July 2013: CEO’s report to the community

1st July 2011 seems like only yesterday.

That was the day that North Coast Medicare Local was established, one of the first tranch of new regional Primary Health Care Organisations. These were formed by the federal government in response to the 2009 National Hospital and Health Reform Commission.

North Coast Medical Local was auspiced by the four General Practice Networks in Northern NSW, the local regional training provider, and the Many Rivers Alliance (representing the local Aboriginal Health Services). In the first 12 months the North Coast Consumers Forum, the Northern Branch of SARAH (representing allied health), and the two Regional Development Associations joined as member organizations. A board was appointed with appropriate governance and industry skills – and I was appointed as CEO.

With the benefit of hindsight, it is interesting to reflect on some of the early experiences of our new organization.

Mission

Our mission is to improve the health of our communites through better provision of primary care. We make sure that every person and their family can partner with the care team that they need to better manage their health.

What have we achieved?

From the point of view of our community:

– each person can clearly identify who is part of their own ‘care team’. They know where to get help for their family when they need it – they have ready access to their ‘medical home’, and they know how to access help after hours. Their contact with the health system feels ‘joined up’ – they have confidence that their own story is known to all those in the health system that they have reason to see. They can access information about their own health through the web, and are more confident that they have the knowledge and resources they need to better manage their own health and to better care for their families. The voice of the community is heard when decisions are made about health planning and delivery.

From the point of view of our General Practice partners:

– general practice remains the cornerstone of health care. Families continue to have long term relationships with a particular general practitioner. Practice teams are supported so that the care delivered ‘in the medical home’ can be more comprehensive. It is easier for practices to partner with other services and allied health providers to form patient care teams – relationships are fostered, and accurate and timely clinical communication is the norm. Practices are also supported to improve their provision of proactive and systematic care. Within each part of our region, general practice collegiality is maintained, and practices come together regularly to share innovations and for continuing professional development. Continuity of care with general practice is maintained when patients are admitted to hospital. Collectively, general practice has greater capacity to make sure that resources are allocated appropriately to better support the health of their communities.

From the point of view of allied health and other provider partners:

– to a much greater extent, all providers feel that they are part of a patient’s care team. Providers are supported to improve the quality of the systems in their practice. They have the clinical information that they need to better care for their patients and to communicate with other members of the care team. An inter-disciplinary collegiality has been fostered, and collectively allied health has a greater role in health planning and resource allocation.

Six Pillars

We can demonstrate early success, and we believe this can be attributed to ‘six pillars’.

1. Team based Model of Care

It quickly became clear to us that to make a real difference we needed to ensure that each person and their family can partner with the care team they need to best manage their health. Our Medicare Local therefore determined that it would be ‘the organization that supports Integrated Patient Care Teams’. This patient-centered team-based model of care informs all our activities, and is the first ‘pillar’ of our success as a Primary Health Care Organisation.

We make sure that each family can partner with a general practice (or health service) team to receive comprehensive care, based on long term relationships, delivered in their local community. We make sure that this partnership can team with other providers and services when they are required. We make sure that these care teams are integrated from the patient’s viewpoint – improving the ‘patient journey’, and increasing both efficiency and reliability.

We particulaly seek to make sure that disadvantaged and ‘hard to reach’ groups have access to this patient-centered care.

2. Team based Governance

Reflecting our focus on local care teams, an interdisciplinary Clinical Advisory Council was established in each of the four regions within our Medicare Local to advise on local health needs and to develop solutions. Each local advisory council had broard representation, including health consumers, general practitioners, allied and specialist health providers. Bringing together a diverse range of providers and patients was found to have unanticipated immediate benefits in producing innovative local responses to community needs, and the groups were supported to ensure there was ‘an agile’ implementation model to test ideas for improvement.

Representatives from each local advisory group were chosen to form a Regional Clinical Advisory Council to provide direct advice to the board and management of the Medicare Local on clinical issues.

Our Medicare Local is very aware of the broad determinants of health and have auspiced a high level Regional Health Leadership Group comprising CEOs and directors of our Local Hospital Networks, Local Councils, Dept of Education, Regional Developement Australia, Dept of Community Service, Clinical Leaders Group and our regional university. This meeting of the minds has opened up previously unimagined opportunities to cooperate on region-wide health improvement programs.

3. Engagement with our Provider Partners

All of the GP practices, Aboriginal Health Services and most of the community based allied health providers, medical specialists and community pharmacists have elected to become provider ‘partners’ of our Medicare Local. They proudly display this partnership in their premises and on their stationary – it is now a highly respected local brand. We support our provider partners to deliver better patient care. They agree to certain standards of communication, reporting and quality improvement activity.

Our divisions of general practice had developed excellent relationships with our local practices and had staff whose experience and skills were largelly irreplaceable. These factors were respected from the earliest planning of our new organization, and we made sure that we maintained our staff as they were ‘transitioned’ from the division to the Medicare Local.

The ‘divisions’ still exist in different form as vehicles for supporting specific local activity. Their membership has expanded to include medical specialists, and we have auspiced similar local networks to support allied health providers and consumers in each of the four parts of our region. Commonwealth funded program activity has transferred to the Medicare Local.

4. Quality, Informational Consistency and Data Management

Integrated care is dependent on each patient and their care team having access to accurate clinical information, and to be working ‘off the same page’ when looking at goals, targets and tasks. Our open source shared electronic record has been a major contributor to the improvements in efficiency and reliability that have been achieved. Just as important is the ongoing support in data management provided by our local program managers to practices and other providers.

We use accurate collated clinical data submitted by our practices to guide quality improvement across the region. We are more confident that patients are receiving high quality care at every point of contact with our ‘partner providers’. Practices receive monthly reports on their patient outcomes which inform their improvement efforts. The aggregated data is used in turn by our local ML offices to evaluate their own programs.

5. Planning, access and equity, prevention.

The clinical data received from our practices and services is an important source of information for our population health planning. We also work closely with the two Local Hospital Networks and our Regional Health Leadership Group to identify ‘gaps’ and inequality in services and health outcomes. We have an unprecedented ability to map out the health services and outcomes across our region. This information, and the relationships we have built outside the health sector, have significantly enhanced our ability to have a comprehensive preventive health strategy.

6. Workplace Development and Support

As well as new people, we needed new skills for our existing providers to operate in our team-based world. Our expanded breadth of responsibility enabled us to deliver all our training using an inter-disciplinary approach. Our close relationships with North Coast General Practice Training, the University Dept of Rural Health and Southern Cross University have proved invaluable.

We are particularly proud of the demonstrated effectiveness of our patient self management training for both clinicians and patients.

Early Gains

After Hours Care

Our earliest gains were in improving access for after hour general practice services throughout the region. This has required different solutions in each town. We have gained widespread community recognition and support through this program.

Chronic Disease Management

We already had significant experience in systematic chronic disease management and the Medicare Local structure has provided the resources and reach to make this consistent across the region.

Mental Health

We were selected to implement a ‘low intensity’ mental health service and this has significantly improved access to CBT throughout our area, even in the most remote towns.

EHeatth

We now have a consistet secure messaging service across the region, with timely exchange of clinical information between providers, services, patients and hospitals.
Our open source shared EHR is improving health outcome, particularly in providing patients with a ‘portal’ for their goals, measures, targets, care calendar and information about their conditions.

General Practice Hospital Inreach

Hospitals are now recognised as supports for primary care, rather than the other way round. The General Practice Hospital Inreach Program ensures continuity of the primary partnership between a patient and their general practice when they are admitted to hospital.

Aged Care

We have facilitated continuity of primary care as patients move from the community into residential aged care facilities and this has improved access to medical services in these facilities, especially after hours. We have developed improved work processes and tools that make it easier for general practices and the other members of the care team to work in these facilities and for patients to receive the highest standards of care.

Levers

As CEO, the new Medicare Local has provided me with the levers I need to pull to improve the health of our communities – and, just as importantly, it is has given me confidence that I have the information I need to be sure that the levers I use are the correct ones!

What’s more, our investment in data management enables us to demonstrate the effectiveness of each of the programs we deliver (and to move resources away from those that don’t). We have been able to demonstrate significant improvements in outcomes for our patients with chronic disease, better access to acute services for our families, more efficient utilization of mental health services, decreased utilisation of hospitals, better care in aged care facilities, and higher levels of consumer and clinician satisfaction.

At this, the 2 year mark, we look forward to the next part of the journey in improving the health of our communities.

This is an updated version of a talk given by Tony Lembke at the AGPN Forum ‘Claiming the Space’ in Sydney on November 7th, 2009.