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Integration Networks Pathways Addiction & Mental Health District Group. Alistair Watson 7 May 2013. The burden of long term conditions. Almost one in three of the population (and half of those over 60) have a long term condition. This group accounts for two thirds of the health spend.

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integration networks pathways addiction mental health district group

IntegrationNetworksPathwaysAddiction & Mental Health District Group

Alistair Watson

7 May 2013

the burden of long term conditions
The burden of long term conditions
  • Almost one in three of the population (and half of those over 60) have a long term condition.
  • This group accounts for two thirds of the health spend.
  • The number of people with comorbidities is expected to rise by a third in the next ten years.
  • Common mental health problems affect about one in seven of the adult population, with severe mental health problems affecting one in a hundred.
  • These conditions fall more heavily on the poorest in society

Source: Dept. of Health, England (2012)

local maori health statistics health needs assessment 2005
Local Maori Health StatisticsHealth Needs Assessment 2005
  • Cancer death rate 40% higher
  • Respiratory death rate 80% higher
  • More likely to smoke
  • Make up 15.2% MDHB’s pop
    • Poorer health yet 14.2% admissions
  • Three times more likely to not attend outpatients
  • Higher diabetes discharge rates compared to MidCentral overall
  • 18% more than expected COPD hospital discharges compared to MidCentral overall
  • 19% higher than expected neoplasm (cancer) deaths compared to MidCentral overall (age adjusted).
  • Children aged 5 showed poorer dental health than children from Manawatu
  • The highest proportion of smokers among MidCentral territorial authorities (24.6%)
  • 20% higher than expected number of deaths compared to MidCentral overall
  • Lowest % of households with access to a car

Statistics New Zealand, March 2006

the way services are organised utilised does matter
The Way Services Are Organised & Utilised Does Matter
  • Despite standardised approaches to management of common conditions there are major differences in way the care is delivered both nationally & locally
  • Current way services are utilised is based on the way they are structured & provided
  • Limited effectiveness due to fragmented planning & organisation and opportunity for improvement exists at every stage of the continuum
changing models of care
Changing models of care

Moving to care models that shift expenditure / activity away from hospital care, deploying resources more effectively to improve health outcomes and patient experience.

Ref: Dr Helen Bevan, NHS Institute

patients with complex needs integration a report from the nhs future forum
Patients with Complex Needs(Integration: A Report from the NHS Future Forum)
  • Intensive users of services, repeatedly crossing traditional organisational and sector boundaries.
  • Gaps, duplications or poor reliability of care multiplied as their journeys progress
  • More difficulty in understanding their or understanding their often tortuous care journeys making it more difficult to exercise choice or control, or manage their own care
  • Needs may include education, social care, housing & justice
patients with complex needs integration a report from the nhs future forum1
Patients with Complex Needs(Integration: A Report from the NHS Future Forum)
  • Groups most likely to benefit from integrated care include
    • Children and adults with complex needs
    • People with enduring mental heath problems
    • Homeless people
    • Frail older people and their carers
    • People at the end of their lives receiving palliative care
Expectations for patients with complex or long-term needs (Integration: A Report from the NHS Future Forum)
  • To receive care as close to home as possible
  • To be informed about the options available to them
  • The opportunity to discuss their options with a professional skilled in shared decision making
  • Easy access to a named care coordinator who knows them and is able to provide a tailored level of support to navigate their care journey and make choices at appropriate junctures
  • To know what to expect at each step of planned care journeys
Expectations for patients with complex or long-term needs (Integration: A Report from the NHS Future Forum)
  • To have an integrated care plan and where appropriate be offered an integrated budget
  • Every provider involved in the individual’s care to have access to their care record
  • Transitions between professionals, teams and organisations to be safe, smooth and efficient
  • To understand clearly and simply what care and support they are eligible for and how they might pay for it if they are not eligible for state funding
  • To be confident that appropriate information, training and support are available for carers
definition of integration
Definition of Integration

“the act of making a whole out of parts, the coordination of different activities to ensure harmonious functioning”

clinical integration
Clinical Integration
  • Many approaches with different terminology: shared care, transmural care, intermediate care, seamless care, disease management, case management, continuous care, integrated care pathways, integrated delivery networks
  • Patient centric view and needs of complex patients with chronic illness are considered
  • Scope varies but requires some form of seamless care or multiprofessional approach that values the role of all health professionals
  • Aim to improve coordination and integration of services
  • Types of integration (e.g., organisational, professional, clinical, functional)
  • Breadth of integration (e.g., vertical, hori- zontal, virtual)
  • Degree of integration (i.e., across the continuum: linkage, co-ordination to full integration)
  • Processes of integration (i.e., cultural and social as well as structural and systemic)
clinical integration1
Clinical Integration
  • Different models of care: consultative, collaborative, coordinated, multidisciplinary, interdisciplinary, integrative
  • A continuum from informal to formal arrangements with an increasing intensity of governance in the relationship between the providers
  • More fully integrated systems coordinate more information, activities and resources and consolidate organisational structures
  • Unlikely one model appropriate for all organisations or situations
principles of clinical integration valentijn pp int j integr care 2013
Principles of Clinical Integration (Valentijn PP. Int J Integr Care 2013)
  • Coordination of person focused care in a single process across time, place and discipline
  • Requires a person-focused perspective to improve someone’s overall well-being and not focus solely on a particular condition
  • Patient as a co-creator in the care process; with shared responsibility between the professional and the person to find a common ground on clinical management
  • Emphasis should be placed on a person’s needs, with people coordinating their own care whenever possible
requirements for change in healthcare
Requirements For Change In Healthcare
  • The essential requirements for success are:
  • Broad-based clinical leadership
  • District-wide service planning & organisation
  • Avoiding the fragmentation induced by existing service structures
    • (Bate P, Mendel P, Robert G: Organizing for Quality. Oxford: Radcliffe Publishing; 2008)
midcentral dhb journey to date1
MidCentral DHB Journey to date
  • Access
  • Community Participation
  • Coordination of Services
  • Infrastructure Development; increasing sector capacity
  • Integration between primary and secondary care
  • Quality
midcentral dhb priority plans
MidCentral DHB Priority Plans
  • Respiratory
  • Diabetes
  • Cardiovascular
  • Cancer
  • Depression
  • Oral Health
additional clinical services
Additional Clinical Services
  • Locally based primary chronic care teams : smoking cessation, physical activity, clinical dieticians
  • Locally based integrated “disease state” & cancer nurses and respiratory physiotherapists
  • Psychological support
  • Community pharmacy
  • Community specialist cardiology clinics, heart failure service & tests
  • Community GP sleep apnea, pulmonary rehabilitation & spirometry
  • Extended palliative care, Liverpool Care of the Dying pathway, psycho-oncology
other developments
Other Developments
  • Multidisciplinary Disease Management advisory groups
  • Primary Care Health Development Team
    • Professional development Knowledge and skills frame works, Nurse practitioners
    • Developing new models of care; “Long term conditions” nursing
  • Compass Health
    • Provide managed service operations: community nurses
better sooner more convenient business case 2010
Better Sooner More Convenient Business Case 2010


District wide response to providing the best possible patient experience whilst building a clinically and financially sustainable system.

bsmc programmes of activity
BSMC Programmes of Activity
  • Acute Demand Management
  • Older person’s services
  • Integrated family health centres
  • Whanau Ora
  • Systems levers
  • Other
acute demand management
Acute Demand Management
  • Self management support
  • Chronic care management
  • Case management
  • Walk in clinics
  • Enhancing intermediary care/Recovery at home
  • Single point of access to after hours care
older person s services
Older Person’s Services
  • Inter RAI
  • Interdisciplinary older person’s teams
  • Care planning and management tools
systems levers
Systems Levers
  • Clinical networks
  • Clinical pathways
  • Organisation design, leadership & governance
  • Workforce development
  • Information management
organisation design leadership governance
Organisation design, leadership & governance
  • DHB Clinical Leadership Council
  • Combined ALT/CPHO Governance and Leadership
  • DHB Quality Improvement Framework
  • Contracted Providers Network (proposed)
  • DHB Clinical Networks
  • Collaborative Clinical Pathway Programme
  • Health Care Development Team
workforce development
Workforce development
  • Transformational leadership programme
  • Interdisciplinary Knowledge and Skills Framework including LTC and case management
  • Career path for nursing from novice to expert leading to Nurse Practitioners
  • GP training scheme
information management
Information management
  • Traffic Light system
  • “Realtime” GP performance data
  • Shared Care Record (with proposed patient access)
  • Map of Medicine integrated with MedTech (and Houston?)
  • Clinical Portal (“Concerto”)
  • Best Practice
  • Web based Apps
  • Patient access centre
  • Medicines management programme
  • Devolution of radiology
  • Youth one stop shop
  • Urgent community care paramedic pilot (UCC)
network an interconnected group or system
Network: an interconnected group or system

Clinical Network: is a social-professional structure made up of doctors, nurses and allied health staff tied through inter-dependencies such as collegiality, friendship, referrals, function or common interest

Braithwaite 2010

new zealand networks
New Zealand Networks
  • National
    • Cardiothoracic - Stroke
    • Cardiac - Long Term Conditions
  • Regional
    • Cancer
    • Midlands: maternity, elective, cardiac, renal, rural, stroke, mental health/addictions, older people, radiology
    • Central: cardiac, renal, mental health/addictions, older people, population health, (stroke)
    • Greater Auckland Integrated Health Network
  • District
    • Canterbury:
      • aged, child & youth, collaborative care, IFHC’s, laboratory, long term conditions,medication, pharmacy, primary care liason, rural urgent
      • Healthcare pathways
    • MidCentral:
      • child/tamariki, mental health/addictions, cancer, elder, urgent, long term conditions, (elective)
      • Collaborative clinical pathways (Map of Medicine)
network types
Network Types
  • Informational Networks
    • Education, research and guidelines
  • Co-ordinated Networks
    • Care pathways, joint assessments, no binding contract, a ‘managed clinical network’
  • Procurement Networks
    • Budget given to a lead funder or provider, to contract with a range of organisations to deliver integrated care
  • Managed Networks
    • Highly managed long-term network of partners, e.g. Kaiser Permanente delivering and co-ordinating care for a whole population

(Goodwin et al, 2006)


“Need to harness the natural complex sociotechnical properties of the Health System”Braithwaite, Runciman & Merry 2009

two types of networks
Two Types Of Networks

• Type A: purpose-designed, funded or imposed by authority, in structured organisational or institutional forms [designed, mandated networks]

• Type B: those composed of the relationships amongst clinicians, via professional interests, referrals, supports, friendships, communications & advice [natural networks]

Braithwaite, Runciman & Merry 2009


Socialising Network in Emergency Department. Creswick N,Westbrooke JI & Braithwaite J. Understanding communication networks in the emergency department, BMC Health Services Research, 2009 9 247.

natural networks
Natural Networks
  • For every health care problem there are hubs and clusters made up of clinicians & others with a special interest & expertise in that area
  • Form a self selected group with a natural interest to identify and solve ‘coal face’ clinical problems in voluntary collaboration with others
  • Clinicians with common concerns & complementary expertise voluntarily grouped

Conceptual Framework for MidCentral District’s Clinical Networks

Collaborative Workgroups

Long Term Conditions District Group

Child Health / Tamariki Ora District Group

Mental Health & Addictions District Group

Cancer & Palliative Care District Group

Older Persons District Group

Urgent Care District Group

Surgical, Gynaecology & Elective District Group

Maori Health & Whanau Ora Steering Group

Combined/Transitional Steering Group

Clinical Leadership Council

MidCentral District Health Board


District Group


Collaborative Work Group

Collaborative Work Group

Collaborative Work Group

Collaborative Work Group

Collaborative Work Group

Child Health/Tamariki:

To improve the provision of health services to children and their families/whānau through optimised service development and delivery processes

child health tamariki ora district group functions objectives
Child Health/Tamariki Ora District Group: Functions/Objectives
  • Promotes sector wide inclusive approach, that incorporates Whānau Ora
  • Develops an open & supportive environment for those working in the child health/tamariki ora community
  • Improves quality, safety & effectiveness of care
  • Develops & sustains collaboration & communication with stakeholders and between related network groups
  • Develops an annual plan including about 6 time limited projects
child health tamariki ora district group membership
Child Health/Tamariki Ora District Group: Membership

DHB funding manager

Consumer representative

Intersectoral representative

Child health advocate


  • Clinicians:
    • Nursing
    • Allied
    • Medical
  • Managers
  • Community
  • Maori
  • NGO
network forum
Network Forum
  • To engage with clinicians & consumers to:
    • Exchange information on current network activities
    • Identify & prioritise current issues, &
    • Seek advice on strategies to address current issues
  • Open to all interested consumers, clinicians & managers
  • Held once per year, or more frequently according to need
district group work plans
District Group Work Plans
  • Choose about 6 time limited coal face projects
  • May include
    • Developing patient-centred integrated model of service delivery
    • Clinical pathways
    • Developing common performance indicators
    • Developing evidence-based clinical standards, guidelines & protocols
  • Requires formation of about 6 person work group & collaboration with wider clinical community
mental health and addictions work plans
Mental Health And AddictionsWork Plans
  • Development of a robust crisis respite journey
  • Alcohol and drug services targeted for young people
  • Create models for change / treatment journey PHO / GP / Psychiatrist support (to improve connectedness)
  • Increase access to the shared care scheme to support primary delivery
  • Link to Whānau Ora
  • Suicide minimisation across the district
  • Building psychosocial models of care, brief interventions
child health tamariki work plans
Child Health/Tamariki Work Plans
  • ‘Health Home’: Establish a single, principal data repository to link families & whānau with service providers & facilitate access
  • Disability-ASD children: Increase capacity of and improve access to secondary care child health services for children with autism spectrum disorder
  • Behavioral and Learning Referral: Consolidated entry into services for those with behavior & learning issues
  • Parental child health education: Teaching parents how to assess & manage their child’s health care needs & issues
  • Map of Medicine Child/Tamariki Ora: Further integrate 1 & 2 care services for child health

Combined/Transitional Steering Group

Child Health / Tamariki Ora District Group

Mental Health & Addictions District Group

Cancer & Palliative Care District Group

Older Persons District Group

Urgent Care District Group

Long Term Conditions District Group

Surgical, Gynaecology & Elective District Group

To assist MidCentral DHB create and maintain a Clinical Network structure and in doing so ensures that clinicians and consumers (and their family/whānau) are the core of health service development and improvement

transitional steering group membership
Transitional Steering Group: Membership
  • Chief medical officer
  • Director of nursing
  • Chair Central PHO Clinical Board
  • PHO clinical director
  • PHO management representative
  • Funding division representative
  • Operations directors
  • Community representative
  • Manawhenua Hauora Board representative
  • PHO director Maori Health
  • Maori health representative
  • Business case representative
  • Chairs DMGs/Reference Groups
  • Director integrated care (Chair)

MidCentral District Health Board

Community Pharmacy Group

Alliance Leadership Team

MidCentral Health Clinical Board

MidCentral Health

District Wide Clinical Leadership Council

PHO Clinical Board

Central PHO

Laboratory Clinical Council


Clinical Networks

NGO Contracted Provider Network

To provide leadership, direction and influence to ensure clinical quality, effectiveness and sustainability of health services for the people/populations of the district


Governance Structure

  • Central PHO Alliance Leadership Team (ALT)
  • Ultimate programme governance
  • Programme Sponsor

CEOs - MDHB and Central PHO

Sign-off from organisational perspective

MDHB Clinical Leadership Council

Receives all information

Monitors the programme from a clinical perspective

Reviews and advises if significant impacts to delivery of care, funding allocations or resources

Operations Director(s), MidCentral Health, GM and Clinical Director CPHO

Sign off the paper from a managerial perspective

MidCentral Health & CPHO Clinical Boards

Review and sign-off paper

No changes/ No impacts identified in pathway

If changes to resourcing required

If changes to clinical practice

Transitional Steering Group

Approves the final report / outcome

District Groups

Considers report/outcome and feedbacks to working group

Approves the final report / outcome

Working Groups

Undertake to complete working plan of the District Group

Managerial/ Organisational



District Groups/ Clinical Networks

Nominate pathways for development

Develop workplans

  • Network brand
  • Website
  • Network newsletter 3 monthly
  • DHB & PHO newsletters
  • Press releases
  • Presentations at clinical & other meetings
  • Fora
  • Surveys of constituent groups
  • SharePoint for district & collaborative groups
  • Work undertaken as part of usual role (DHB and other employees)
  • Meetings expected to be during work hours
  • Parking & travel expenses for meetings
  • Use of normal DHB support functions
  • 0.5 FTE administration officer
  • 2.8 FTE network manager
  • 0.5 FTE clinical lead

NSW Agency for Clinical Innovation - Clinical Networks Project Logic Framework Haines et al. Implementation Science 2012, 7:16