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Standing Committee on Health - 01/10/2015 - Chronic disease prevention and management in primary health care

BEER, Ms Josephine, Relationship Manager, CarePoint Trial, Department of Health and Human Services, Victoria

THOMAS, Professor Robert, Chief Advisor Cancer, Principal Investigation CarePoint, Department of Health and Human Services, Victoria

Committee met at 09:02

CHAIR ( Mr Irons ): I declare open this public hearing of the Standing Committee on Health and would like to thank you all for your attendance today. Before we begin, I want to ask a member of the committee to move that the media be allowed to film the proceedings today in accordance with the rules set down for committees, which includes not interfering with committee proceedings, and not taking footage or still images of members, committee staff and witnesses' papers or laptop screens.

Ms HALL: So moved.

CHAIR: Thank you. I now call the representatives of the Victorian Department of Health and Human Services. I understand that as witnesses appearing before the committee you have no objection to being recorded by media during your participation in this hearing and that you have read the card in front of you with regard to parliamentary privilege. I now invite you to make a short opening statement to the committee.

Prof. Thomas : Thank you, Chair. I am pleased to appear before this committee. The issue of better integration of care between primary healthcare systems and tertiary healthcare systems is a key issue for the Australian health system. The Victorian Department of Health and Human Services have been working for a period of time on trying to improve the capacity of patients to traverse between those systems. I am pleased to be able to present to you some of the details of the CarePoint trial, which is a program designed to evaluate the effectiveness of some of the new programs to improve the integration of care in the chronic disease setting.

CHAIR: Could you tell us about the CarePoint trial?

Prof. Thomas : Yes. The CarePoint trial is a trial which is jointly funded by Medibank Private and the Department of Health and Human Services. It is a program which is designed for people with severe chronic illnesses. In its essence, it is designed to keep people out of hospital. The entrance into this trial are people who have had multiple admissions to hospital—a total of four in the previous two years—with a significant chronic illness. There are other entrance points, also, but I will not mention them now. We then identify those patients through general practice. So general practice is powerfully involved in this project. And, of course, it is very much patient centred. We try to learn a lot about the patients and their social circumstances. Having identified the patients, we put a program of support for those patients in place. We work with the GPs to produce a care pro-forma—

Ms Beer : A care plan.

Prof. Thomas : A care plan—so this is done together. And we provide supports for the patients alongside that care plan. Will have an outcome of this program in—

Ms HALL: What does the program of support include? Can you walk us through that, please?

Prof. Thomas : Yes. The program of support includes the development of the care plan, which is done in conjunction with the general practitioner of that patient. So it comes to the general practitioner. It provides the CarePoint trial with the name of the patient. The care plan is constructed with the general practitioner. The supports for that program are, firstly, a clinician who works with a GP to help develop the care plan. Perhaps Josephine might be able to detail the variety of other supports.

Ms Beer : As Bob was saying, the first part of the process is that the CarePoint clinician—and that might be an experienced primary care nurse or an allied health professional experienced in primary care—will conduct an assessment in the client's home. Through a structured set of measures, that will then inform our final evaluation. It will also inform the development of the care plan. They typically spend about an hour with each enrolled person to go through that assessment. Part of that is a dialogue with the consumer around their perception of what their needs are. A written report is then produced with the consumer's consent and provided to their GP. That informs the development of the care plan. As Bob has outlined, the care plan is an expand concept beyond the MBS item numbers. It is a multidisciplinary plan of care which includes social aspects of the consumer's needs. The GP will typically have some discussion on that with the consumer just to finalise what is in it. Then it is an e-record that is shared across the team involved in the consumer's care. The various services in the plan are ordered.

Coming back to your question, a couple of examples would be as follows. Say, for example, I am a consumer with heart disease and I have some respiratory problems. Perhaps the GP had suggested to me that it might be good for me to do some respiratory rehab. At the time when it was suggested, I said, 'Sure', but then, when I went home, I realised that I could not afford more expenses at this point in time. So I have not done that. So part of the assessment gets a strong sense of the consumer's social, financial circumstances, et cetera, and how they are tracking in that regard. We will have a discussion along the lines of, 'This has been identified, but I see that you haven't taken that up. Were there any barriers?' We have found that, particularly for severely ill and chronic consumers, the out-of-pocket costs are a barrier to their engagement with plans to improve their health. For GPs, hunting around to see what could be funded through various streams to that level of detail is something that they often do not have time to do. Also, the practice nurses often do not have time to do that. Part of this program is that CarePoint clinicians spend time on the detailed assessment, identifying the local service options. The program is then supported by the care navigator resource that orders a range of things for me—for example, respiratory rehab at the local community centre or, perhaps, something like daily ways if I am tending toward heart failure so that I can be more aware of those. Then, if the weight is tracking in the wrong direction, I might get a call from a care navigator to say, 'We noticed your weight is starting rise. How are you feeling?' and perhaps they are identifying that I am short of breath. Then they might organise an emergency visit from the general practitioner to intervene before I deteriorate to the level where I would need to go to hospital. It is putting those supports in place for the consumer—as Bob said, for people with serious chronic diseases. There are the gaps in the system at the moment. They are still drawing on the existing system resources but also plugging some of those gaps to keep them healthier in their own homes.

Ms HALL: So it is basically a case management model backed up by an interdisciplinary team and services that are needed in the community.

Ms Beer : Similar to that. The caseloads for the CarePoint clinicians are 150 enrolled consumers per clinician. When we were looking at the design aspects of the trial, we were looking at what had come out of the diabetes coordinated care trials. Part of the findings was that targeting consumers who could benefit from this approach is important, but, also, designing the model to be cost-effective is very important. That will evolve as the trial goes forward; it is an action learning approach. There is a 150 caseload with risk management and a real-time e-record to inform that risk management, which is backed up by support from the key navigators as well for clinical governance and patient safety. The caseload is higher than some of the existing case management models.

CHAIR: How long is the trial expected to last?

Prof. Thomas : It will be finished in 2018. We have enrolled some 1,500 patients in this trial now, which is the expected number.

CHAIR: Is that just in Victoria?

Prof. Thomas : This is in Victoria. It is about half and half Medibank Private patients and so-called public patients. The evaluation is going to be done by an independent group, BCG. They will be evaluating this on the basis of expected reduction in admission rates—we are hoping to get a 25 per cent reduction in admission rates—and also on the basis of patient experience and understanding of what went on and how they feel about the particular process. There is a quite rigid process around it.

CHAIR: What are the desired outcomes of the trial? To expand it eventually, once the assessment has been done? To implement it? There has to be a purpose to the trial.

Prof. Thomas : That is a good point. There is a purpose to the trial.

Ms HALL: If it is successful we would hope that it will be rolled out across the state.

Prof. Thomas : Yes, in some form or other. Whether it is would be rolled out exactly in this form, I do not know. There are lots of issues about this trial which are good. I might say that every bit of feedback we have heard, from GPs or consumers and patients and other people that are involved with this, is that they have enjoyed this, that they have felt supported and value the support.

Ms HALL: Is the interim data showing that it is actually moving towards achieving its goal?

Prof. Thomas : All we have from that at the moment is a lot of personal vignettes saying that people feel supported. One of the really good parts of this project—we have not told you exactly how it works—is that we have a call centre approach to this, which is Medibank Private's experience in this area. We have had examples where people who, at 6 o'clock on a Friday night, have been sick or unwell, and, where they would normally call an ambulance and go to hospital, they ring the call centre and the call centre arranges for a GP, if their own GP is not available, to come and see the patient. They usually see them in a couple of hours and they can usually settle them down. There have been examples where they have not had to go to hospital because of that. We have that—it is not evidence, but it is a feeling that we are on the right track.

CHAIR: In an instance like that, if they were going to a hospital, for what sort of time length would they be going to the hospital? By having a GP visit them, what is the saving?

Prof. Thomas : The saving is huge because, otherwise, the patient gets an ambulance, they go to hospital and then sit in an emergency department for six hours, and by that time it is midnight, so they will probably be admitted for several days, if not overnight. They would go to a general medical ward. The whole exercise starts again when they are out of hospital. My particular field is more in cancer, but anything which keeps people out of hospital and even out of out-patient departments and keeps them in GP systems and in their home is both cost-effective and good for patients.

CHAIR: Are the people who are running the program—the trial—siloed or are they still working in other health areas at the same time? Are they purposefully allocated to this particular trial or do they have other duties outside the trial?

Prof. Thomas : The care coordinators and the care navigators are working on this trial. They are essentially full time.

Ms Beer : The clinical team that we have described—the CarePoint conditions and the care navigators, and there is also a head of integrated care, who is a GP. We have recruited a GP to the program as well, in Victoria, because being GP-led is an extremely important part of the model.

Prof. Thomas : A GP is essential. It is absolutely essential. This is almost seen to be a GP-led program and that has been part of the success, I think.

Ms Beer : They work across the whole service delivery system, depending on where the patients are interacting with it. We talked about how they do assessments in patients' homes; they work with the GPs and the consumers in general practice and, if the people are admitted to hospital, they participate in hospital liaison—whatever part of the system is required. We have been working—until the commissioning of the Primary Health Networks—with the Medicare Locals in the trial's areas of operation. That has been really helpful as well, given that Medicare Locals now have the PHN role, with GP engagement and with integration, so that is another part of the system that they are actively engaged with.

CHAIR: You said the patients have been valued and I guess that helps in their overall health environment. If they are feeling better about their treatment, that could be bit of a placebo in itself, couldn’t it?

Prof. Thomas : Oh yes, absolutely.

Ms HALL: It is the support; yes, you are right.

Prof. Thomas : A very common thing we hear is that, actually, many of these people are lonely and isolated and often not living in very good circumstances, so having somebody who they can talk to about their issues is an elevating process in itself.

Ms HALL: And elderly?

Ms Beer : It is a mixture of ages. It is 18 years and over. It is largely the older cohort, but there are younger people, who are working. One of the vignettes that we have is a fellow who is a single parent with three children. He has been unable to work because of his various conditions. One of his goals is to have his health stable enough, not to be in and out of hospital, so he can get back to work and be more engaged with his family, and so the clinical team are working through a program to help him get back on track.

CHAIR: I was also interested in your comment in regard to finding local clinicians or people to assist with them. Is there any part of the system that says, 'This is my postcode; this is my chronic disease' and they type that in and, bang, they come up with a list. I thought that might have already been available.

Prof. Thomas : My experience is in the cancer field. This is such a changing issue and it varies from year to year. You use a book or some sort of web page and then it changes. It is difficult to keep it going.

Ms HALL: But diabetes is one of those things where you can type a postcode in and there are clusters.

Prof. Thomas : Yes, that is right. In diabetes, of course, the issue is how that person then gets to see those people and have it found.

CHAIR: Hopefully the GP.

Prof. Thomas : Except for the GP.

Ms Beer : There are a range of things that are being progressed in that space, some at the national level, with the National Health Service Directory, looking at what some of the gaps are that could be filled in and which would offer benefits for all Australians, and some at the local level, where we have been working with various partners involved in this trial, trialling a few different ideas to see what could make that work better and in a more sustainable way.

CHAIR: Does the trial, or any portion of it, have part management by the patient themselves in their program, encouraging them to actually participate?

Prof. Thomas : Yes, basically letting the patient better understand their condition and deal with their condition is very much part of that process of interaction with the patient. When I look at the vignettes, most of the patients we are dealing with require a lot of support. This is the top end. These are not the people with a bit of chronic illness. These are the people with severe multiple issues, chronic illness. But, of course, self-education, understanding, a healthy lifestyle and all those sorts of things are part of the program.

Ms HALL: Absolutely.

Ms Beer : As Bob was saying, an aspect of it is literacy, and that can be about consumers and the system. Part of it also is around patient activation. As Bob said, we all have a reasonably basic understanding of healthy behaviours, but are we motivated to put the doughnut down and go for a walk and those sorts of things.

Ms HALL: Socioeconomic factors come into it too.

Ms Beer : Yes, and environmental factors as well. Looking at the consumer's local environmental, what are the consumer's goals? The first part of the process is stabilising their health condition and dealing with immediate challenges and then setting some goals to improve their health status. It might be exploring their appetite, reducing smoking, taking up an exercise program—all of those types of activities that will improve their health.

CHAIR: Is there an incentive portion in the program, or anything like that, besides getting healthier? Is there any reward system for people who are taking—

Prof. Thomas : Not in this program. Essentially, if we do this we want to see if we going to make a difference. Also, one of the important things has been the support within general practice. What we have seen is that, almost alongside this, general practice is taking more of an interest in this element of the health of their patients. We have heard stories of practice managers taking patients on walking tours. It was very important to get support to the general practice because they are overloaded with work. They cannot stop and think outside their workload, so putting some sort of care and support into the general practice has been a big issue in making this program work.

CHAIR: If the program is successful and you want to roll it out on a national basis, what sorts of changes would need to be made to the MBS system for it to integrate? You must have thought about this before you implemented the program.

Ms HALL: The million-dollar question.

Prof. Thomas : Absolutely, there needs to be change to the MBS to account for the particular needs of this particular group of patients, moving from the current individual item-of-service fee type of arrangement to an integrated program, a bundle payment, accountable care or paying for outcomes. Theoretically, that is the best way to go, but there a fair step to take before that actually happens. Perhaps I am speaking individually now and not from the department: we could add a few extra item numbers in, if you like, or items of service which might help with coordination. But the reality is that, for a big improvement, you probably need to look at how you can wrap up a whole bunch of services for a patient with a chronic illness and have them managed within one payment program.

Ms HALL: Maybe so many thousands of dollars to manage a program, modernise the program, approve the program and then deliver the program. Would that be an approach?

Prof. Thomas : That will be the sort of approach. What we do know about these things is that you have to have a cohort of patients. You cannot really put this across for every patient; you have to define the group of patients that you might have. Then you find the outcome you want in a year or in two years. Then you put a payment in place to cover all the particular issues that a patient might have—

Ms HALL: Progressive payments.

Prof. Thomas : You literally have a rewards system which says: if you do all these things, a patient might have a good outcome. Some form of incentivisation in that sort of process is good.

Ms HALL: What sort of incentivisation?

Prof. Thomas : There are two sorts: either support for a practice or a business in some form or other or pure monetary incentives.

Ms HALL: How would you see the monetary incentives working?

Prof. Thomas : Accountable care generally says that you are paying for an outcome—you are not paying for no outcome. The incentive there is to say: 'We did reduce hospitalisations for this particular group base. We did make them more comfortable and happier in their system. We did prevent excessive use of the PBS because we managed their drugs better.' If you can see a benefit in that case then it is reasonable that some of the money that might be saved in that would be given to—I would hesitate to say given to the doctor—the system that surrounds the doctor so that they can live a better life.

Ms HALL: Are there tools that have been developed to measure these outcomes to work out a system that you can use for this incentivisation?

CHAIR: Established KPIs. I am sure there would be enough data.

Prof. Thomas : There is a ton of data out there.

Ms HALL: Something you can measure it against if you are going to be making payments.

Prof. Thomas : But this is still a difficult area. Even measuring outcomes and value of medical treatment is quite complex. One of the things we are doing in a joint project with the state government and the federal government is looking at the data along a patient pathway. We need a better understanding of what is an optimal pathway for a patient. We do not have that data. The data is there but we have not really done this work. We are doing it. If we can work out exactly what is a good pathway for the patient then we can work out a program of incentivising people who are outside that pathway to get into the pathway. So there are things that are happening but it is quite a complex area.

Ms HALL: Do you have any other programs that are operating in Victoria? What are the stats around chronic disease in Victoria—are they increasing or are there clusters?

Prof. Thomas : It is a terrible problem. The stat that is around at the moment is that there are 60,000 patients in hospital unnecessarily, if you like, at any one time. These people are in hospital because they do not have a good system of management outside of the hospital. There is a huge interest and pressure in getting those patients good care out of hospital—and I am not saying we should diminish their care. There are other programs that the Victorian government has been working on for a number of years trying to keep people out of hospital, but this is the next step.

CHAIR: Does that need more GP focus on people with chronic disease on a daily basis in a GP clinic?

Prof. Thomas : I do not think we need to say it is a GP problem. I think the GPs are just overloaded. When a patient with problems comes in in a wheelchair they can give them only 10 minutes or something. That is not really the right way to deal with it. Those patients need a lot of other supports. We have known from the vignettes that people who have lung disease cannot get physiotherapy for their lungs so consequently if they get a chest infection they go to hospital. If you can provide physiotherapy for that group of patients then you can expect to keep them out of hospital. These are the things that are currently not in the mix for funding really and need some more attention.

Ms HALL: So rather than the GP being the key case manager is there a role there for a nurse or an allied health professional to be that key case manager, the focal point for the person, the No. 1 contact for that person, and then linking into the GP service or whatever service they need? Does it need to be the GP or a practice nurse?

CHAIR: That is what your trial is doing now, isn't it?

Prof. Thomas : But it is still GP led. I think still the GP is the centre of the arc of service, if you like. I mentioned practice managers. Many GP practice managers will do this sort of role—'Hello, Mrs Smith. How are you today? Do you have a problem?' Those sorts of things are very effective.

CHAIR: Do you have any documents that you can submit to the committee in the future that would explain your CarePoint trial system?

Ms Beer : We are exploring that in our authorising environment and will get back to you on that.

CHAIR: It would be nice to have it as an exhibit, or an example or submission. We look forward to the outcomes of your trial. If you have been asked to provide additional information, could you please forward it to the secretariat by Thursday 15 October. If the committee has any further questions, they will send these to you in writing through the secretariat. Once again, thank you for coming today—we appreciate it.