Renewed efforts at the state level could help realise long-held aspirations for more integrated healthcare, much to the benefit of older people who currently struggle to navigate the disjointed system.
You might call it the Holy Grail.
For policy makers and providers, the notion of ‘healthcare connections’ or ‘integrated healthcare’ has doggedly remained an elusive goal – despite their best efforts.
Indeed, Google these terms and you will find an online graveyard of policies and programs that, over the years, sought to bring about integrated healthcare.
The challenge has been well documented. The health system is made up of a mishmash of various components including hospitals, Medicare Locals, GPs, aged care, allied health, rehabilitation, hospice – the list goes on.
Each of these components is effectively ring-fenced by their respective funding mechanisms, policy frameworks, information systems, individual workforces, and accountability processes.
The lines of demarcation are clearly drawn. And people tend to stay in their patch.
Now, picture an older, frail individual, attempting to navigate this veritable maze of systems and staff as they seek out the care and services they require.
It’s not hard to see how people can fall through the gaps.
While there have been pockets of success, individual pilot projects that have improved the healthcare journey in places, the uptake across systems has remained stubbornly low.
Furthermore, since the move of ageing from the Department of Health to the Department of Social Services, some have expressed concern about a further erosion of the links between aged care and its healthcare counterparts.
Others highlight the recent trend of governments moving from block funding of health services to funding on a competitive basis – the result being a greater number of service providers, with potentially less integration.
System response in NSW
Notwithstanding this gloomy picture, there is hope.
Many eyes will be on NSW this year, as the various players in the state’s health system embark on a new strategy to improve the linkages between them.
In March, the State Government released its integrated care strategy and is providing $120 million over four years to fund its implementation across the system.
NSW Health Minister Jillian Skinner says the strategy had been in development since 2009 when, as then shadow health minister, she argued for a reform of the governance of NSW Health from eight large health services into local health districts.
“I said one of their roles would be to facilitate the development of partnerships which would provide a seamless range of health services to people who need them, whether that involved hospital treatment or community-based primary healthcare,” Skinner tells AAA.
“I had been shadow health minister since 1995, and in my 20 years in parliament I have spent 19 years involved in health. I had developed very good relationships with people working right across the system. I had travelled overseas and talked to people there about the challenges; because this is an international issue. We have to find better ways of providing that seamless range of healthcare,” she says.
Katherine Burchfield, the director of the Integrated Care Branch within NSW Health, says the strategy seeks to strike an important balance between facilitating projects that are local but which also have sufficient impact and scale.
“It’s about recognising that it’s not very helpful for us to sit in an ivory tower and say ‘Thou shalt integrate care in the following ways’. But, we also need to get away from the small individual pilot that hasn’t advanced us far enough. This approach is a compromise,” she says.
A key component is to foster greater relationships between Medicare Locals (ML) and Local Health Districts (LHD). Together, MLs and LHDs would act as the primary pillars in a region, drawing together the various other players such as GPs, aged care and allied health.
“It’s a level that makes sense because you are getting some economies of scale, but you are still local,” Burchfield says.
The concept of a LHD and ML collaboration underpinning integrated healthcare at the regional level is one supported by Chris Shipway, director of primary care at the NSW Agency for Clinical Innovation (ACI).
Shipway says aged care providersshould be partners in these collaborations and suggests a shared governance committee, comprised of representatives from the LHD, ML, residential and community care providers, which would agree on a vision for integrated healthcare in their region.
“There has been some promising work between LHDs and residential facilities, and MLs are getting in on this as well, in providing training to the residential care workforce around dealing with acute situations, for example,” Shipway says.
From the consumer perspective, Ian Yates, chief executive of the Council on the Ageing (COTA) Australia, agrees that greater collaboration at the regional level could advance integrated healthcare.
Yates says MLs could also take the lead in areas such as demographic profiling and implementing programs that respond to local needs.
But he stresses this should be addressed from a wellness, rather than an illness perspective. “You can’t have integrated health and aged care if you don’t have a much greater investment in health promotion and illness prevention.”
He says the funders of health services – government, and increasingly private health funds – have realised their interests are served by ensuring there are sufficient preventative health services. “They can see that demographic shift impacting on their viability. Governments just need to look at who the people coming down the front drives of their hospitalsare.”
Plan for action
To help progress integrated healthcare across NSW, and in response to the State Government’s whole-of-government ageing strategy, the ACI in March released a strategic framework, based on extensive consultation with stakeholders.
Shipway says the framework outlines a series of guiding principles, rather than specific directions. “You can’t be too prescriptive; people need to work out what will work locally and what will build effective relationships,” he says.
The need to involve older people at every step of their health journey is one such principle, which Shipway acknowledges is “enormously challenging”.
“Most health professionals discover when they consume the health system themselves that it’s not that easy to be an empowered consumer. It’s a really important principle but there is a lot of work to do in terms of how we design services so they really are patient-centric.”
The use of technology is another guiding principle. It offers enormous opportunities, particularly in rural areas where distance is a barrier, often confounded by a lack of transport, Shipway says.
Making it happen
Those behind the NSW framework are determined to see it implemented; for the promise of its lofty principles to be realised in local settings across the state.
To that end, the ACI is about to begin presenting the framework to the chief executives of MLs and LHDs, as well as “aggressively promoting it and creating opportunities for training and planning, service redesign and collaboration” Shipway says.
“I would expect residential facilities to be part of that mix as well. Certainly I see aged care peak bodies as being a key part of this process and we will be working with them.”
As such, Shipway was part of a forum on integrated healthcare organised by Aged and Community Services NSW & ACT in late February. ACS NSW chief executive Illana Halliday says the forum showcased effective collaborations between aged services and other elements of the health system.
Halliday believes that with the move of ageing to DSS at the federal level, it is crucially important that stakeholders at the regional level maintain their efforts and ensure the work around integrated healthcare is not lost.
Burchfield, meanwhile, is under no illusions about the scale of the challenge facing her and those involved in the state’s integrated care strategy.
“Getting to the point where we have a more integrated health system is a 10- to 20-year journey. We’re starting to invest now but with no expectation that in a couple of years’ time everything will be perfect.
“However, this investment is really central to what we’re trying to do, what our government is trying to do, in terms of achieving a better system that meets the needs of people,” she says.
For Yates, the issue of integrated healthcare needs to be championed from the top, in order for real strides to be made. “It ought to be in the KPIs of the CEOs of every health system in Australia. It ought to be a high priority for federal Health Minister Peter Dutton.”
And, Yates believes, there should be financial incentives built in to the Commonwealth-State health relationship for both sides to share in the subsequent savings. He says this might help, finally, to bring about real progress in this long-standing area.
Case study: Integrated healthcare in action
Victorian aged care provider Benetas last year partnered with Bayside Medicare Local to pilot a better approach to supporting older people as they move between their homes, hospital, rehabilitation and aged care.
Dr Amee Morgans, head of research at Benetas, says the partnership began with months of information gathering to determine the barriers to integrated healthcare.
That informed the six projects that will run this year as part of the partnership. These focus on the residential aged care workforce; transition care; communication among stakeholders via a health advisory council; transport; and the relationship between residential facilities and their local GPs, says Morgans.
Dr Elizabeth Deveny, CEO of the Bayside Medicare Local, says her organisation is well placed to connect the various stakeholders.
“Because we’re local players, we know the issues,” she tells Australian Ageing Agenda. “I can tell you we have 700 GPs in our area, almost 200 practices, almost 100 residential aged care facilities. We know the GPs who are interested in aged care, the ones that visit nursing homes. So we provide that kind of local knowledge to assist Benetas in connecting aged care to local primary healthcare.”
Communication is crucial in facilitating integrated healthcare, Deveny says. “If you have a lot of small businesses, which is effectively what most primary care is, you have to get them to communicate with each other before they can better coordinate their services.”
Deveny says she is hopeful the project will identify models for working together, as well as a greater appreciation among stakeholders of each other’s roles and responsibilities. “And to learn what it is we can do to support better care for older people, and people in aged care.”
The project runs until March 2015.