Excellence delivered with humanity

Health Needs Analysis – one year on

RNZCGP conferenceJuly 2019

Dr Sue Wells

Excellence delivered with humanity

1. Our Picture of Health needs analysis

2. Population health strategy and implementation

plan

3. Next steps for practices

4. Addressing equity

Outline

p. 3p. 3

• Pop demography

• Practice FTE

• visits

• risk factors

• long term conditions

• patient experience of care

• portal access

• ED visits

• acute hospitalisations,

• ASH (ambulatory sensitive hospitalisation)

2018 health needs analysis

p. 4p. 4

ProCare population 1 January 2017

p. 5p. 5

ProCare population 1 January 2017

p. 6p. 6

ASH rates/1,000 by ethnicity 0-4 years

p. 7p. 7

ASH rates/1,000 by ethnicity 5-14 years

p. 8p. 8

ASH rates/1,000 by ethnicity 15-24 years

p. 9p. 9

ASH rates/1,000 by ethnicity 25-44 years

p. 10p. 10

ASH rates/1,000 by ethnicity 45-64 years

p. 11p. 11

ASH rates/1,000 by ethnicity 65-74 years

p. 12

p. 13

“Start where you areUse what you’ve got

Do what you can”

Arthur Ash

p. 14

Population Health Strategy

p. 15p. 15

A life course approach

p. 16p. 16

20%

p. 17p. 17

A series of workshops

p. 18p. 18

Each group worked together…

p. 19p. 19

Shared insights…

p. 20p. 20

And voted on priorities

p. 21p. 21

The result

Increased engagement with primary care (15-24 years)

Improved quality of life for older people

Healthy start to life (0-4 years)

Engaged and enabled to improve wellbeing

Improved quality of life for people living with LTCs

Five key goals that span all the ages of our lives

p. 22p. 22

KPIs in five years

• Increased and equitable access for youth to primary care

• 50% of practices have implemented youth friendly changes

• Increased and equitable access for youth to primary healthcare (incl80-90% have visited a GP in the last two years)

• Reduced teen pregnancies

• Reduced chlamydia infection rates

Increased engagement with primary care(15-24 years)

• Reduction in ASH rates for older pops & ASH inequities

• 80% of target pop have received holistic assessment

• Improved communication & co-ordination via shared care plans & care co-ordinators

• Equitable optimisation medical management

Improved quality of life for older people

• Reduced ASH rates for 0-4 year olds and ASH inequities

• 80% of pregnant women have a systematic assessment for health and social determinants and have plans in place according to unmet current and postpartum needs

Healthy start to life(0-4 years)

• Increase in equitable access to effective behaviour change services

• Improvement in patient experience of care

• Reduced suicide rates and inequities by population group

Engage and enabled to improve wellbeing

• Reduction in ASH rates attributable to diabetes and ASH inequities

• Improvement of care processes for primary and secondary prevention of CVD, diabetes, heart failure, COPD and gout

Improved quality of life for people living with LTCs

p. 23p. 23

•For each health goal, interventions and

actions were proposed

•Rapid review of national and international

literature

•For each review, key questions were:

What is the evidence to support this

intervention?

Will it improve equity of health outcomes?

Literature review

p. 24p. 24

Strategy summary

p. 25p. 25

Consultation draft developed and discussed with:

•ProMa

•ProPa

•Tainui

•Ngāti Whātua

Community focus groups:

•Samoan, Tongan, Cook Island

•South Asian

•Chinese, Japanese, Korean

•Refugee groups

Community consultation

p. 26p. 26

Implementation Plan-Year 1

'We haven't got the money, so we'll have to think’Earnest Rutherford

p. 27p. 27

Implementation plan - year one

• Youth friendly stocktake

• Co-design enhancements to Toolbox

• Digital technology & virtual

• Develop metrics

• Youth health checks

Increased youth engagement

• E-Assessment tool/ care plan & social support

• Flu + Zoster vaccination

• Scoping Care transitions

• Co-design care pathways

• Improve dashboard

Improved quality of life for older people

• Assessment tool

• Referral pathways for unmet needs

• Piloted LMC Hub w S/W

• Stocktake

• Flu and maternal vaccinations

Healthy start to life(0-4 years)

• Te Tumu Waiora -continue pilot practices, evaluation and roll out

• Training – FACT, HIPs and health coaches

• Smoking cessation referrals

• Alcohol ABC

Engage & enabled to improve wellbeing

• Diabetes +CVD clinical audits

• Read coding gaps for LTCs

• Collate care bundles

• Co-design project on care planning

• Implement HCH

Improved quality of life living with LTCs

p. 28p. 28

Impact on practices

• Practices continue to focus on CURRENT clinical indicators• Practice-specific HNA - consider and develop practice plan for year 2

• Clinical indicators plus new indicator(s) related to specific activities chosen by practice• Practices focus on one or more selected activities pus recommended universal ones• Review practice plan for year 3

• Clinical indicators plus new indicators (universal plus practice activity measures)• Practices focus on another selected activity and or continue prior work• Review practice plan for year 4

• Clinical indicators: universal plus new indicators (activity measures)• Practices focus on another selected activity and or continue prior work• Review practice plan for year 5

• Clinical indicators: universal plus new activity measures• Practices focus on consolidating the outcomes for selected activities

Year 1

Year 2

Year 3

Year 4

Year 5

p. 29p. 29

Practice needs analysis

• A detailed analysis which is specific to each practice’s enrolled population

• Available late 2019

p. 30p. 30

Practice needs analysis

• A detailed analysis which is specific to each practice’s enrolled population

• Available late 2019

p. 31p. 31

Practice needs analysis

• A detailed analysis which is specific to each practice’s enrolled population

• Available late 2019

p. 32

Addressing equity

p. 33p. 33

•measures stratified by pop groups•Health goals

where greatest unmet need

•Targeted pops for health goal

•KPIs directed at equity gaps

•Activities based on evidence effectiveness, equity

•Practice-specific activities acc to enrolled pop•Co-design

activities with Māori, Pacific consumers

•Work force dev e.g. ethnic-congruent health coaches

•Partnerships with health, education & social services

Equity

p. 34p. 34

Conclusion

More information

Visit procare.co.nz for:

• Health needs analysis

• population health

strategy (coming soon)

• Implementation plan – year one

underway

• Practice-specific HNAs being prepared

• Annual practice review

Excellence delivered with humanity

Thank you

Sue WellsAssociate Clinical Director

M +64 21 664 337E susan.wells@procare.co.nz

Allan MoffittClinical Director

M +64 21 366 772E allan.moffitt@procare.co.nz