Integrated Care Collaborative – Richmond & Tweed

What is a Collaborative?

A Collaborative is a specific method of quality improvement used to distribute and adapt existing knowledge to multiple groups to achieve a common aim. The Collaborative methodology is user friendly and simple to apply. It promotes rapid change, allowing your team to create results and reap the rewards in short time frames. You are supported throughout the Collaborative and provided protected time to solve problems as a team.

The methodology is designed to implement change in small, manageable cycles, and identify where a change actually leads to an improvement.

The Collaborative methodology is underpinned by:

• The psychology of change, which suggests that knowing and learning from peers who have successfully made a change improves an individual’s own motivation to change. In this context, a culture of trust, peer learning and support, and the engagement of clinical leaders are important.
• Active clinical engagement in the Collaborative and support from the wider clinical community.
• The collection of data, in line with the following principles:
• Measurement and data collection for improvement, rather than judgement or research
• Use of data to inform activity and identify when a change leads to an improvement; and
• Primary care health service and hospital data sets are owned by the respective bodies and not released beyond participants. These data are used for supporting the Collaborative infrastructure.

Background

Northern NSW Local Health District, North Coast Primary Health Network, local Aboriginal Medical Services and NSW Ambulance are partners in the Northern NSW Integrated Care Strategy, funded by NSW Health under the Planning and Innovation Fund. The partnership has been involved in conducting and Integrated Care Collaborative with the support of the Improvement Foundation. This quality improvement approach has been effective in engaging clinicians to test and adopt changes to provide better integrated care.

Approach

The implementation of an Integrated Care collaborative provided a mechanism to engage with clinicians from across the system and gave these clinicians with the license to test new ideas by implementing small changes and measuring the effects of these changes.

• Our aim was to build bottom up change that would work across a health system that has some long standing funding and structural barriers to change.
• Complexity Science suggests that in complex systems precedence cannot be relied upon. We needed to do things in new ways and foster innovation.

Outcomes / Results

• More than 130 clinicians participated in the Integrated Care Collaborative
• More than 200 ideas for improvement were submitted and shared
• Nearly 200 patients with chronic conditions and complex care needs were enrolled and managed by integrated care teams with clinician judgement a key determinant of which patients would most likely benefit
• Integrated care teams comprised clinicians from across the system – primary care, general practice, Aboriginal Medical Services, LHD clinicians
• 35% increase in the number of patients with GP Management Plans (GPMPs) and/or Team Care Arrangements (TCAs)
• 15% increase in number of patients with Advance Care Directives (ACDs)
• Automatic electronic patient Admission & Discharge Notifications (ADNs) for enrolled patients

Take Home Message

It is possible to run a collaborative that spans the health system embracing clinician led change to improve integration of care for this cohort of patients.

The role of the participating organisations in the ICC was one of enablement – trusting and supporting clinicians to effect clinical level (microsystem) change for the benefit of patients.