Planned Proactive Care - a Quality improvement framework

摘要

Introduction : Faced with increased demand for secondary services, a restricted financial environment and inequalities in outcomes, Counties Manukau Health has developed a programme to improve outcomes for patients with chronic conditions. The At Risk Individuals approach utilises risk stratification, care co-ordination, care planning, a shared IT platform and a flexible funding model to provide more integrated care for complex patients. Description : The model is underpinned by a partnership approach whereby patients are supported to develop a goal based care plan on a shared IT platform. This approach ensures that patients are fully engaged and activated to make informed decisions regarding improving their health. The electronic shared care plan outlines “what matters to the patient” and allows visibility of their goal, and interventions tailored to meet their individual needs. After the first year of implementation, it was recognised that the information being populated in the shared care plan was reflective of a medical model and encompassed a medical plan rather that a person centred approach. To support the culture change necessary for improving patient centred care planning, a quality improvement/learning and framework was introduced in the 2015/16 year. This framework was co designed by DHB Clinical leads, learning and development and PHO representatives; and endorsed by the Project Board. Year 1 outcomes were: ? Ensure consistency of person centred care plans ? Introduce a quality improvement philosophy ? Provide an opportunity to reflect on everyday patient interaction with patient data collection ? Ensure collective Practice Meeting time ? Promote Practice Champion to lead framework ? Expand General Practice educational networks The quality improvement framework was launched in all CMH Practices utilising the ARI model of care, and funding incentives were aligned to the milestone approach developed. Highlights : Evaluation of the first year of this quality improvement framework has endorsed the milestone approach as well as the decision to focus on care planning. The core curriculum courses developed – including health literacy, care planning and goal setting, motivational interviewing and mental health awareness sessions were well subscribed and all had positive post session evaluations. In addition Practices are requesting additional courses to support communication in the next year of the framework. Efficiencies within the patient journey and improved patient experience is being seen more broadly with feedback from patients and practice nurses indicating that the quality improvement framework has streamlined the patient centred care planning process. Adoption of the personalised care planning model is also resulting in a perception shift regarding the concept of ‘amenability to change’ as more holistic approaches to chronic condition management and the use of self management support is being embedded. Conclusion : The initial 12 month period of this quality improvement framework has concluded and significant benefits are being experienced by patients and clinicians. Opportunities to change practice process to enable a more personalised approach to care planning have lead to successful stories of change. Further development of year 2 milestones for the framework is planned to further support quality improvement activities in over 95 General Practices within the Counties Manukau region.