis… gives

them confidence of their own symptoms” (PD).

More empowered

“I get more people calling up asking for help, and more confident asking to get what

they want when they come in” (PN).

“More confident… there was a lady, 58 years old, and never had a smear done. She

was coming for a dressing change every second day and every day I talked about

being due for a smear. One day she finally said yes, do my smear”. (CN)

More accessible and responsive

“reduces their hospital admissions. One particular lady [pause] tetraplegia,

asthmatic, had bronchiectasis, she’d had several admissions with her chest

condition… we used email to say coughing or change in sputum email us to send a

prescription” (PD).

New programme, needs to be sustained


“Early days, Rome wasn’t built in a day. We need to roll this over with more clinical

input to get it to work but for longer, would be detrimental if it were to stop” (PD).

“Yes, although I’m still trying to get people confident to adjust their meds [pause]

increasing insulin if fasting blood sugars are too high”. (CD)

“About half of the patients, those who engaged with the practice, were thought to

be more confident. Some patients set targets, “One particular guy with a HbA1c level

he wants to get to… it’s made him more focused” (CN).

“The ones that really understand and are really involved I’m sure they do. The ones

that are hard to get hold of every three months I’m not sure” (H).

Service impact on patient interaction with primary and secondary care services

Access to no-cost general practice consultations was thought to decrease patients’ use of

secondary services. “We’re keeping them out of the clutches of secondary care” (PD).

“We’ve helped them understand how to manage their condition better so their first

point of call is coming to us rather than hospital” (PD).

“I’ve encouraged them to come here before going to Middlemore. They have done so,

and doctors are very good at seeing them here” (CN).

“Little bits of change… I ask them to call me first before they go to hospital. That’s a

change, even if feeling horrible they will let me know and come here first” (H).

One doctor reported that for some patients referring to secondary care had produced good

results and another commented on a better attendance to outpatient clinics.

“I’ve probably increased my referrals to secondary care. One went to the respiratory

clinic got spirometry and we kept a close eye on her here. We engaged a lot better

because of the complete medical review… and she’s a new person” (PD).

“For some they’re attending outpatients a lot more…. they’ve more engaged” (CN).

An increased use of specific primary care services, such as psychological services and self

management programmes was evident, as providers saw direct benefits to patients and

continued to make referrals.

“More so with… social workers and physiotherapists, occupational therapists...

hospital is still a barrier to them. Psychologist is good” (PD).

“Psych services and the SME programme have been really great additions” (PD).

“It increased my knowledge on all the services I can refer to… getting to learn a lot

more about mental health… you have to be proactive to learn, it’s making a

difference” (PN).


Question 2. What benefits do you think the LTC programme has had for you

as a care coordinator/GP/allied health professional or other stakeholder?

Benefits included shifting ‘doctor work’ to nurses, insights and confidence in patient care,

flexible funding, teamwork and communication and care coordination.

Shifting work to nurses

“Being able to pass on the management to the nurse who has a lot more time to deal

with specific things than I have... not trying to rush it all in one 15 minute

appointment. I can do this bit knowing I’ve delegated that bit” (PD).

“Patients that require extra time are able to access it without having to pay… mainly

nursing time. Doctors act as consultants” (PD).

“Nurses have some time to coordinate services. That has helped” (PD).

Nurses gained insights into patient’s lives and described becoming more confident and

practical - “I’ve been more proactive” (PN). A greater number of referrals to social services

like WINZ and Housing NZ were reported.

“I’ve probably become more confident in starting a process of care on my own

without the doctor… more confident picking up this patient needs to be seen by

physio, without having to talk to someone first… much more confident in making that

decision myself” (PN).

“Giving me funded time to spend with patients. I get one day a week” (PN).

“You have your own time to go through everything… not rushed [pause] ticking off

what social needs or medical needs they need help on. That way we can do referrals

or further education” (PN).

“It’s given me a lot more insight... we’re quite medically focused and focus on the

issue rather than what the patient wants… this has made us listen.” (CN).

Flexible funding

“It’s made us and some services more accessible to patients. Compared to CCM it’s

more flexible and that’s a good thing... I’d like to see myself doing more with it - it’s a

time thing really. We’ve been quite busy here. That’s an irony. Good for a busy

practice in a low cost area but we’re too busy to hook into it” (CD).

“Funding is more flexible, that’s the main benefit. If one person is using more and one

person is using less and it can be flexible. It’s not a one year log off. You can continue

for a couple of years. ARI has been more difficult to get my head around because it’s

not as set a criteria and the paperwork is quite labour intensive” (CD).

Administrators, doctors, nurses and health care assistants talk about the enormous amount

of time and personal effort they have put into the ARI programme, but say it’s worth it.


“It takes an extraordinary amount of time to get people used to these programmes

and get the full use out of them…. We have to be very interested and motivated to do

that but so many calls on our time. I’d like to spend a good half day, no phone calls

etc. and just fiddle with it. I think that would probably do it” (CD).

“A lot of time and energy is put into a few people… there’s a lot of people that (we)

haven’t engaged with but could… it’s broadened my knowledge of what’s available

for people” (PN).

“It was a really big learning curve… lots more admin work involved as an

administrator when I came to invoicing, also in terms of the batch updates, you have

to make sure that gets done every day… identifying ARI patients took time. I can see

benefits for patients” (CA).

“It actually makes me learn more about patient care. It’s the binding between me and

the patient. It gives me more knowledge of patient care” (H).

Care plans provide a mechanism to identify health exacerbations early. Patients are aware

of their symptoms, have action plans and “know they can come in and be seen quicker”

(CN1). “COPD patients, yep, it’s excellent. The ones that I work with, they know when they’re

early warning signs, if they’ve run out of back up antibiotics they’ll ring” (CN).

“It gives the patient a bit more of a voice and gets them involved in it. Until they get

involved it’s really hard to get buy in and change happening” (PN).

Teamwork and communication

“It’s been awesome working with the VHIU team… (who) notifies us about

patients….VHIU will pay for 6-8 visits to help to get them engaged with us” (CN).

“Greater communication between the nurse, GP and patient resulting in better care

coordination was noticed in contrast to less dialogue with CCM” (CA).

“Compared to CCM, there’s more social input. We didn’t have so many areas we

could refer them to, didn’t know and have connections” (PN).

“If there’s a care coordinator they can open up… (they) relay that to the doctor. You

see the whole part of patient life, not just… wounds - they benefit more” (H).

“You need very good effective communication from the top down” (H).

Question 3. What types of people do you think the programme most or least

benefits?

There were conflicting perspectives about the types of people who benefited most or least.

Repeatedly providers made distinctions between those they perceived were motivated, and

those they perceived were not. Patients that providers had not engaged were often termed

difficult and could be considered undeserving.


“Sometimes you wonder what’s the point of us trying so hard, if they’re really not

engaging there’s no point. We do so much to the patient it just goes to waste” (H).

Few providers reflected on their own efforts, like the doctor who commented below.

“Those who do poorly are the same people we’ve struggled with for years. One

disappointing thing is we still get frustrated about those we know could do better but

somehow don’t manage to have the skills to look after themselves better. Haven’t

broken that conundrum” (CD).

“For Maori who have engaged it has helped, but unfortunately because prices here

are slightly higher they don’t engage with doctors much. They do engage with the

nurse but not often do they get that extra clinical care” (PD).

People with long term conditions were seen to ‘benefit most’ by some, and ‘least’ by others.

People who could benefit included those with COPD, heart disease, uncontrolled diabetes

(those who had lost limbs), asthma, hypertension, obesity, psychiatric problems, and those

who were terminally ill and without family. A person with a single focus on a condition or

intervention was seen as someone would benefit, as was a population of younger people,

older adults, or widow/ers who could attend the practice.

Those who benefited least included people who had fewer health needs or were managing

well, those not suited to the programme (which was not further defined), who were working

and could not make time, had mental health issues, or who were poor younger adults with

additional barriers to care.

Most benefit

Motivated and engaged

“have raised awareness and are motivated” (PD).

“those motivated to change” (PN).

“newly diagnosed conditions we’re able to motivate” (PD).

“early in illness but with high level of motivation”(CD).

Single focus

“people who have just one issue… weight loss... really intense management” (PD).

“weight loss and lifestyle related diabetes patients” (CD).

”those with HbA1c massive drops real benefits” (CN)

Long term conditions

“people who have multiple problems and issues and need multiple visits” (CD).

“not coping with illnesses well, taking meds late and turning up late for medical

reviews so markers that they’re not self-managing well” (CD).


“chronic care patients” (PD).

“our biggest healthcare issue is diabetes” (CD).

“chronic multiple conditions” (PD).

“people with chronic conditions, with good health literacy respond well” (PN).

Populations

“widows or widowers that don’t have family support” (PD).

“younger patients… willing to engage (PD).

“elderly patients they come in” (PN).

“those with a low health literacy… that’s pretty pervasive round this area” (CD).

“Pacific Island people, we have lots of those people who are diabetics and

hypertensive. Some of the Maori people” (CD).

“Pacific and Maori people with very bad [pause] most of them very overweight and

little knowledge of self-management so very beneficial for them” (PN).

Least benefit

Not motivated or there are barriers

“a group… no matter how, they’re just not registering… unstable diabetes, no matter

what we do, just not motivated” (PD).

“patients who are obese and not engaging... non-compliant” (PN).

“doesn’t matter if they are Maori or Pacific Island if they’re not engaging it won’t

make a difference. I’ve had 60 year olds and 20 year olds, but no difference” (CH).

“those not involved won’t gain anything” (CD).

“people that give up easily and have a lot of barriers that prevent them from

accessing, like transport to come into practice, or their own cultural beliefs and

values” (PN).

“patients who… know everything” (PD).

Programme not suitable, stable patients

“those persuaded to join, but it didn’t suit them” (CD).

“patients we rushed to put on because we needed to get numbers up but they don’t

need to be on it, their health is stable and being managed (PN).

“those with less problems or if things are running well” (CD).

“don’t have obvious medical problems… to be under specialty services” (PN).


“Doesn’t work well for patients that just don’t want it” (PN).

Complex, long term conditions

“chronically ill who have had lots of input” (PD).

“really complex patients who it’s actually difficult to keep out of hospital” (PN)

“people who work” (PD).

“patients that have social issues… that are anxious and every time they get unwell

they go to hospital” (CA).

Populations

“Younger people who are poor, and don’t know what services are available - who

can’t drive or don’t have transport (CN).

“(people with) mental health problems has been least effective” (PN).

“(working) very busy they don’t have time to… go to gym and exercise” (PN).

“Older men, who are working age don’t make the time” (PN).

Question 4. Do you feel that the new model of care better improves the

access to care and increases equity of care to all patients?

Overall the response was “yes” across providers. A focus on access to services for new, very

unwell patients, now followed up, related to dedicated nurse time.

“he said you wouldn’t want to take me as a patient… he had… been sent to prison…

we did blood test and I told him if you get chest pain you should call an ambulance.

Second week he had chest pain, he called an ambulance, and he ended up with a

stent. He had a heart attack. He doesn’t want to spend time in hospital so he takes

early discharge and turns up here for meds on Friday afternoon. We didn’t even know

his INR level, and he was only 5 days post-stent. (Nurse) goes to his property and she

was in shock to see where he lived. Now he comes almost weekly and he’s one of the

most ideal patients” (PD).

An example of a patient previously on CCM who relied on free doctor visits was no longer

visiting the general practice.

“one of my patients who was a very badly compliant diabetic was used to 3 monthly

CCM free visits has only come in once or twice. ARI was new and we said possibly

some funding could go to GP visits. I think that was a barrier at the start not knowing

what ARI could or could not cover. Now it’s been a year and we haven’t heard from

her. Some people who really do need us are slipping through the gaps” (CD).


Equity was mostly seen within the context of time, cost and accessibility.

“for relevant patients there is an equity not here before” (CD).

“We have 30 minutes set aside to help them find services” (CN).

“it’s free to see nurse every three months or earlier than that... so they can come

more often. If it was a paid one they wouldn’t be interested” (PN).

“gives patients the opportunity of one-on-one with the nurse… more time and more

home visits” (PD).

Gender, demography, ethnicity and coordinated care

There was acknowledgement of ethnic diversity, but few providers explained what this

meant for their own practice. Some comments implied othering (not-one-of-us) and other

comments indicated racial bias.

“there is diverse ethnicity groups here, if you have one of their own they feel comfy

and they can communicate better with their language” (CD).

“You have the time to ask them more about their cultural habits and standards and

morals and values” (CN).

“Pacific Islanders like to just be given a goal” (CN).

“for myself, most Maori patients they engage quite well with me… some Indian

patient’s don’t want to see Indian nurses, but some are happy to” (CN).

“I’ve found a lot of problems with getting my Maori and Pacific Islanders to even

agree to go on the programme. Caucasians are more willing to take up the

opportunity. Seems there’s a bit of denial and not willing to own their disease, wrong

phrase, but take responsibility and learn about their conditions. Whereas Caucasians

seems to have been more willing to take opportunity to learn and work on their

conditions” (PD).

This nurse described changing the approach to better understand the things most important

to the patient.

“I don’t think you do it differently. Now I spend a lot of time asking, What do you

want? or What do you think you need? or How do you think you can change things?

and What can we do to help you? rather than just identifying the medical issue they

come in with” (PN).

Question 5. What was your experience in working as part of a

multidisciplinary team?


MDT meetings were valued because information was gained. Some nurses reported outside

this interaction their work had not changed. Nurses more often coordinated MDT meetings.

“Just seeing our team grow in their capability and the enthusiastic way they’ve prosecuted it.

Great” (CD).

“MDT meetings are the main thing” (PN).

“MDT meetings are quite good for peer awareness and review... need a team that

works with the patient” (PD).

“MDT meetings are helpful… you learn quite a bit… find other options for patients

that I generally might not have known” (CN).

“The MDT meeting was good to at least see a face and know there was someone out

there who we can coordinate care with” (CD).

More interaction outside of meetings was wanted

“I still feel like I’m working solo most of the time. I haven’t had a lot of interaction

with the doctors… the doctors are seeing their own patients and their list and you’ve

got your patients and your list” (PN).

“More engagement from the doctors… that would be my biggest thing... to have their

backing and input more often than at the moment” (PN).

Organising MDT meetings was challenging

“Challenges… getting the whole team… giving me the names so I can coordinate it.

Timing is a problem because not all doctors are always there” (CN).

Doctors are better supported by nurses

“You feel that you’re not alone, that you have support around you. You can always

ask someone, fall back on someone, there’s support” (CD).

“It’s been hard to make, to translate the effort from MDT into success. The amount of

work required to get material change in patients has been quite large. It’s taken a

while to find the workload for the different people. The social work and MDT didn’t

manage to find the caseload we thought we should for whatever reason. Even having

(psychologist) here… apart from seeing patients, I didn’t get a sense she became an

extended part of the practice in terms of sitting down and sharing advice about

patients, she still remained a consultant even though co-located” (CD).

Question 6. Were there any particular groups of stakeholders who you

found challenging to deal with?

Both nurses and doctors reported variability in doctor’s engagement in the ARI programme.


“Probably my colleagues, some are keener than others. It’s got to be said. Staff have

been pretty good” (CD).

“Some doctors” (CN).

“Mainly the GPs who are used to certain model of care and the other time restraints

of that 10-15 minute appointment” (CD).

Although “pharmacist time” was not paid within the programme, some expected changes in

pharmacists behaviour.

“Pharmacy springs to mind, if we had a better pharmacist to access their input we

could do more on the medication side… a pharmacist who was more willing with LTCs

and wanted to really take part in that MDT group that would be good” (PD).

Patients

“Stubborn patients… don’t want to engage” (CN).

“Some, not very compliant and very hard to get through to… say one thing but do

something else” (CD).

“Yes, but it’s hard if the patients don’t want to do anything… frustrating to us if they

fall… if you spend a long time talking about Hba1c and then they skyrocket it’s like oh

man she didn’t take anything in. Patient compliance is the thing” (CN).

Question 7. What aspects of the service could be improved in the future and

how could the service be made more sustainable?

Sustainability was repeatedly and strongly linked to patients’ ability to pay for doctors’ time.

While not funded within the programme, the cost of filling a prescription was also reported

as a barrier.

Patient cost

“at the moment they end up paying to see doctor, I think that’s still a barrier at the

moment. They see nurse and see us and think why are we charging for it” (PD).

“Lots of patients prefer if they have a funded one with the doctor. They only have

funded consults with nurse” (PN).

“they see the doctor that’s $17.50. We waive that sometimes for ARI patients. They

have five meds that’s $25. When they go to the chemist they don’t get them all

because they don’t have enough money… some patients haven’t cashed in those

prescriptions they have three months ago” (H).

Engaging general practice in the longer term


“More funding. That way practices won’t be reluctant to engage. It needs more

clinical input… more doctor’s time that would make a difference” (PD). “Recognising

that the cost to general practice to do anything like this are quite high. At the

moment it relies very heavily on nursing... you need senior well educated nurses who

can then just leave the practice and leave you with a hole” (PD).

“Getting the GPs more involved. I think some funded checks need to be done by the

GP, they can’t be alienated from the case” (PD).

“if anything funding for doctors to be more involved” (PD).

“it’s more how we use the ARI money… other practices use some of that funding for

doctor’s appointments as well… we’re only using for nurse appointments. It would be

beneficial to have some of that funding for doctor’s appointments” (PD).

All about claiming costs

“It’s all about money rather than the patient…. Always drumming on about claiming

it this way and that way, rather than going on about this is what you can do for these

patients. It’s more about how to claim and this has changed. Always the way primary

care is, but ideal to focus more on patients” (PN).

More funding than ever before

“Primary is funded better than it ever has been in my view, better for us, I hope we

can get to show some good results from that” (CD).

Additional staff employed

“We’ve got dedicated nurses but maybe extra staff members to take on that load.

Another health care assistant… paperwork and recalls and lists… that would be a

huge help” (CN).

“More support for the care coordinator role, its demanding” (CN).

“We’re mostly time constrained especially if there’s not enough staff” (H).

Technology

Online access

“We ask patients if they want online access, most of them they hardly check” (PN).

“Patients can access parts of their care plan… a lot aren’t interested… (they) have

limited areas that they can see. They can see blood pressure, weight… we’re getting

younger populations as well” (PN).

“It can be good for those with internet access and who are computer literate, but

with elderly people that don’t know how to use computers or don’t have internet

access it’s not going to work for them” (PN).

Desktop to cell communication


“The IT side of it is pretty important. I think the one thing, not from ARI, but we’ve

found really useful is to have desktop to cell phone communication. The messaging

has been a real boon. Our recall systems are pretty important, they’re not fit for

purpose they could be improved. The care planning system is essential but is not easy

to use” (CD).

Skype

“Skpying, the hospice is trying to do that with teleconferences or phone messages

once a month when you can ring in. There’s a little bit of that beginning to happen for

palliative patients. That would be useful” (PD).

Computer speed

“Computer speed really. Seldom access the care plan. We do a lot online… but I don’t

know that it’s saving us time. The other thing is we get old doctors notes online.

They’re harder to access than the old written ones are. You don’t get paper files

anymore, when you did you could find immunisations much easier. The only way

technology can catch up with that is if we have very large screens” (CD).

“Our computers are so slow and so time consuming. I don’t know whether it’s

Medtech or the computer” (CN).

“Our systems are really, really, slow so shared care plans take a long time to open.

It’s improved quite a bit with the last few upgrades. We have the CCMS portal which

is more helpful…. it’s quite user friendly for people like us who know about computers

but the ones who aren’t so clued up they struggle and it takes time to teach” (CN).

Technical ability

“I have very limited technical knowledge, I just have basics. When something goes

wrong I don’t know… I feel like what I’m doing I’m okay with it. Hard for me to

change. Other girls know more” (CN).

“More support with the care coordinators. Maybe more training through, not all of us

really know computer” (H).

“I don’t like technology…. it could work having skype with patients and others” (H).

Medtech

“Having it linked with Medtech, easy log on, less waiting time, hopefully

selfpopulating. That might be a good idea” (CD).

“(we) double up in Medtech through ARI. Nice if it writes into Medtech, make it more

efficient” (CA).

“missed opportunities… a woman saw the doctor one week earlier, but had not been

entered into Medtech. She returned for an ARI consultation” (CN).

Policies and guidelines


The need for clear guidelines on eligibility to the ARI programme, and how to claim was seen

as important. The Practice did not always know who should or shouldn’t coordinate care.

There was confusion over whether health care assistants could be care coordinators.

“Having a standardised policy for who you can… enrol for ARI” (CN).

“The way it’s specified is quite good because it puts a value on a service and you

know what you’re spending when you order something. Keeps you mindful of the

value you’re getting from doing something equals dollars being spent, rather than

just having ability to pull in services without regard for cost” (CD).

The use of a checklist that went beyond the RAG (Risk Assessment Guideline) that nurses

sometimes used, to further ask about issues, such as flu vaccination, 5-yearly pneumovax

(pneumococcal vaccine), and social issues was viewed as important. In addition, clinical

guideline information, “More info on dynamic pathways” (CD) was requested.

One nurse thought making claims, which had occurred in the past with patients enrolled in

the CCM programme, prompted better care. (The CCM programme is still available but no

practice income can be generated from patient enrolment).

“We had a CCM programme, diabetes CCM we’d see patients every 3 months - check

feet, check eyes and do referrals. That’s not happening anymore… if they’ve gone to

ARI… it’s not mandatory… but I felt that did provide good care. In order to get claim

through we had to fill in those things so because we don’t have to fill in the form no

one’s doing it. That level of care has dropped” (CN).

Specific skills

There were specific and general skills related to delivering the programme that were

identified. Some doctors perceived the psych-social-clinical skills they had developed over

time would take nurses with postgraduate qualifications more time to develop.

“The skillset we’re asking of our team is really sophisticated and takes a lot of

experience. It also means people need to have the skills to look at the wider

dimensions, so good psych-social-clinical acumen. This is something that we as

doctors have honed over 30 years of practice and asking a two year postgrad nurse is

a big challenge” (CD).

The programme

“Proper training with regard to referrals, community resources, and the skills to run

the programme… home visiting, clinical skills, and a non-judgemental attitude” (CN).

“Understanding the cultural needs of the person, that’s where I’ve learnt a lot about

Maori culture, before that I was totally oblivious” (PD).

“There needs to be more investment in people… (gaining) familiarity with it. That’s

the biggest problem. I think if we had someone spending two hours with an individual

running through various things that would probably do it” (CD).

Care coordination skills


“Definitely MDT, especially nurses having more one on one time… dedicated time so

they’re not having to triage patients when they have ARI. Phone consults to keep

track of how patients are between visits. I’m not sure whether physios or other allied

services are on board yet but for chronic pain that would be quite helpful” (CD).

“Having ARI time set aside each week made the difference to us… for me it’s just the

right amount of time for 34 patients. But maybe if you’ve got 70 patients or 100

maybe they need more time. I’m barely catching up for my 34 patients in 3-4 hours”

(H).

“Skills to do care planning” (CD).

Accountability

“It is an issue with nurses taking on more responsibility or more duties and actions

and not necessary we won’t see patient all the time. There’s a duty of care there as

well and responsibility that needs to be accepted and I’m not sure if some nurses are

at the point of accepting that yet” (CD).

“I support the notion that the general practice is that patient’s medical home. We

should be held responsible for ongoing care of patients while they’re in the

community” (CD).

Key messages

“we’re so distracted and the way the process runs there’s insufficient dialogue

between nurses and GPs about patients” (CD).

“the SME programmes, those are quite good and very effective. Should pay more

attention and give more information about those SME programmes” (PD).

“Always done like after the event has happened. Nice if it was planned, tried and

smoothed out before it’s widely implemented. Like to be communicated ahead of the

event happening rather than on the day” (PN).

Question 8. Does this new model of care better equip the healthcare sector

and increase the knowledge base of healthcare stakeholders?

Built knowledge of primary care and community resources

“made me more aware of how to go about referring people for others things other

than just their basic health needs… social stuff, getting them involved with social

welfare when they need it” (PN).

“Yep it does. Connecting in with other external services and providers, they become

more knowledgeable about what’s out there resource wise” (CA).


“Yep. Possibly because we’ve had lots of Friday CME sessions where we’ve done

networking, problem solving, one where we were looking at a whole lot of services

for mental health or social issues, things like that so we were gathering all our

knowledge and sharing all that stuff as well” (PN).

”Learning the social worker role. Finding out more about what’s around in the

community. Before I didn’t know so much, and now I do… broadens your knowledge

in terms of services” (PN).

Benefits to patients / whanau

“It helps us to give the (patients) more knowledge” (CN).

“Yes if you spend time with one person in the family suddenly the whole family’s

health improves” (PD).

Nurse motivation

“Also there’s education you can attend. You have to be proactive. You want to learn

because you’re dealing with these things because you don’t want to look like a fool

not knowing anything about it so you’re a bit more proactive” (PN).

“When I first started I had no idea what to do. Now I think I have more skills and

knowledge about how to run the ARI programme” (PN).

Training in motivational interviewing was highlighted by both doctors and nurses as useful.

Training in care planning and developing the skills and confidence to refer to social workers,

psychologists, community podiatrists, and other community services was described.

“Training did help with motivational interviewing… and the advance care planning

course helped us to have difficult conversations and frame questions in a different

way” (CN).

“motivational interviewing session so far with GPs” (CD).

“more counselling type skills” (PN).

“Advance care planning is a very good step forward, we didn’t have before” (CN).

“knowledge of care plans, had training” (CN).

“case management, coordinating with external services” (CN).

“we’ve had access to a social worker onsite” (PN).

“improved access to the community podiatrist” (CN).

Question 9. Do you think this service effectively utilizes the various services

offered by different healthcare providers?


Services and individual providers were identified. These included green prescription, Work

and Income NZ (WINZ), financial services, Housing NZ, hospice, churches, CMDHB ‘Very High

Individual User’ (VHIU) team, social workers, community podiatrists, psychologists,

dieticians and district nurses among others.

The text below notes “making use of the privilege” rather than perceiving access as a right

of the programme. Implicit bias could lead to limiting access or gatekeeping if individuals

were seen as not motivated or engaged and therefore not deserving.

“The social workers and psych we’ve worked with them as a team referring on our

patients that needs help…. some of my patients have started attending gym exercises

and are really making use of the privilege of cheaper gym membership” (PN).

As a result of the programme providers say they are accessing a greater range of services.

“we’re engaging with a lot more services than we were before” (PN).

“In the beginning we weren’t really going out there looking at what’s out there.

Towards the end of this we’re realising there is more resources we can use” (CA).

“We need to use more of these (community) services” (CN).

“social services, no one taps them on the shoulder and says we’ve got a patient here

if they’re not active. Don’t think their inertia has been a barrier, more about how we

here use it” (CD).

“Feedback has been it doesn’t reach the social work criteria. Social worker or key

worker resources in that area would be good…. and copy to us so we know what’s

going on” (CD).

“social workers… it’s hard to get hold of them” (PD).

“It could be done better somehow… though our church we run so many things for

community but hardly anyone comes. We run diabetes courses and vegetarian and

health courses. We should tap into these services more. If they’re running them all,

instead of creating our own” (CN).

“It’s only been nurse time so focused on what to do here. I haven’t tried to find out

what other services are because been told no” (PN).

Multidisciplinary team meetings and care planning

Multidisciplinary team meetings and primary care

Benefits

“assessment of the wider dimensions of patients’ experiences… trying to work out

what’s going on behind the scenes” (CD)

“its way more primary than secondary. Social work and stuff are primary” (PN).


It gives you good focus. Helps those coming in to the team and they can see at a

glance what’s happening with that patient at the time” (PN).

Limitations

“mild to moderate... if we all just consult each other on an as required basis rather

than trying to set up dedicated time where we do everything together” (CD).

“Very time consuming” (PN).

“It’s time consuming, time is a factor here” (CD).

Secondary care

“we’re actually very lucky to have an efficient and well run secondary care service. It’s

pretty accessible” (CD).

“one benefit, I got to know the VHIU team and I could ring through the switchboard

and get something sorted, which was a new experience for me. That was more

productive than setting a time and going round the lunchroom” (CD).

Question 10. Do you think this type of service results in a higher level of job

satisfaction?

The majority of nurses said “Yes” despite the considerably increased workload.

“satisfying – a lady on warfarin on ARI, I’ve since had better communication with her

grandson who’s now clued in, not aggressive, more understanding and knows what’s

happening… this elderly lady is going to be well managed” (CN).

“More work, but yes it does. We know we’re giving them better care than what we

would have normally” (CN).

“Yeah, I do feel like I’m contributing to the team. I’m helping patients make a

difference in their lives… simply by just helping them reach the goals that they set

themselves. I feel satisfied that I’m contributing” (PN).

“Sometimes during the meetings people say you’re doing a really good job with your

ARI and it feels good to have that support” (PN).

“more of nurse’s time and benefits for the patients” (CN).

Feeling like you’ve failed

“When they’re successful you feel very proud. With the patient you’ve achieved

something for them. Then you feel opposite when they don’t turn up. Leave another

message, send another email” (PN).


“When you get some positive outcomes, definitely... you feel like yes you’ve achieved

something and you’ve done it on your own so to speak. It has a positive effect on

yourself and your work. The people you can’t get in and you feel like you’re starting

to hound… they’re usually the ones that need the most help, so you feel a bit of a

failure when you find yourself in that situation” (PN).

Not my job

“lots of it does feel like social work and that’s not my job” (PN).

Paperwork and stress

“lots of paperwork involved” (PN).

“creates more stress for me… I don’t feel like I have a lot of expertise in a lot of those

diseases so it’s challenging” (PN).

“workload is dissatisfying” (CN).

“for nurses there’s a lot to do… positive end outcomes there’s satisfaction from that

for us and nurses, but… a lot of pressure on the nurses to go through all their ARI

patients, lots of phone calls and follows ups” (PD).

“Probably be duplication of notes… time consuming [pause] legal requirements for

patient notes then have to go into care plans” (PN).

Feedback on administration, reception and finance

New insights gained by administrators

“It’s allowed me to get more insight about patients. I didn’t have the same insight as I

have now…. Gives you more empathy, especially for those with high accounts and

there’s things going on other than not coming in paying” (CA).

Batch updates

“I really don’t like the fact I have to do batch updates all the time. It’s extra work and

does take a long time to do. You can’t use your computer when you’re doing a batch

update and when you have 200 odd patients it takes a long time. What happens is if

the patient sees the GP or nurses they comes to the front desk and I have to claim.

We see 15 patients a day to claim, I do all the claiming for them” (CA).

Information needed

“We sit in on meetings, but I’m still not 100% on ARI. When patients say what’s ARI I

give briefest of the brief and forward to a nurse” (CA).

“Bit more information with it… we’re at the front… we could have that knowledge

when the patient comes in, and not taking them as just the patient… only had one big

meeting with whole practice. Normally don’t get included” (CA).


“I have an idea what ARI is but I don’t think it’s changed a lot for admin, because we

don’t have much to do with it apart from invoicing, getting them to see which nurse

they’ve connected to for ARI” (CA).

Knowledge of the patient's care coordinator

Administrators were clear that they could identify the care coordinator.

“It’s on the right hand side of our screen a red alert and the nurse’s name”(CA).

“we do patient alerts. If I put in a patient’s name, it will come up that’s nurse xyz

patient” (CA).

Self-Management & Shared Care Evaluation Report · ProCare Self-Management & Shared Care Evaluation...

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