Batten, L

Bevan, M

Cooper, P

Davies, D

English

Massey Research Online

PRIMARY HEALTH CARE NURSING INTEGRATION: BRIDGING THE GAP WITH CO-DESIGNED SHARED CARELesley Batten1, Mandy Bevan (Presenter)2, Debbie Davies2, Paul Cooper11 Central Primary Health Organisation, Palmerston North, New Zealand  2 MidCentral District Health Board, Palmerston North, New Zealand  INTRODUCTIONThe Primary Health Care Nursing Integration project is a collaboration between the Central Primary Health Organisation (CPHO), the MidCentral District Health Board (MDHB) and primary health care services, all based in the lower North Island of New Zealand. The MDHB region covers a population of over 170,000, stretching from the West to East coasts. This population has a higher than average proportion of priority populations.While the initial project focus related to the lack of alignment of the many Primary Health Care (PHC) nursing roles, the primary system dysfunction was the lack of integration between and across PHC and secondary services, resulting in disjointed patient care.  Aims include best use of the total PHC nursing workforce, irrespective of employer, and nurses working to the top of their scope.  The use of coproduction methodologies has broadened the project to encompass implementation of a co-designed model of shared care to bridge the gaps between services. This significant directional shift results in the scope extending past ‘roles’ and ‘personnel’ to care approaches and streamlined systems. PROJECT APPROACH• Via an expression of interest process, all General Practice Teams (GPTs) in the region were invited to become co-design partners with the MDHB District Nursing Service (DNS). Four GPTs (5 sites), with a representation of rural, urban, new Integrated Family Health Centres (IFHC), small and large practices, and Mäori Health Providers are involved.  •  MDHB District Nursing Service - over 1,000 patients shared with all GPTs across the region  •  MDHB District Nursing Service - over 1,000 patients shared with all GPTs across the regionKauri Healthcare - new IFHC, urban, enrolled pop. 20,903, high needs pop. 25%Best Care Whakapai Hauora - Mäori Health & Social Service provider, urban, enrolled pop. 2596, high needs pop. 83%Tararua Health Group, rural, enrolled pop. 14188, high needs pop. 45% •  Dannevirke  •  PahiatuaFeilding Health Care, new IFHC, urban, enrolled pop. 19248, high needs pop. 30%FUTURE FOCUSDISTRICT NURSING BASESCO-DESIGN PARTNERSNEIGHBOURING  DISTRICT HEALTH BOARDSDannevirkePalmerston NorthPahiatuaFeildingShannonEketahunaPongaroaLevinOtakiFoxtonWaikanaeParaparaumuBullsHuntervilleTaihapeWaiouruRaetihi• Implementation was designed to be completed in 4 phases. TIMELINE 	PHASE ONE • The overall focus was improving patient care - bridging the gaps in patients’ journeys – and equity of service access and outcomes. No preset model was chosen. However, based on a literature review, we adopted a theoretical perspective that integration occurs along a continuum from segregation to full integration. There is no single degree of integration that is optimum for all services or care programmes.  Phase One Methodology   Methodology - scoping & co-design • Interviews•  Data & document analysis• Focus groups• Mapping patient journeys• Observations• Considering national & international lessonsPHASE TWOLocal priorities were developed from each phase one workshop and testable solutions for Plan-Do-Study-Act (PDSA) cycles agreed. One PDSA example was to test the development of a ‘shared care clinic’ run by District Nurses within a new IFHC. Objectives were to:• Improve visibility of District Nurses as new members of the IFHC team• Offer shared patients the option of receiving District Nursing care at their ‘health home’ (IFHC)• Test processes of District Nurses documenting in-clinic care in the IFHC clinical records• Improve shared understanding of patient care roles• Improve understandings of shared patient care, especially for those with long term or complex care needs.• Case Study – test shared care clinic 	 • The clinic started three part days per week and has now increased to five days per week, with very positive outcomes for patients and staff (both the GPT and District Nursing).• Shared care clinic process changes   • Shared care clinic outcomes – trust, team, teamwork  Patient choice – opportunity costs Time released to care Earlier interventions Appropriate, timely referrals to other services Patients know team (& know the wider team knows!) Reduced requests for patient details Plan of care – in notes, identical plan given to patient Staff satisfaction Seamless transfers...   Change Processes and Priorities Relationships – face to face meetings,  patient care discussion opportunities Understanding other services  (& how they work, what they do, what they need) Streamlining processes & workflows Using other tools, such as clinical pathways Linking with other projects for consistent messaging, reducing service burden Testing, evaluating, testing, evaluating ICT – sub-project Different degrees of alignment depending on service configurations.• Consumer engagement took place through in-depth interviews. With consent, patient journeys were mapped. These maps were utilised to initiate discussion at co-design workshops. Patient Journey MapFemale, 70s, independent,  lives alone. District Nursing involvement 4-5 times over the past 18 months for a. Post surgical wound dressing;  b. Lower leg eczema. Has another chronic condition, self managed WHAT WOULD MAKE A DIFFERENCE: If I could just go down to the clinic & ask the nurses to look at them. And if the doctor could listen – but because I haven’t got a GP, they just sign things. I would certainly like to know the doctor I am going to, that I can go to every time. I have got another condition & nobody there knows about it. I’m not given my results. Everyone tells me something different. A shared plan would be useful.• Does as much as she can to manage her condition – uses creams, wears stockings, elevates legs when possible• Doesn’t have a written ongoing plan• Do the GPs know what the DNs are doing? – No; Do the DNs know what the GPs are doing? – No• I don’t have the same doctor, I have seen about 5 or 6 doctors & I just get to see whoever is around. No one has said ‘what are you on all these tablets for?’ They all have different ideas about what to do. There are all these different doctor’s names on the letters & prescriptions & I don’t know who the person signing the prescription is. There is no continuity of care.  I don’t know who my GP is. KEY PATIENT MILESTONESAn active life, including caring for a family member for over a decade Refer to District NursingDN clinic visits for leg dressingsReferred for DopplerAdvised to wear compression stockings The Practice Nurse sent me to the District Nurses due to the cost.  If I go down there [to the GPT] I have to keep paying. I think I paid $35.00. Even if they put a Band-Aid on I have to pay. The District Nurses only had to dress it from the ankle up [usually bandage from toes to knee].  My eczema was breaking out again but they wouldn’t treat that as well – ‘because that’s not on the referral’. The District Nurses came home for a while because I couldn’t weight bear. I’m not sick so that’s why I go down to them [clinic], I am quite able to. There is probably someone out there that needs them to go to them more than I do. Set appointment times work – time doesn’t bother me. Visit twice a week, usually a Tuesday & Thursday. I take the bandages off, have a shower & go down to the clinic & they put the dressings onMy feet hurt, especially when I’m walking. I can only walk about 10 minutes before my calves & feet get sore & I need to come home. There doesn’t seem to be much I can do, I can’t do the gardening any more – I have to pay someone, I like to get out & do things & it’s stopping me. This one aches & this leg is painful. I feel there is nothing else they can do for them•I’ve had eczema all my life. As I have got older it has got worse, on the bottom of my feet & legs – it makes me feel yuck, I’m over it. When it breaks down & is weeping I don’t like people seeing them.I saw another nurse for a Doppler & she suggested UV light for the eczema – I’m still waiting for the appointment. I used to go to the sun bed & my [previous] GP knew & my legs were good then.  Skin cancer taken off lower leg [under local] – they were going to do a skin graft but they didn’t, they just sewed it upThe eczema gets really good, but it is always thereReferral to District NursingI like looking nice & then I have to wear these stockings – the DN said ‘don’t be vain’ – but I like to look after myself. I’ve got to wear these stockings all the time & with summer coming, my feet sweat•They discharge me & the moment they discharge me it all flares up againPHASES Home GPT District Nursing clinicHospital day surgeryGPT referral District Nurses  [home visits] Home GPT District Nurses  [clinic]HomeTIME 3-4 weeks  OVER APPROXIMATELY 18 MONTHS  • Key findings Phase 1 Patient focused care but: Busyness & heavy task workloads Silo-ed services – gaps, uneven patient transitions, unintended consequences Poor information transition Poor knowledge of other services, coordination across services Absence of ICT for District Nurses Complex needs, complex care Multiple projects underway Co-location ≠ integrationCO-DESIGNED MODEL  OF SHARED CARE• This co-designed model was a key outcome of Phases One and Two, and provides the basis for Phase Three.• TOOLKIT COMPONENTS, necessary for the Shared Care Model to work effectively, have been tested in PDSA cycles on individual sites. However, due to delays in ICT implementation across the health sector, not all components have been tested on all sites• All ICT ENABLED components have been tested in a limited way. MDHB progress on their Digital Strategy will ensure all can be tested in the future TOOLKIT COMPONENTS ICT ENABLED•	 Identifying	patients	shared	between	services•	 Identifying	clinicians	involved	in	each	patient’s	care.	Flexible	care	coordination•	 Flexible	coordination	of	care,	especially	for	patients	with	complex	needs•	 Shared	care	clinics	for	early	referral,	information	sharing,	seamless	care	transfer•	 Nurse-to-nurse	regular	meetings,	including	attending	General	Practice	Team	(GPT)	huddles•	 PHC	team	involvement	in	MDT	discussions,	incl.	specialist	meetings	such	as	Health	of	Older	Person	team•	 Increased	use	of	clinics	for	those	able	to	attend•	 Home-based	care	when	appropriate•	 Streamlined	transfer	of	care	processes	to	provide	advice	at	referral,	earlier	care	at	referral	when	appropriate•	 Increasing	supported	self	management•	 Skills	and	knowledge	shared	for	better	patient	outcomes,	focusing	on	the	right	person	with	the	right	skills	and	knowledge	providing	care	in	the	right	place	at	the	right	time•	 Better	understandings	of	patient	complexity	factors	(research	underway)•	 Early	transfers	of	care	in	all	directions•	 Local	communication	routines	for	the	PHC	team•	 Reduced	care	documentation	processes	for	District	Nurses•	 Link	roles	for	smaller	practices•	 Increased	service	level	relationships•	 Using	the	General	Practice	Team	Patient	Management	system	(GPT	PMS)	for	shared	clinical	records•	 District	Nursing	Service	(DNS)	template	for	clinical	records	in	the	GPT	PMS•	 Remote	District	Nurse	(DN)	access	to		the	GPT	PMS•	 Communicating	electronically	for	non-urgent	matters•	 Identifying	other	clinicians	/	roles	involved	in	clinical	records•	 A	single	patient	focused	plan	of	care	(including	for	self	management)•	 Transfer	of	care	to	the	GPT	on	DNS	discharge•	 Accessing	the	GPT	patient	summary		via	the	MDHB	portal•	 A	lower	limb	wound	prevention	and		management	health	pathway•	 Supported	self-management	plan	discharge	summaries	for	patients•	 Virtual	consults•	 Clinical	photos•	 Standardised	referral	templates		for	GPTs•	 Automatic	acknowledgement	of	referrals	received	by	the	DNS•	 GPT	alerts	to	DNs	for	events	with	shared	patients,	such	as	hospitalisations	or	deathsOver phases one and two many lessons have been learned, which are being considered in Phase Three.• Lessons Learned  Co-design takes time (& expertise) Link with like projects Use data (& evidence) for change & evaluation Blue sky thinking is hard ICT is an enabler, not the project There is much goodwill, but resourcing is important One bite at a time Working across services, including public and private, comes with its own challenges. PHASE THREE UNDERWAY • Plan for Phase Three Increasing the number of General Practice sites,  equity focus Implementing shared care @ home Reorganising the District Nursing workforce for complexity Scaling to the wider PHC nursing workforce Testing other degrees of alignment across the range of numbers of shared patients between services.CONCLUSIONThis project is work-in-progress. It demonstrates the positive impacts of following co-design principles to address widely experienced health sector integration challenges. The model of shared care that emerged from the first project phases, and which is being used to structure the third phase, has shifted the initial focus from roles and employers to care approaches and streamlined processes. ICT integration across organisations remains a key barrier to progress. However, effective service-level relationships have been developed, and patient and family focused solutions are informing all future developments. Corresponding Author Lesley BattenLesley.Batten@midcentraldhb.govt.nzCORE ELEMENTS DESCRIPTIONPatient & population focus for a cohort of shared patients Care within a broader team for those who would benefit.  Those shared between services (and those who could benefit from the other’s expertise, with or without a formal referral)PHC TeamAligned and virtual team of PHC clinicians from  multiple rolesCare duration Across long-term and episodic relationships  with seamless transfer of care between  PHC servicesKnowledge & skills Shared across an aligned and virtual team Complexity and collaboration Early identification and planning for  complexity with multidisciplinary  managementService responsiveness, accessibility & equityAppropriate point of care with shared  clinic based care, more community care sitesCommunication channels Face to face, relationship based, electronic  tools such as tasking via a General Practice  Patient Management System + phoneClinical recordsShared care, documented in one shared clinical record. Better sharing of pertinent care informationAdministration & paperwork. Lean efficienciesCo-designed processes that smooth the workflow  and reduce clinicians’ administration loadCO-DESIGNED MODEL OF SHARED CARE FOR PRIMARY HEALTH CARE NURSING INTEGRATIONPrimary HealtH Care NursiNg iNtegratioN iN tHe midCeNtral distriCt Board regioN  EMERGING CO-DESIGNED MODEL OF SHARED CARE   EMERGING CO-DESIGNED MODEL OF SHARED CARE    EMERGING CO-DESIGNED MODEL OF SHARED CARE    EMERGING CO-DESIGNED MODEL OF SHARED CARE    EMERGING CO-DESIGNED MODEL OF SHARED CAREICT  enabled                    ICT  enabled                  ICT  enabled                  ICT  enabled                   ICT  enabled                    ICT  enabled                    ICT  enabled                   ICT  enabled                   ICT  enabled                   ICT  enabled                   ICT  enabled           Patients, family and whänau, PoPulations  and equityPHC TeamCollaboration for complexitySharing knowledge  and skillsService responsiveness, accessibilityCommunication channelsShared clinical recordLean administrationCare duration - transfer of carePOSTER 16    |     INTERNATIONAL FORUM ON QUALITY & SAFETY IN HEALTHCARE, MELBOURNE, SEPTEMBER 2018'The wider General Practice & District Nursing Teams worked together really well. They all had access to all the information they needed & the District Nurse had the backup of GPs as necessary' [Patient interviewed as part of  clinic evaluation]'This has been of enormous  benefit to Kauri Healthcare patients. I wish to thank [District Nurse] for all the advice and support she has given me. Thank you' [KHC staff survey for  clinic evaluation]MASSEY UNIVERSITYMASSEY RESEARCH ONLINE http://mro.massey.ac.nz/Massey Documents by Type Conference PostersPrimary health care nursing integration:Bridging the gap with co-designed shared careBatten, L2018-09-19http://hdl.handle.net/10179/1514120/01/2020 - Downloaded from MASSEY RESEARCH ONLINE

Primary health care nursing integration: Bridging the gap with co-designed shared care

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Primary health care nursing integration: Bridging the gap with co-designed shared care

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