Mr Hamish FranklinExecutive

Integrated Care

Green Cross Health

University of Auckland

9:20 - 9:45 Reducing Demand and Improving Outcomes Through

Continuous Care

CHANGE IN PRIMARY CARE FUNDING

MANAGING DEMAND: SIMPLY

• The problem: the situation in general practice is consistently challenging

–Work is frantic: a constant stream of 15 min sessions, often shorter if there is an urgent care queue

–The paper work; clearing the red dots and inbox and happens from 5.30pm onwards

• Capitation makes General Practice a stakeholder in risk managing the population, yet in many cases practice capitation is nearly exhausted by demand

• The opportunity presented by managing demand: for practices to survive the current funding pressure, and for the workforce to have a lifestyle that is sustainable

WHERE DOES THE DEMAND ORIGINATE?

• Lets look at the demand through a lens that aligns with funding

$(500.00)

$(400.00)

$(300.00)

$(200.00)

$(100.00)

$-

$100.00

$200.00$

Number of patient visits (utilisation)

Retained earnings per patient per visit

Total Revenue Total Costs Retained capitation

0 1 2 3 4 5

CAPITATION: GENERAL PRACTICE AS A RISK-HOLDER

No. of visits

PRACTICE POPULATION SEGMENTED BY RETAINED CAPITATION

Higher cost

Higher value

Avg. 1.0 visits

Avg. 6 visits

39%visits

61%visits

Funding > utilisation

Funding < utilisation

78%pts

22%pts

19Kpts

39Kvisits

Avg. 2.0 visits

PRACTICE POPULATION SEGMENTATION

GP SEGMENTATION

GREEN CROSS COLLABORATIVE CARE

A further look into higher utilising patients, with high clinical need

Age Group Count of Pts Total Visits Avg Visits 0 to 12 48 226 4.71 13 to 17 8 25 3.13 18 to 24 18 84 4.67 25 to 44 95 424 4.46 45 to 64 81 480 5.93

65 and over 19 188 9.89 Total 269 1427 5.30

WHAT CAN BE DONE SIMPLY?

• Proactive repeat medicines management

–Patients prompted to ask GP to review (and renew) medicines prior to script expiry

–Highlight to GP pre-booked appointments, outstanding recalls if any, and potential opportunities for synchronising medicines

• Using entirely existing workflows & tools

• 45% response rate from patients

TARGETED INTERVENTION STRATEGIES

NHH Model: Migrate these people using phone and email to significantly reduce utilisation

Improve self manage and drive to remote models of continuous care

Many of these people are ill, or pre-ill, and in need of illness prevention interventions

RISK STRATIFICATION

• How do we effectively risk manage the population

–A lot of effort has gone into predicting hospitalisations

–But General Practice is incentivised to maintain the health of it’s population (not just keep them out of hospital)

–So lets help people maintain and improve their health – by intervening with those most at risk of health decline. How?

–By understanding illness severity, and illness trajectory – and target those whose health is in the most serious decline

RISK STRATIFICATION APPROACH TO SELF MANAGEMENT

•We use risk stratification to identify those at some risk of health deterioration

•We prioritise those at most risk of illness decline (based on the trajectory of their illness decline)

Acute presentations

(patients visiting frequently)

People who are for the most part

in good health

People at high risk for illness/health decline

People at moderate risk for illness/health decline

RISK STRATIFICATION

Illness Trajectory Factors ‘Valence’

Measure Description Reduce Increase

BP Sys Systolic blood pressure +ve -ve

LDL Low density lipoprotein +ve -ve

HDL High density lipoprotein -ve +ve

TC Total Cholesterol +ve -ve

eGFR Glomerular filtration rate -ve +ve

TG Triglycerides +ve -ve

BMI Body Mass Index +ve -ve

CVD risk Cardiovascular disease risk +ve -ve

HbA1c Haemoglobin A1c +ve -ve

ACR Albumin creatine ratio +ve -ve

Weight Kg +ve -ve

RISK STRATIFICATION REPORTS ID PATIENTS FOR SELF-MANAGEMENT SUPPORT

RISK STRATIFICATION APPROACH TO POPULATION HEALTH

Acute presentations

Package 1:High intensity, MDT led care

Package 2: Nurse led, Health Coach

managed (3 months intense support)

Package 3: Health Coach led, self mgmnt focus

(2 months intense self-mgmnt support)

•Within the at-risk group, we have three tiers of support, depending upon the person’s clinical needs

• The MDT assigns patients into each package of care

People at moderate risk for illness/health decline

OUR APPROACH

•We use risk stratification to identify the next tier of people with declining health status, particularly those most disengaged with their GP

•We collaboratively (with Pharmacy) engage these people in low cost self-management programs to proactively improve their health behaviours

Acute presentations

(patients visiting frequently)

People who are for the most part

in good health

People at high risk for illness/health decline

People at moderate risk for illness/health decline

HEALTH COACHINGIMMEDIATE IMPACT AND SUSTAINED BEHAVIOUR & OUTCOME CHANGE

Control Blood Pressure Target Achievement

Sys BP 140 (baseline 165)

Coaching plus collaborative care platform

Coaching without collaborative care platform

Traditional GP care

HEALTH COACHINGEVIDENCE OF EFFECTIVENESS

Blood Pressure

Target Achievement

<140/90

Office Visit Reduction

Total Cost of BP Care

(per patient per year)

COACHING & SELF-

MANAGEMENT

56%

NOT PUBLISHED

$2,693

100PATIENTS

COACHING + CARE

PLATFORM

85%

66%

$1,498

250-500PATIENTS

STANDARD VISIT-

BASED CARE

30%

NONE

$2,130

N/APatients Per Coach