The Power of Self Management
‘Helping People Help Themselves’
Lisa Gestro
GM Primary and Integrated Care
1
Why Self Management?
• Unsustainable growth in demand
• A system that is now over specialised
• A generational shift away from families and communities
caring for each other
• The disease burden of lifestyles will shortly overwhelm the
system
2
Unsustainable Growth in Demand
• CMDHB has both the highest population
growth rate and the highest ageing rate in
the country.
• Counties is forecast to run out of hospital
beds in mid 2013 based on current growth
patterns.
• Middlemore hospital is already too often full
• Our ED sees nearly 100,000 people per year
• We are not the only DHB grappling with
these issues
3
Supply and Demand Imbalance
Projections of bed demand against planned beds for medical and surgical
services in Middlemore Hospital
650
Existing & planned beds
Existing & planned beds (subjected to
approval)
Number of med/surg/AOU/MSSU beds
600
Projected demographic and nondemographic growth (high growth)
550
500
450
400
350
2010
2011
2012
2013
2014
Year
2015
2016
2017
Over Specialisation
• 118 unique nursing delegations that work across
175 departments
• 5 cars in the driveway
• Each tasked with only a very narrow scope of
practice and accountability
6
Intergenerational Change
‘we used to have Self Management in the 50’s, it was
called family’ Professor Harry Rea, Clinical Director Integrated Care,
CMDHB
• People have become disempowered as medicine as
become more complex
• Busy lives have overtaken our ability to care for
eachother
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So what’s happening at Counties to tip
this balance?
What is System Integration?
Its just a step to the left…
AN OPERATING SYSTEM
What are the core ingredients?
• Understanding and responding to community
needs and engagement with community resources
• Flexible use of system resources to respond to this
within the district wide framework that has been
agreed
• Clinicians able to respond flexibly to best meet the
local needs and work together in a sustainable
way to achieve this
• A learning system that allows local innovation but
also supports shared learning about our successes
and failures
12
Coordinated Care for
At-Risk Individuals
Very
Very
High
High
Risk
0.5% of population = comprehensive assessment & care plan
GP, Registered Nurse, Social Worker or Health professional facilitated to
include for eg:
•End of Life care
•Hospital at home nursing
•Specialised therapies (eg stoma care)
•Continence care
Risk
High Risk
High Risk
Moderate
Moderate
RiskRisk
Low
LowRisk
Risk
5% of population = integrated health and social care plan
GP, Registered Nurse, Social Worker or health professional facilitated to include
for eg:
• Rehabilitation, recovery, reablement
• Telehealth
• Medication review
20% of population = self care plans
Primary care identifies people with LTCs, disability, or social needs
Proportionate assessment to create a co-produced, goal led care plan, for
example:
•Referral to Expert Patient Programme /peer educators /health trainers
•LTC pathways eg., diabetes, dementia
•Assistive technology / telecare
80+% of population = health promotion plans
Primary care identifies people with lifestyle risks (eg. smoking, high blood
pressure)
Brief interventions to screen, give advice & refer or sign post:
• Smoking cessation assistance
• Exercise options
•Depression / anxiety (referral to IAPT)
•Social isolation (referral to 3rd sector support)
•Housing related support
AT RISK INDIVIDUALS PROGRAMME
Risk
Assessment
Care
Planning
Stratification
Predictive Risk Tool
Funded
Measuring
Interventions
Common
assessment tools
Consistent care
planning system
Interventions
clinicians can deliver
or refer to in order
to provide extra
support to patients
Evaluation and
outcomes
measurement
IMPLEMENTATION TASKS
Finalise
predictive
risk tool – agree
Develop and
agree budgets –
input vs.
outcomes
Develop
and agree
consistent
assessment
tools
Develop roll
out plan for
e-shared care
Agree core set of
interventions to
be consistent
district-wide –
both value add
General Practice
and second tier
services
Disease
specific
outcomes
Patient
experience and
health status
outcomes
Acute demand
outcomes
2.
SERVICE REDESIGN
WORKSHOP PARTICIPANTS
Name
Position
Allan Moffitt
Clinical Director, East Health and Alliance Health Plus
Benedict Hefford
Director, Primary Health & Community Services
Beven Telfer
GP Liaison - MMH
Brad Healey
GM, Medicine
Campbell Brebner
Chief Medical Advisor – Primary Health - MMH
Denis Lee
GP Pakuranga Medical Centre and Chair of East Health Trust
Dot McKeen
Manager, Middlemore Central
Geraint Martin
CEO
Gillian Cossey
GM Surgical & Ambulatory Care
Jenni Coles
Director, Hospital Services
John Baird
Facilitator
Linda Bryant
GM Eastern
Lisa Gestro
GM Primary Care & Service Dev.
Lynda Irvine
GM Manakau Locality
Martin Chadwick
Director, Allied Health - MMH
Denise Kivell
Director of Nursing – MMH
Karyn Sangster
Acting Nurse Leader, Primary Health
Paulina Baird
Facilitator
Peter Didsbury
Chair, Procare Networks
Peter Gow
Clinical Director - MMH
Peter Watson
Clinical Director – Mental Health - MMH
Harry Rea
Consultant – MMH and Professor of Integrated Care
Simon Bowen
GM Otara/Mangare
Tim Hou
GP – Mangere Health Centre
Willem Landman
Palliative Care Physician - MMH
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