Associate Professor Joe McGirr
Collaborative Care
Playing Ball – Embracing Collaborative
Care and Reducing Load on Rural Practice
Through True Multidisciplinary
Integration
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through true
multidisciplinary integration
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Associate Professor Joe McGirr
Collaborative Care Outline of
Presentation
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What is it and why do it?
What does it look like?
Key elements
Issues
NSW health integrated care strategy
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
What is collaborative care?
A system of care in which multiple professionals of
different areas of practice co-operate across different
settings to care for a patient
Why?
Chronic disease contributes to more than 70% of the
disease burden and by improving management health
care will improve with reduced costs
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Collaborative Care – what does
it look like?
• Communication between service providers – usually case conferencing
• Systems to support coordination of care – shared care plans and shared
decision support tools
• Coordinating clinical activities – organising consultations in appropriate
succession or shared assessments
• Support for service providers - supervision or reminders
• Patient support – education, reminders
• Health system organisation
• Joint facilities
• Joint planning, funding or management
• Organisation of the health care system
Davies, G, Harris, Mark, Perkins, David, Roland, Martin, Williams, Anna, Larsen, Karen, & McDonald, Julie. (2006). Coordination of care within
primary health care and with other sectors: a systematic review.
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Elements in a collaborative care program
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Providers
Governance
Information technology
Patient education
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Elements - Providers
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General Practitioners
Allied Health
Practice nurses
Mental health specialists
Aged Care personnel
Care coordinators
Non-health providers – meals on wheels
Range of remuneration models and incentives
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Elements - Governance
• Local Health District
• Acute
• Sub acute
• Community
• Mental health
• Primary care – Primary Health Networks
• Aged Care
• Assessment teams
• Facilities
• Consumers
• Private Health Insurance funds
• Other providers e.g. telephone health services
Providers
work in and across organisations
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Governance – Example
Riverina Palliative Care Alliance
• Partners
• Murrumbidgee Local Health District
• Nursing, Community health, funding for inpatient
beds
• Murrumbidgee Medicare Local
• General Practitioners
• Calvary Health Care Riverina – private hospital
• Aged Care facilities
• Consumer representatives.
• Model of care
• Rules of operation
• Agreed outcomes and monitoring
• Working group to implement
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Elements - Information technology
• Discharge summaries
• Electronic health record
• State
• Commonwealth
• General Practice
• Decision support tools
• Apps for patients and professionals
• Shared care planning tools
• My Aged Care portals and other portals
• Risk stratification tools
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Elements - Patient Education
• Is seen as critical
• May be more difficult than appears
• Not helped by current ICT systems
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Issues
• It is difficult
• Role of specialists
• Documentation of benefit
• NSW Connecting Care Program
• Risk stratification
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Chronic complex care can be difficult
• Conditions interact
• Risk factors interact
• Prioritisation challenging – some one has to make a
decision
• Patient literacy
• Overlapping specialist care
• Communication between team members
• Information systems are still not optimal
• There are many programs
Harris, M, Dennis, S and Pillay, M (2013). Multimorbidity: negotiating priorities and making progress. Australian Family
Physician, 42, 12 , 850- 854
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Role of medical specialist
• Arguably linked to episodic hospital based care
• Have some teams themselves
• Stroke units
• Rehabilitation
• But not linked to prevention or secondary
prevention
• Come to them when they have had a poor event
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Documenting the benefit – does it
work?
NSW Health Chronic Disease Management
Program
• Aim to reduce avoidable acute hospitalizations in
people with chronic disease by better connecting
their care and support
• Older patients and those with chronic disease
account for over half of acute hospital admissions
in NSW Health
• Care coordination and self management support
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
NSW Health CDMP Elements
Feyer, A-M, McDonald, A, Billot, L, Cass, A, Turnbull, F, Corcoran, K, . . . Viney, R. (2014). Statewide evaluation. NSW Health Chronic Disease
Managment Program. Final Report 2014: The George Institute for Global Health, The Centre for Primary Health Care and Equity, UNSW, The
Centre for Health Economic Research and Evaluation, UTS.
Associate Professor Joe McGirr
NSW Health CDMP Evaluation
• Identifying, managing and tracking enrolments
• Limited by ICT
• Usually when patients at their worst
• Integration with other chronic disease management
programs/services
• Rehabilitation and community health reasonable
• Aged care - less
• Governance structures
• Integration with primary care variable
• Aboriginal groups and consumers least represented
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
NSW Health CDMP Evaluation
• Evolution over time
• Enrolments peaked at peak service use times –
reductions seen in service use would be expected
with reduction to mean and were matched in
controls
• No effect of the program of admissions when
compared to control group
• Unexpected increase in unplanned admissions
http://www.health.nsw.gov.au/cdm/Documents/CDMP-Evaluation-Report-2014.pdf
Feyer, A-M, McDonald, A, Billot, L, Cass, A, Turnbull, F, Corcoran, K, . . . Viney, R. (2014). Statewide evaluation. NSW Health Chronic
Disease Managment Program. Final Report 2014: The George Institute for Global Health, The Centre for Primary Health Care and
Equity, UNSW, The Centre for Health Economic Research and Evaluation, UTS.
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Issues - Risk stratification
• Who do we target with collaborative care?
• Top 1% account for 22% costs; top 20% for 80%.
Hall, M A. (2011). Risk Adjustment Under the Affordable Care Act: A Guide for Federal and State Regulators: The
Commonwealth Fund.
• There appear to be a range of tools to do this
Haas, L R, Takahashi, P Y, Shah, N D, Stroebel, R J, Bernard, M E, Finnie, D M, & Naessens, J M. (2013). Risk-Stratification
Methods for Identifying Patients for Care Coordination Am J Manag Care, 19(9), 725-732.
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Risk Stratification - NHS
• Predictive accuracy modest
• Some interventions designed to improve the
impact of risk stratification may worsen health
inequality
• May lead to an increase in overall costs
NHS England. (2015). Next steps for risk stratification in the NHS. Retrieved from http://www.england.nhs.uk/wpcontent/uploads/2015/01/nxt-steps-risk-strat-glewis.pdf.
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
NSW Health Integrated Care Strategy
• “Seamless, effective and efficient care that responds
to all of a patient’s needs, across physical and mental
health, in partnership with the individual, their carers
and family.”
• “…services connected across many different
providers…”
• “Locally led integration … will appropriately address
the coordination and provision of services…”
• “ … primary, community and acute care….public,
private and not for profit…”
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
NSW Health Integrated Care Strategy
• Joint governance, shared financial incentives, IT
systems and tools for communication
• Statewide roll out of fully linked-up electronic
health record
• Tools to identify early intervention opportunities
• Systems for tracking patient outcomes and for
patients to provide direct feedback
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Murrumbidgee Local Health District CHESS initiative
• Chronic/Complex Healthcare: Engaged with all
Stakeholders and Services
• High rate of avoidable and repeat admissions
• Places the GP at the core of the service overseeing a
coordinated multidisciplinary team that will provide
alternatives to acute hospital admission
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
GP
GP
GP
Care
Care
Coordinat
or
Care navigator
in patient flow
unit
Can link to
home
monitoring
teams
Care
Coordinator
Care
Coordinator
Care
teams
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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Associate Professor Joe McGirr
Closing Summary – Collaborative Care
• Consensus that collaborative care is important
• The collaboration involves organisations and
personnel
• The collaboration should be underpinned by strong
systems and governance
• Ongoing need for evidence
Edgy Issues Topic 2- Playing ball- Embracing collaborative care and reducing load on rural practice through
true multidisciplinary integration
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