The Australian Health Care Integration Experience

T

here has been a long history of exerted effort to enhance the integration of health care services in Australia. This paper provides an overview of some of the success and failures, and lessons learned.

Like Canada, Australia is an amalgam of a number of health care systems. Unlike Canada, Australia has not clearly assigned the responsibilities for health care among the various government levels which tends to result in cost and blame shifting. This map outlines the geography, population and health structure of the Australian states.

For the purposes of this paper integration is defined as:

The integration examples include:

1. Multi-purpose services
2. National Hospital Demonstration Projects
3. Coordinated Care Trials
4. HARP
5. Primary Care Partnerships

1 - Multi-Purpose Services

Eleven multi-purpose services (MPS) were piloted in 1992 / 93 and there are now more than 117 MPS throughout the country. The MPS is an amalgamation of hospital, aged care, home and community (HACC) funding streams into a single budget in small, isolated rural communities. This was one of the first programs to combine national aged care funding with state/territory and municipal funding for health services. The services are expected to comply with the National Quality Improvement Framework for Multipurpose Services.

The MPS initiative would suggest:

• a single, flexible funding pool enables coordinated and client centred health, residential and community care services
• service integration was achieved, leading to improved viability and cost effectiveness ³

This has resulted in recent suggestion to move to next level to aim for integration at the sub-regional level. The factors that have been identified with the success of the MPS include:

• Small catchments (3,000-4,000 people
• Contiguous service boundaries
• No more than one of each type of service
• GP support
• Redevelopment grants available, which facilitated community acceptance, and
• Management expertise.

2 - National Demonstration Hospitals Project (NDHP)

The first phase of NDHP focused on waiting times for elective surgery; the second phase was bed management; and the third phase from 1999-2001 was aimed at improving the integration between acute, non-acute and community sectors. The NDHP comprised four consortia, with 25 hospitals that used a lead hospital/ collaborating hospitals model to implement the integration strategies.

Integration was measured as:

• Number of contacts between GP and hospital before patient arrival and within 48 hours
• Number of hospital patients using hospital in the home(HITH), and
• Percentage of patients 75 years and older not admitted with re-presentation

The lessons from the Phase 3 NDHP included ⁴:

• There is a need to adequately define ‘integration’. In particular, quantitative outcome measures were problematic.
• It was suggested that organisations must integrate services internally before integration across boundaries can be effectively achieved.
• Evaluation criteria must be contractually agreed

3 - Coordinated Care Trials (CCT)

The CCTS were a joint initiative of national, state and territory governments to strengthen primary health care for chronic and complex care needs. The first round was completed in 1997 to1999, with nine mainstream and four Indigenous trials. The second round in 2002 to 2005 had three Indigenous and two mainstream trials. In round two, three Indigenous-specific trials were conducted in Katherine, Northern Territory; Bunbury, Western Australia; and Port Macquarie, New South Wales, and two mainstream trials were conducted in Brisbane, Queensland; and Melbourne, Victoria.

The intent was to pool the funds of ‘usual care’, and the trials would seek to deliver services and care coordination within this fund pool. CCT1 trials adopted a wide variety of methods to provide this requirement, none of which was seen to be applicable in a generic context. Accordingly, a ‘risk-based capitation model’ was created at the end of CCT1 to support a more rigorous and generic fund-pooling approach in CCT2.

The findings were that the Indigenous trials were successful in removing barriers to service access, but there was little evidence that the mainstream trials were successful. The Indigenous trials reported removal of barriers to access such as: physical constraints (e.g. lack of transport) or infrequent visits to remote communities; communication constraints in terms of language dialects and the complexity of spoken and written English; lack of understanding of Indigenous sensitivities (e.g. need for gender-specific health professionals); and perceived discrimination against Indigenous people by mainstream workers. It was suggested that had the mainstream trials operated longer, the total intervention costs might have fallen below the control costs, and may have absorbed the costs of care coordination, but that CCTS seemed to be more about case finding then service integration.

The full fund pooling approach envisaged was not achieved even for the mainstream trials. While the Commonwealth proceeded with a ‘cash-out’ of MBS and PBS funding, state/territory public hospital and community care funders were not prepared to fully commit to this approach. Stakeholders perceived that the main impediment was the uncertainty and risk surrounding their estimated funding injection compared to an unknown potential service utilisation. The experience of CCT2 validated the caution of stakeholders. It emerged that: the risk-based capitation rates estimated from CCT1 data in respect of inpatient services and community care services were found to be inaccurate, largely due to data inadequacies in CCT1; and trials did not receive adequate ‘tracking data ‘to monitor their utilisation expenditure, and hence were unable to fully implement the flexible funding methodology.

A generic approach to ‘managing’ the trials through a variety of project officers and contract managers appointed by each funding body was problematic, and would be unlikely to succeed in a real-life sub-system of care coordination, including the flexible use of funds. In fact, the evidence from the evaluation suggests that difficulties in the implementation of trials led to an atmosphere of uncertainty and lack of trust among key stakeholders in the live phase of trials^{. 5}

The lessons from the CCTs included ⁵:

• One size does not fit all
• Integration costs before it pays (and it may never pay)
• Workforce sustainability was difficult
• Governance was critical, but difficult.

It was suggested that “Perhaps the primary learning … has been the enormous complexity and difficulty in establishing a trial and, by implication, in rolling out a real-life sub-system of care coordination” and the “Inability to achieve electronic communication, networking and data flows was a major impediment”. ⁵

4 - Hospital Admission Risk Program (HARP)

HARP comprised a range of community/ hospital partnership projects governed by service agreements to reduce hospital admissions. There were around 90 projects that costs approximately $150m over four years. At this stage the HARP projects are being ‘mainstreamed’ to recurrent budgets through the Victorian Chronic and Complex Program; Emergency Department Care Coordination and GP Liaison Officers.

The HARP programs were built on a population health model that suggested only a portion of the population required the integrated programs of HARP ⁶.

click on the image to enlarge it

The outcomes from the HARP projects were reported ⁷ to be:

Improved health outcomes

• More support for carers
• Consumers liked it
• 35% decrease in ED attendances
• 52% fewer ED admissions
• 41% fewer days in hospital
• Community/hospital collaboration with benefits beyond HARP

The outcomes were reported for the HARP clientele pre and post, but in comparison with control groups there was a different picture. Overall in all but the complex over 75 year cohort, the HARP clients had more ED attendances and emergency admissions that the control group. However, those programs with specific target groups had greater success in comparison with control groups.

The lessons from HARP included:

• Not all patients need integrated care – those that do benefit from a holistic approach. There appeared to be greater impact with specific defined target groups that took a whole of patient approach. For example, initiatives that aimed to understand respiratory disease across the continuum had better patient outcomes.
• Develop a system, not individual projects. It was suggested that incremental implementation of new models can result in: further fragmentation, duplication, competition and compartmentalization.
• Service agreements are essential
• Integration costs before it pays (does it ever pay?)

5 - Primary Care Partnerships (PCPs)

Thirty one PCPs were introduced in Victoria in 2001, with Memorandum of Understanding (MOU) used as the mechanism to define the relationships among service providers in defined catchments. While previous integration strategies had attempted to effect change through correcting the fragmented funding arrangements, PCPs aimed to effect change through organisational partnerships. The PCPs were meant to:

• inform and coordinate initiatives that require partnerships across primary health, or between primary health and other services and sectors
• service coordination, specifically the development and implementation of statewide tools
• implementation of the integrated health promotion (IHP) framework

The recurrent core funding for PCPs comprised $3.2 million for partnership activities and $1.5 million for IHP program planning and evaluation reporting. In addition the rural PCPs received anadditional $750,000 for health promotion.

In the 2005 evaluation the participants indicated that the benefits of being involved in the PCP outweighed the cost for almost 80% of agencies. This was a reversal of opinion for many agencies from that recorded in the 2003 evaluation ⁸.

The lessons from the PCPs included ⁸:

• Robust, flexible partnerships and service linkages were achieved through the Community Health Plan development
• There was a focus on local integrated health promotion
• There appeared to be improved care for people with chronic and complex conditions. In particular shared service coordination tool templates (SCTT) were useful in improving integration.
• Misaligned service boundaries were a major challenge planning for integrated services
• Need for meaningful performance measures
• Resourcing difficulties – providers may be involved with more than one PCP and this took a lot of time to participate
• Despite the coordination, workforce availability remained an issue.

Conclusions

It is pretty clear from the integration pilots that pooled funding enables organisation of services to better meet client need (for those who need it). Unfortunately in Australia there is no will to eliminate the national / state funding divide that could improve the integration of health care services. The National Health and Hospitals Reform Commission (NHHRC) was established by the new Labour national government to comment on reform of the health care systems. The Commission had not recommended major reform, but the NHHRC believes that the divide should remain, and the Australian Health Care Agreements (AHCAs) between national and state/territory government should outline shared responsibility by Commonwealth and states. That is one government should be held accountable by the public for overall service performance in each area. This is seen as a mechanism to improve the overall integration of the health care system. Some remain unconvinced.

references

1. National Health Strategy 1991 The Australian Health Jigsaw - Issues Paper Number 1, p 1
2. Dunt D, et al. 2006 Mapping GP integration in the health care system in different locations in Australia. Australian Journal of Primary Health 12(1): 47-55.
3. Sach and Associates 2000 Multi-Purpose Services Program Evaluation (Victoria)
4. Commonwealth of Australia 2001 Measuring the Impact – A Sample of Project Results. National Demonstration Hospitals Program.
5. Commonwealth of Australia 2007 The National Evaluation of the Second Round of Coordinated Care Trials. Final Report.
6. Department of Human Services 2008 HARP – Chronic Disease Management. Accessed December 11, 2008. Available at http://www.health.vic.gov.au/harp-cdm/
7. Bearing Point 2004 Hospital Admission Risk Program (HARP): Establishing the base for preventive services. Victorian Department of Human Services.
8. Australian Institute for Primary Care 2005 An Evaluation of the Primary Care Partnership Strategy

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