One of the country’s long-term conditions care pioneers has been bubbling with innovation but lagging behind in patients signed up to its basic care package.
“We’ve been doing a lot of work around LTC for a long, long time,” says
Melanie Taylor the project lead for chronic care management for the Central PHO and MidCentral District Health Board.
“So it’s kind of an irony that our (Care Plus) package of care wasn’t picked up and wasn’t working.”
“We had a very low number enrolled. We only had 19 practices out of our 42 practices providing Care Plus and only nine of those were seeing anywhere the number of clients they should have been seeing ... so we really weren’t performing.”
The region has been a pioneer in primary health care nursing leadership, the integration of primary and secondary services in long-term conditions (including specialist outreach clinics), and training and supporting a PHO community nursing team proficient in either diabetes, respiratory, or heart conditions. It is also one of the Government’s nine successful Better Sooner More Convenient (BSMC) business cases and was busy working on a web of innovations to improve primary health care delivery.
So Taylor says when the PHO realised much of its region wasn’t offering a basic Care Plus package of care it stopped, took stock, and set out – using Ed Wagner’s Chronic Care Model as its guide – to repackage, enhance, and relaunch its own programme known as EnhancedCare+.
The repackaging included “a u-turn” to change the focus of the PHO’s community nursing team – a 23 FTE strong team working with practices across the PHO – from focusing on a single condition like diabetes to becoming more generic LTC nurses.
The aim is that a client with diabetes, hypertension, and a respiratory disease is no longer being passed from nurse to nurse like a parcel to ensure they get the care they needed. Instead, the nurses have become community clinical nurses long-term conditions (CCN LTC) and are now expected to be not only proficient in offering care for one chronic condition but also competent in the other conditions so they can offer a whole package of care for clients with multiple chronic conditions.
The new EnhancedCare+, offered with the support of the CCN team, was launched in July 2011, and at present, half of the practices have taken it up. Each package of *EnhancedCare+ includes an initial comprehensive health assessment (CHA), a client care plan and up to four more consultations to work with the client on meeting their care plan goals.
Entry criteria are similar to Care Plus and are targeted at people with chronic conditions or high needs (aged over 65 if Pākehā and over 45 if Māori or Pacific) but with the flexibility of including some people who are younger or only have one chronic condition if it is felt they could benefit.
In larger practices, the package is delivered on a 50/50 basis, with half of the clients having the package delivered by a community clinical nurse (CCN) – usually the most complex or challenging patients – and the other half by a practice nurse, with both working in collaboration with the client’s GP and the rest of the team.
The initial assessment can last up to 90 minutes and takes a holistic approach that covers a client’s social and cultural background, as well as their physical and mental health. Taylor says while the assessment itself is seen as valuable, the “clunky” and “unstable” CHA electronic tool has received nothing but negative feedback, leading to another “u-turn” in 2012 and the decision to invest in developing a more user-friendly web-based tool to be rolled out in the near future.
She says the initial tool’s reputation has seen some practices put off or delay offering EnhancedCare+ but the CCN team still works alongside these practices to support clients with chronic conditions.
Therefore, the PHO is yet to be running the new EnhancedCare+ at full max and the package is still evolving and developing as the project team analyses and responds to feedback.
Taylor says the results are promising, with the first formal survey of EnhancedCare+ patients – carried out late last year with 68 responses – showing “considerable progress” in how patients rated their care over earlier surveys carried out by Jenny Carryer’s research team (see main story) using the same Patient Assessment of Chronic Illness Care (PACIC) questionnaire.
“There are some considerable measure points where we’ve made considerable progress.”
The PHO plans to do the patient survey and the related health practitioner survey annually. This year, it will also be part of a major joint Victoria University and University of Otago research project evaluating the MidCentral and Wairarapa BSMC business cases.
(more information on evaluations of the BSMC business case and EnhancedCare+ can be found at www.centralpho.org.nz)