Two or more long-term conditions + four low-cost or free visits to your nurse or GP + three monthly gaps between visits + one wellness care plan = ??
Does Care Plus add up to better care for patients? It seems few get the same answer when they do the sums.
First piloted a decade ago, Care Plus is a primary health care funding stream targeted largely at supporting patients with multiple chronic conditions.
It opened the door to nurse-led care of long-term conditions (LTC) and patient-centred care plans – and in some places, it led to innovative models of care.
But in other areas, little changed for patients, leading to criticism of ‘tick box’ health care and concerns that the quality of care funded via Care Plus was a lottery or “health by post code”.
Many patients just stuffed their care plans into a drawer and regarded Care Plus as just offering cheaper visits to their GP or nurse.
Nobody disagrees that Care Plus has offered nurses a greater role to play in chronic care management, but many believe it could and should have offered much more.
On the horizon is bulk-funding of Care Plus, offering great flexibility and electronic shared care plans and allowing greater integration of services provided to LTC patients. But first, many would argue long-term conditions care needs to go back to the basics and get them right this time.
“Care Plus was simply seen as a bundle of money that could be used predominantly by nurses to improve chronic care management, says Dr Eileen McKinlay (left).
“It gave nurses extra time to work with long-term condition patients but not the necessary skills, resources, and theoretical framework to do the work well,” says the nurse who lectures in long-term conditions (LTC) for the University of Otago.
This is echoed by Massey University nursing professor Jenny Carryer: “At most, Care Plus gives some nurses more time to see some patients, and even that was not consistent across the country.”
Both agree that innovative models have appeared in pockets around the country but in spite of, rather than because of Care Plus, as it is simply a funding stream and not a model of LTC care management.
Puzzled piloters evolve own model
“People think Care Plus is a programme for people with long-term conditions but it’s just a bunch of money,” says Alyson Clare (left).
The lack of a programme soon became clear to Clare and
Dr Shane Cross, (left below) a senior practice nurse and GP at Kaikohe’s Broadway Health Centre, when the practice put its hand up to pilot Care Plus back in 2003.
By then the practice had already been offering nurse-led diabetes clinics since the early 1990s, and Kathy Menary, now a nurse practitioner, had also pioneered offering nurse-led insulin starts as about ten per cent of its adult clients have diabetes. The practice, serving a mostly Māori community, was keen to offer more structured care to its patients with other long-term conditions and to involve nurses more.
“We certainly found when we first started it (Care Plus) that there was very little help from the Ministry or anyone about how we should go about setting it in place in the practice,” says Clare.
“I think that was really one of the flaws of Care Plus, really,” says Cross. “It didn’t really define in any way the expectations about the roles or how it was to be delivered or what was the patient’s involvement. It was very generalist.”
It did call for Care Plus to provide a patient-centred plan and goals, but with long-term conditions management still in its infancy in New Zealand, there was a lack of education of health professionals about how to go about it, says Cross.
“Now lots of models of Care Plus have developed from the extremely basic – essentially just collecting the extra money and not doing a lot for it – through to things that are a lot more complex.”
Broadway’s own model evolved over time. At the beginning, LTC patients were leaving their first lengthy nurse consultation with a glossy folder containing a one sheet summary of their medication and one sheet setting out their health goals.
But Clare says this paper care plan was soon outdated as electronic record keeping became the norm and patients kept forgetting or losing their take home file.
In early 2010, Cross started rolling out the practice’s own LTC model, known as the Star programme, with every eligible Star client allocated a doctor and one nurse to work with them and daily chronic care clinics offered by one of the six Star nurses.
Cross also developed a electronic care plan tool for Star, based within MedTech, that pulls together the doctor’s clinical management plan and the nurse’s assessment with its wider social and cultural focus to draw up an individual wellness plan and goals for the patient.
So what ‘added value’ does Care Plus provide patients? Not that much, is the short answer, according to research into patient perceptions of their LTC care.
Julia Ebbett’s (left) qualitative research found patients basically just saw Care Plus as providing cheaper visits to their general practice.
As a nurse and Care Plus project manager for a group of Hawke’s Bay practices, she had noticed nurses’ competency in delivering Care Plus was variable, with goal setting a particular issue.
“At times it seemed patients were given a telling off or goals that seemed challenging to keep.”
Her Master’s research project – into patient’s perception of nursing’s contribution to Care Plus – soon found that patients had little understanding of what Care Plus was, let alone felt able to discuss the nurse’s role. Though with more probing, it appeared that patients did feel “guided” through their LTC management by their nurse. They also saw it as significant that their nurses were accessible to provide knowledgeable follow-up care but wanted their nurses to offer more support for pain, mental health, and sleep issues.
A major longitudinal study, led by Jenny Carryer, (left) into general practice care for people with chronic illness also found patients reporting mixed experiences post-Care Plus, though they were satisfied with being able to receive “prompt attention from a known and trusted source”.
The two-prong study surveyed hundreds of patients between 2005–2010 in the MidCentral District Health Board region and the data showed patients found appointments “brief and often left much unsaid”, that many still chose not to seek help because of cost or “not wanting to be a nuisance”, and nearly 60 per cent revealed “significant pain levels”.
Across both survey periods, patients expressed a desire for “connection, co-ordination, information, health education, interpretation, and assistance with planning”.
Nurses and GPs in Carryer’s second survey showed subtle changes, such as increased use of nurses, more emphasis on team work and complementary roles, and more structured care for people with LTC.
But the health practitioners still rated themselves more highly than their patients did in providing self-management support. Though nurses were perceived to provide more self-care support than GPs, Carryer believes more fundamental change is needed if patients are to get the support they deserve (see MidCentral sidebar).
She was not surprised that a similar survey, carried out more recently and at the other end of the country by Robin Gauld (left), professor of health policy at the University of Otago, came to similar findings.
Gauld says the research team surveyed a cross-section of 500 Southern PHO patients and their GPs and nurses about the care coordination provided under Care Plus.
“What we found was that the results left a lot to be desired,” says Gauld of the yet-to-be published research. “The GPs and nurses tended to have a more sanguine or positive view of things (the care provided) than the patients.”
Cut down the barriers and ‘set nurses free’
Gauld says also emerging from his research is that the current primary care and Care Plus funding system is “not ideal” for delivering long-term condition services.
“Providers receiving the funding don’t necessarily shift the way they provide care … for the most part, they still seem to be focused on the 15 minute appointment …” says Gauld.
“If you maintain a fee for service type model – which is centred around getting patients through the door – it is not necessarily going to provide the optimal treatment and ongoing coordination and care of people with LTC.”
This is not news to Carryer, whose personal mantra for many years has been that fundamental reform is needed of the primary health sector – particularly the removal of funding, structural and employment barriers. She says nursing has been sending that clear and consistent message to district health boards, primary health organisations (PHOs), and the Ministry of Health for more than a decade, particularly in the 2003 Investing in Health report by the Expert Advisory Group on Primary Health Nursing and the follow-up 2007 report by the College of Nurses and New Zealand Nurses Organisation.
“Set the nurses free to do what they do well … nurses are educated in how to work with people with LTC, and if they are free to do that, then we’ll start to see care being transformed,” says Carryer.
The newly negotiated PHO agreement has not resulted in radical reform of primary health funding as the biggest proportion of government funding to the sector –capitation funding – is left unchanged.
But it will lead to the expectation that all PHOs will form an alliancing agreement from July 1 with their DHB as a prerequisite to bulk funding of their Care Plus funding into a flexible funding pool.
Alliancing agreements were used by the Better Sooner More Convenient (BSMC) business cases (see Masterton and MidCentral sidebars) and Cathy O’Malley (left), the Ministry of Health’s deputy director-general for sector capability and innovation, says the agreements will see PHOs and DHBs working much more collaboratively together in planning and delivering services, including to people with long-term conditions.
“We want to get away from siloed funding streams and attaching specific money to specific professional groups… we’re trying to break all that down,” says O’Malley.
Instead the Ministry wants DHBs and PHOs to discuss how to use the total resources – including DHB funding – and the total workforce skills in the best possible way.
Is there an easy answer?
So what is the best possible way of delivering quality LTC services to people in the community?
There is no simple answer but many people point to Ed Wagner’s Chronic Care Model as a good foundation and checklist for what a good model of care should include (see sidebar). The extensive recommendations of the 2007 National Health Committee report on meeting the needs of people with chronic conditions are seen as another good starting point.
What is commonly agreed is that whatever does make up good chronic conditions care, the current Care Plus tick list requirements of four quarterly visits and a wellness care plan far from guarantees that LTC patients will receive the support they need to better self-manage their health.
A key to slowing down the growing financial burden of chronic disease is to engage and support patients so they can be active partners in managing their own health. That takes more than just turning up to three-monthly appointments and taking home a script and a paper plan.
Dr Janine Bycroft (left), the founder and clinical director of the Health Navigator self-management website, does some training around the country in self-management and chronic health conditions.
“I still find quite a few areas where clinicians are not that comfortable around patient-centred goal setting, They are still prone to advising or directing patients as to what their goals should be for their hypertension or diabetes rather than spending a little bit of time finding out what the patient sees as important and what they’d really like to work on.
“If the patient doesn’t chose (the goals), their chances of following through is really low.”
Bycroft is also the primary health care clinical champion on the National Shared Care Plan programme (see sidebar), which is piloting a collaborative electronic shared care plan accessible by not only a patient’s health professionals, both primary and secondary, but the patient themselves.
When asked for her three wishes for better national LTC care, her number one is a single electronic shared care record, with a care plan component. This is followed by adequate funding to provide case management for the top five to ten per cent of the most complex and high need LTC patients and care co-ordination for the next 20-30 per cent. Her third wish to would be to obtain clear measurements of what differences an LTC programme is making to a patient’s quality of life.
The fact that Care Plus only measures outputs like patients through the door and not quality of outcomes is one of its weaknesses, says Rosemary Minto (left), an NP and chair of the College of Primary Health Care Nurses.
She joins Jenny Carryer in pointing to the nursing sector’s 2007 review as a model for improving Care Plus and LTC care, whose recommendations have largely been ignored by funders and planners.
“The most crucial is national consistency around nursing leadership positions in primary health care.”
Some opportunity for changing the model may be provided by the new flexible funding pool, but again, like Carryer, she thinks bigger barriers remain.
“The current private business model in general practice is still a substantial barrier to any big changes that would positively affect health service delivery for patients – particularly high needs patients.”
Others also talk about Care Plus criteria curbing the ability to provide care when and where needed; the need for greater integration and collaboration between professions and sectors; the need for more education on offering patient-centred care; and the need to improve patient consent processes so patients actually know what they are signing up to.
Meanwhile, pockets of excellence do pop up around the country as individual PHOs, practices, or nurses whittle their way around the limitations of Care Plus to develop their own LTC services with their own assessment and care plan software and their own care co-ordination or case management models. But ad hoc pockets of excellence does not equate to a successful formula for LTC care.
It is clear that many nurses and their health professional colleagues want Care Plus and any successor to add up to much more for many more people with long-term conditions.
Care Plus: Facts at a Glance
- Care Plus is a primary health care funding stream targeted at supporting high needs patients –particularly those with chronic long-term conditions (LTC).
- A nurse or GP can assess whether a patient is eligible and offer the extra clinical support either individually or as a team.
- Care Plus is worth an extra $244 (GST exclusive) a year for every patient a primary health organisation signs up.
- There are currently about 190,000 people on Care Plus and the government is expecting to spend $50 million on Care Plus this year.
- To be eligible for Care Plus, an LTC patient must have at least two or more long-term conditions – like diabetes, hypertension, or respiratory disease.
- Care Plus services on offer differ from PHO to PHO and from practice to practice.
- Funding criteria means most Care Plus patients receive four reduced cost (or free) visits to their local nurse or GP at three-monthly intervals.
- The first Care Plus visit is usually a lengthy comprehensive assessment leading to the development of an individual care plan with health and lifestyle goals.
- The Ministry of Health says the aim of Care Plus is “to improve chronic care management, reduce inequalities, improve primary health care teamwork, and reduce the cost of services for high-need primary health users”.
- A funding lid for Care Plus was set at five per cent of the population but that funding threshold has never been reached across all PHOs.
- The Budget allocated an extra $3.2 million a year to Care Plus for the next four years to top-up the Care Plus funding pool to the five per cent level.
- Care Plus funding is to be bulk-funded as part of the flexible funding pool model (used in the Better Soon More Convenient business cases) being rolled out this year to PHOs after they negotiate alliance relationships with their district health boards.
Wagner’s Chronic Care Model (CCM)
The Chronic Care Model (CCM) was developed by Edward Wagner in response to the increasing burden of chronic disease and the disparate approaches to managing and caring those with chronic illness. The model sets out six essential elements for an effective chronic or long-term conditions care model:
- Good health care organisation (or health system culture changes)
- Community engagement in resources and policies
- Self-management support
- Delivery system design (or redesign)
- Decision support
- Clinical information systems.
Electronic collaboration for better LTC patient care
- An electronic Shared Care Plan means a patient and their health professionals can securely access key health record information and care plan details from any setting be it home, hospital, or general practice.
- The programme also promotes a collaborative approach between all health care providers to develop a comprehensive and coordinated care plan for their patients and to message each other.
- The plan is patient-centred and is built around mutually-agreed goals, actions, and timeframes for addressing problems.
- Three Share Care Plan pilots began in 2011 in Auckland across the three district health boards with each DHB focusing on a different area: Auckland on heart failure, Waitemata on respiratory disease, and Counties-Manukau on gout and metabolic syndrome.
- In Christchurch, there is the Collaborative Care programme, which uses the same New Zealand developed software system as Auckland and has focused on COPD and heart failure, frequent visitors to ED, and high needs patients in the community.
- Currently about 530 (CHECK) patients are signed up to the Auckland pilots and more than 200 health professionals are registered as users.
- There are about 36 (CHECK) patients using their patient ‘portal’ to access their diagnoses, medication, recent medications, care plan, and to view which health professionals have viewed their record and care plan. There is also the option of patients messaging their health professional and updating their own measurements like blood pressure, weight, and blood sugar.
- By the end of next year, the Ministry of Health’s National Health IT Board hopes to start rolling out the Auckland shared care plan model nationwide for patients with long-term conditions.