Locality clinical partnerships –
principles for contracting & funding
Martin Hefford
8 December 2011
Locality Clinical Partnership Objectives
 Deliver Better, Sooner, More Convenient
Healthcare
 Improve patient health outcomes
 Reduce avoidable hospitalisations
 Improve clinical governance
 Deliver more integrated healthcare
 Deliver better value healthcare
Locality clinical partnerships: overview
Locality Clinical Partnerships to commission and review the work
Locality Health
Profile
• To identify
health
priorities
Models of
Care
• To address
health
priorities
Enablers
• To achieve
models of
care
An opportunity to create a clinically led integrated healthcare system that bridges
the divide between primary care, community health services and secondary care.
Enhancing primary care to make it more accessible, comprehensive and proactive.
Enrolled populations of CMDHB service localities, Q3 2011
Locality
Total
% of pop enrolled in CM
practices
Rank by size
Eastern
102,590
23%
3
Franklin
45,570
10%
4
Mangere/Otara
138,230
31%
2
Manukau
156,870
35%
1
Grand Total
443,250
100%
Source: PHO enrolment register Quarter 3, 2011, analysed by CMDH, December 2011
Ethnicity of the service locality enrolled populations
Franklin
Eastern
Maaori
Pacific
Indian
Maaori
Pacific
Other
Asian
European/
Other
Other
Asian
European/
Other
Mangere&Otara
Other
Asian
Indian
European/
Other
Manukau
Maaori
Indian
Maaori
European/
Other
Pacific
Pacific
Indian
Other
Asian
Proportion of locality population defined as ‘High Need’
PHO funding and monitoring frameworks include proportion of
enrolled population defined as ‘high need’ – Maaori, Pacific or
living in area defined as high socioeconomic deprivation
(NZDep, quintile 5)
Locality
Eastern
Franklin
Mangere/Otara
Manukau
Total
% High Need
7%
26%
81%
53%
48%
Within each locality, practice age structures vary
Locality
% of locality
0 – 14 yrs
% of
locality
15 – 44 yrs
% of locality
45 – 64 yrs
% of
locality
65+ yrs
Eastern
20%
40%
27%
13%
Franklin
25%
37%
25%
13%
30%
46%
18%
6%
Manukau
24%
42%
23%
10%
CMDHB
25%
42%
23%
10%
Mangere/
Otara
Size of practice enrolled populations
Locality
0-4,999
patients
5,000-9,999
patients
10,000+
patients
Total
Eastern
21
6
1
28
Franklin
1
2
2
5
12
4
5
21
Manukau
38
6
1
45
CMDHB
72
18
9
99
Mangere/
Otara
How are the population distributed across practices
Total hospitalisations
Distribution of hospitalisations by ethnicity
Crude rates acute med-surg-EC MMH by practice
Note, crude
rate not age
standardised,
EC presentations
Percentage of EC presentations statistically admitted
Locality
Age Grp
0-14 years
15 years &
over
All ages
Total
Mangere
Eastern Franklin
Manukau
/ Otara
Total
CMDHB
localities
42%
50%
43%
43%
43%
70%
72%
63%
65%
66%
64%
67%
57%
59%
60%
Volume of specialist OP visits
Contracting for Locality Clinical
Partnerships
INITIAL THINKING
Alliance agreement
mandates:
• Leadership group –
clinically lead, focused
on service integration,
better value
healthcare, and quality
improvement
• Risk and gain sharing
and $ commitment
• Management support,
incl analysis and
reporting
Agreement
GPs, PNs,
Pharmacy,
Alliance Agreement
• Locality clinical
network – broad
interest based
membership
DHB
NGOs,
social
services
Clinical
Leadership
Group
PHO 1, 2, 3
Locality
clinical
network
NASC,
DNs,
home care
SMOs,
allied
health
Management support – enablers, IS,
reporting, project management
GAIHN contracting guiding principles (subset)
• Incentivise the achievement of outcomes not the
provision of service
• Build collaborative trust-based systems and
processes
• Keep contracting simple, collaborative and outcome
focused
• Have transparency in all dealings
• Use a broad ‘dashboard’ of measures to prevent the
manipulation of single measures
Locality Clinical Partnerships - commissioning
 Determine current use of primary and secondary
health resources by locality (shadow budgets)
 Allocate budget decision making rights to three
streams:
1. We discuss, DHB decides (eg hospital services)
2. We discuss, LCP decides (eg community services)
3. We discuss, primary care decides (eg capitation)
 Move to equitable budgets, & increase LCP
decision making over time
Commissioning – evolution over time
Decision making
We discuss,
DHB decides
We discuss,
LCP decides
Time
E.G. Hospital operations, IDFs.
E.G. POAC, After hours, community and home based services,
primary mental health, CCM, Careplus …
We discuss,
Primary care
decides
E.G. SIA, HP Capitation
Acute demand costs
Acute demand gain sharing - overview
Net saving
P&C costs
planned
Time
Acute demand risk & gain sharing - principles
 Funds that would have been used for extra
hospital staff/resources will be invested in
primary & community settings to buy
additional services.
 Net gains to be re-invested in extra primary /
community services – locality clinical
leadership groups to advise on use.
 Risk of poor outcome to be shared between
DHB and primary care partners (say 75:25).
 Acute demand targets & gains to be allocated
by locality.
Fitting the pieces together
Regional initiatives
GAIHN /
NHC / AH+
•
•
•
•
20,000 bed
days
Risk tool
Care pathways
POAC
Whanau ora
• Evidence and
collaborative support for
acute demand
management in
localities
BSM
business
cases
REGIONAL
Plan
• IS - shared care,
e-referrals,
• Auckland clinical
networks
(diabetes, CVD,
etc)
• ISG led business case
for service integration
MOC and primary care
development with
emergent LCP.
Locality clinical
partnership
•Alliance agreement
•Locality leadership
group,
•Clinical network
Next steps
 Develop locality clinical leadership groups
 Use 20,000 better care days as an initial
programme for contracting
 Use Better Sooner More Convenient Business
cases to develop alternative models of care &
service integration plans for localities
 Develop shadow budgets
 Put in place partnership agreements
 Monitor performance, evaluate, and adjust
over time.
Discussion points for board members
 Do we want to share some risk with primary care?
 Do we agree to take the largest share of risk?
 Do we agree that LCPs should decide on the use of
any conserved resources?
 Locality Clinical Partnerships could be as an alliance
agreement or a formal joint venture – thoughts?
 Proposed that the agreement is with PCOs (or
PHOs?) but the network is wider. Thoughts?
 Do we consider that future employment of
community health staff could change?