one system - nhs imas · endometrial cancer i hyperplasia ... align the model of care across the...
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The Journey To An Integrated System
A Canterbury NZ Case Study
Dr Ian Sturgess FRCP
Director IMP Healthcare Consultancy Ltd
Clinical Advisor Quality Improvement
Canterbury DHB
IanSturgessimphccouk
IanSturgesscdhbhealthnz
One System
A way of working that embeds continuous system
improvement
One health system one budget
Removing barriers and perverse incentives created by
contracts and organisational boundaries by planning and
working collaboratively across the public private and Non-
Governmental Organisations (NGO) sector
Its about people
Key measure of success at every point in the system is
reducing the time patients waste waiting
Right care right place right time delivered by the right person
Its about leadership
The District Health Boardrsquos (DHBrsquos) role is to buy the right thing
for the population
Clinicians are enabled to do the right thing the right way
Transforming the System
ldquoOrganisational Ambidexterity can lead to high performance organisationsrdquo
There are two key elements
Understand and successfully operate theexisting business - Alignment
Explore new often uncertain opportunities -Adaptability
Target Audience
All health system staffAny staff interested in learning amp applying the principles of Lean Thinking amp who are seeking to be part of change in their work environment This should be viewed as an ideal programme to get teams of people linked into Lean Thinking methodology within their environment
All health system staffAny staff member that is attempting to make improvements at all levels of the health system Ideal for people who are getting frustrated at the ability to enable change or enlighten people to their point of view
All health system leadersFirstline Leaders to senior leaders (Management Clinical Operational Support) Two programmes targetted at different audiencesFour week programme Firstline leaders to middle managementOne week programme Middle management to senior leaders ndash particularly senior medical officers (SMOs)
Span of Focus Making improvements in the personrsquos immediate workplace Team orientated improvement focus
From Self to health system span of improvement From Self as a leader to health system view
Commitment 2-day course time over three months (approx) with a project to do between workshop 1 amp 2
14 hours over three separate days 8 Days plus project time
Key Learnings bullHealth system ViewbullLean Thinking basics (foundation)bull Knowing ones own personality and how this impacts on others (introduction level)bull Patient safety principlesbull Communication principles (introduction level)bull ProjectImprovement work amp Presentations
bull Health System viewbull Identify skills and attributes that will empower the individual to influence othersbull Understand the importance of the environment emotion and logic in making change through the Elephant Rider and Path work from Dan amp Chip Heathbull Knowing self and others through DISC personality with emphasis on engaging others (more depth)bull Understanding how to evaluate the worth of ideasbull Focus on key Canterbury Health system principles and testing ideas against these principles
bull Health System Viewbull DISC (introduction level)bull Consumer viewService designbull Production management principlesbull Lean Thinking basics (foundation)bull Leadership principlesbull Business support toolsbull Learning application - project
Calendar Available through LampD Calendar To be posted on LampD Calendar June 2012 August 2012 October 2012
Contact Booking Christine MacDonald PDUChristinemcdonaldcdhbgovtnz
Information Lynn Davies
Booking Bev McVicar BDU
Information Felicity Woodham
Booking Bev McVicar BDU
Information Richard Hamilton BDU
All Staff Firstline to Senior Leaders
Potential Change Agents
The Role of Funding Mechanisms
Can act as a barrier to change
ldquoyou get what you pay forrdquo
Rarely drive the right change
Can create perverse incentives
Can lead to unintended consequences
Need to be used to supportembed change
Need to be openly and transparently applied
0 Home
0 Allied Health amp Nursing0Acute and Urgent
0Child Health 0 Investigations 0 Lifestyle0f1edical
0 Mental Health
0Older Persons Health
0 Pharmacology
0 Surgicala Womens Health
0 Breastfeeding0 Contracept ion and Sterilisatioa Gynaecology
G Abdominal Pain in Young WD Cervical Polyps0 Cervical Screening
0 Dysmenorrhoea
0 Endometrial Cancer Low Ri0 Hea or I r re ular Mense
D Hysteroscopy Outpatient Pr0 Intermenstrual andor Post
0 f1enopause0 Ovarian Cyst0 Pelvic Pain (Chronic)
0 Pipelle Biopsies
0 Polycystic Ovarian Syndrom 0 Post Menopausal Bleeding 0 Prolapse0 Ring Pessaries
0 Sub Fertility
0 Urinary IncontinenceIIVulvodynia I Superficia l Vul
DReferral to Gynaecology amp 0 Pregnancy Related Conditions DReferralto Gynaecology amp Ob0Canterbury Initiative Services
0 Resources
Heavy or I rregula r Menses
0 About heavy or irregular menses
flowchartRed Flags
Endometrial cancer I hyperplasia
Risk factors include age e 45 years or gt 35 and one or more of
Weight e 90kg
Exposure to oestrogen without progestogens
bull Nulliparit y infer tilit y PCOS
bull MaoriPac ific Islander
Assessment
1 Check the patients 0 history of the condition
2 Carry out a speculum and bimanual examinat ion
3 Check t he patients smear history and repeat if necessary
4 Consider doing endocervical and chlamydia swabs if Mirena is an option or there is a risk of infection
5 Investigations
bull test CBC and ferri t in
bull consider thyroid funct ion tests if t here are ot her signs or symptoms of thyroid dysfunc tion
bull consider tests for Polycystic Ovarian Syndrome if periods are irregular
Practice Point
Copper IUCDs can increase menstrual blood loss If the patient has no risk fac tors requiring investigation changing contrac eptive methods may be all that is required to improve menorrhagia
6 If the patient
bull is e 45 years or
bull is 0 high risk or
bull has persistent intermenstrual bleeding or failed medical treatment
ltv
Cumulative Count of Practices using ERMS
67
7882 84
8894
98 99 101 102
113 115
0
20
40
60
80
100
120
140
n b r r y n l g p t v ca a p a u u u c oJ Fe M A M J J A Se O N De
2011
Clinically Led Integration
Electronic Referral
Management System
HealthPathways 610 established clinical pathways
11000 visits a month
74000 page views a month
(Restricted to clinicians only)
We do more in the community
Acute admission avoidance programme (ADMS)
now manages 18000 people per annum in their
own home
Acute Demand Programme
Canterbury-wide Programme - established 14 years ago
Now manages over 25000 episodes per year
Common Presentations include
Cellulitis
Respiratory
Pyelonephritis
Diverticulitis
Heart failure
Deep Vein Thrombosis (DVT)
lsquoGenerally unwellrsquo
Nursing amp Medical teams
Five bedded observation unit
Acute demand liaison nursing team (Hospital based)
Close working relationships across primary secondary care amp
ambulance
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
A way of working that embeds continuous system
improvement
One health system one budget
Removing barriers and perverse incentives created by
contracts and organisational boundaries by planning and
working collaboratively across the public private and Non-
Governmental Organisations (NGO) sector
Its about people
Key measure of success at every point in the system is
reducing the time patients waste waiting
Right care right place right time delivered by the right person
Its about leadership
The District Health Boardrsquos (DHBrsquos) role is to buy the right thing
for the population
Clinicians are enabled to do the right thing the right way
Transforming the System
ldquoOrganisational Ambidexterity can lead to high performance organisationsrdquo
There are two key elements
Understand and successfully operate theexisting business - Alignment
Explore new often uncertain opportunities -Adaptability
Target Audience
All health system staffAny staff interested in learning amp applying the principles of Lean Thinking amp who are seeking to be part of change in their work environment This should be viewed as an ideal programme to get teams of people linked into Lean Thinking methodology within their environment
All health system staffAny staff member that is attempting to make improvements at all levels of the health system Ideal for people who are getting frustrated at the ability to enable change or enlighten people to their point of view
All health system leadersFirstline Leaders to senior leaders (Management Clinical Operational Support) Two programmes targetted at different audiencesFour week programme Firstline leaders to middle managementOne week programme Middle management to senior leaders ndash particularly senior medical officers (SMOs)
Span of Focus Making improvements in the personrsquos immediate workplace Team orientated improvement focus
From Self to health system span of improvement From Self as a leader to health system view
Commitment 2-day course time over three months (approx) with a project to do between workshop 1 amp 2
14 hours over three separate days 8 Days plus project time
Key Learnings bullHealth system ViewbullLean Thinking basics (foundation)bull Knowing ones own personality and how this impacts on others (introduction level)bull Patient safety principlesbull Communication principles (introduction level)bull ProjectImprovement work amp Presentations
bull Health System viewbull Identify skills and attributes that will empower the individual to influence othersbull Understand the importance of the environment emotion and logic in making change through the Elephant Rider and Path work from Dan amp Chip Heathbull Knowing self and others through DISC personality with emphasis on engaging others (more depth)bull Understanding how to evaluate the worth of ideasbull Focus on key Canterbury Health system principles and testing ideas against these principles
bull Health System Viewbull DISC (introduction level)bull Consumer viewService designbull Production management principlesbull Lean Thinking basics (foundation)bull Leadership principlesbull Business support toolsbull Learning application - project
Calendar Available through LampD Calendar To be posted on LampD Calendar June 2012 August 2012 October 2012
Contact Booking Christine MacDonald PDUChristinemcdonaldcdhbgovtnz
Information Lynn Davies
Booking Bev McVicar BDU
Information Felicity Woodham
Booking Bev McVicar BDU
Information Richard Hamilton BDU
All Staff Firstline to Senior Leaders
Potential Change Agents
The Role of Funding Mechanisms
Can act as a barrier to change
ldquoyou get what you pay forrdquo
Rarely drive the right change
Can create perverse incentives
Can lead to unintended consequences
Need to be used to supportembed change
Need to be openly and transparently applied
0 Home
0 Allied Health amp Nursing0Acute and Urgent
0Child Health 0 Investigations 0 Lifestyle0f1edical
0 Mental Health
0Older Persons Health
0 Pharmacology
0 Surgicala Womens Health
0 Breastfeeding0 Contracept ion and Sterilisatioa Gynaecology
G Abdominal Pain in Young WD Cervical Polyps0 Cervical Screening
0 Dysmenorrhoea
0 Endometrial Cancer Low Ri0 Hea or I r re ular Mense
D Hysteroscopy Outpatient Pr0 Intermenstrual andor Post
0 f1enopause0 Ovarian Cyst0 Pelvic Pain (Chronic)
0 Pipelle Biopsies
0 Polycystic Ovarian Syndrom 0 Post Menopausal Bleeding 0 Prolapse0 Ring Pessaries
0 Sub Fertility
0 Urinary IncontinenceIIVulvodynia I Superficia l Vul
DReferral to Gynaecology amp 0 Pregnancy Related Conditions DReferralto Gynaecology amp Ob0Canterbury Initiative Services
0 Resources
Heavy or I rregula r Menses
0 About heavy or irregular menses
flowchartRed Flags
Endometrial cancer I hyperplasia
Risk factors include age e 45 years or gt 35 and one or more of
Weight e 90kg
Exposure to oestrogen without progestogens
bull Nulliparit y infer tilit y PCOS
bull MaoriPac ific Islander
Assessment
1 Check the patients 0 history of the condition
2 Carry out a speculum and bimanual examinat ion
3 Check t he patients smear history and repeat if necessary
4 Consider doing endocervical and chlamydia swabs if Mirena is an option or there is a risk of infection
5 Investigations
bull test CBC and ferri t in
bull consider thyroid funct ion tests if t here are ot her signs or symptoms of thyroid dysfunc tion
bull consider tests for Polycystic Ovarian Syndrome if periods are irregular
Practice Point
Copper IUCDs can increase menstrual blood loss If the patient has no risk fac tors requiring investigation changing contrac eptive methods may be all that is required to improve menorrhagia
6 If the patient
bull is e 45 years or
bull is 0 high risk or
bull has persistent intermenstrual bleeding or failed medical treatment
ltv
Cumulative Count of Practices using ERMS
67
7882 84
8894
98 99 101 102
113 115
0
20
40
60
80
100
120
140
n b r r y n l g p t v ca a p a u u u c oJ Fe M A M J J A Se O N De
2011
Clinically Led Integration
Electronic Referral
Management System
HealthPathways 610 established clinical pathways
11000 visits a month
74000 page views a month
(Restricted to clinicians only)
We do more in the community
Acute admission avoidance programme (ADMS)
now manages 18000 people per annum in their
own home
Acute Demand Programme
Canterbury-wide Programme - established 14 years ago
Now manages over 25000 episodes per year
Common Presentations include
Cellulitis
Respiratory
Pyelonephritis
Diverticulitis
Heart failure
Deep Vein Thrombosis (DVT)
lsquoGenerally unwellrsquo
Nursing amp Medical teams
Five bedded observation unit
Acute demand liaison nursing team (Hospital based)
Close working relationships across primary secondary care amp
ambulance
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Transforming the System
ldquoOrganisational Ambidexterity can lead to high performance organisationsrdquo
There are two key elements
Understand and successfully operate theexisting business - Alignment
Explore new often uncertain opportunities -Adaptability
Target Audience
All health system staffAny staff interested in learning amp applying the principles of Lean Thinking amp who are seeking to be part of change in their work environment This should be viewed as an ideal programme to get teams of people linked into Lean Thinking methodology within their environment
All health system staffAny staff member that is attempting to make improvements at all levels of the health system Ideal for people who are getting frustrated at the ability to enable change or enlighten people to their point of view
All health system leadersFirstline Leaders to senior leaders (Management Clinical Operational Support) Two programmes targetted at different audiencesFour week programme Firstline leaders to middle managementOne week programme Middle management to senior leaders ndash particularly senior medical officers (SMOs)
Span of Focus Making improvements in the personrsquos immediate workplace Team orientated improvement focus
From Self to health system span of improvement From Self as a leader to health system view
Commitment 2-day course time over three months (approx) with a project to do between workshop 1 amp 2
14 hours over three separate days 8 Days plus project time
Key Learnings bullHealth system ViewbullLean Thinking basics (foundation)bull Knowing ones own personality and how this impacts on others (introduction level)bull Patient safety principlesbull Communication principles (introduction level)bull ProjectImprovement work amp Presentations
bull Health System viewbull Identify skills and attributes that will empower the individual to influence othersbull Understand the importance of the environment emotion and logic in making change through the Elephant Rider and Path work from Dan amp Chip Heathbull Knowing self and others through DISC personality with emphasis on engaging others (more depth)bull Understanding how to evaluate the worth of ideasbull Focus on key Canterbury Health system principles and testing ideas against these principles
bull Health System Viewbull DISC (introduction level)bull Consumer viewService designbull Production management principlesbull Lean Thinking basics (foundation)bull Leadership principlesbull Business support toolsbull Learning application - project
Calendar Available through LampD Calendar To be posted on LampD Calendar June 2012 August 2012 October 2012
Contact Booking Christine MacDonald PDUChristinemcdonaldcdhbgovtnz
Information Lynn Davies
Booking Bev McVicar BDU
Information Felicity Woodham
Booking Bev McVicar BDU
Information Richard Hamilton BDU
All Staff Firstline to Senior Leaders
Potential Change Agents
The Role of Funding Mechanisms
Can act as a barrier to change
ldquoyou get what you pay forrdquo
Rarely drive the right change
Can create perverse incentives
Can lead to unintended consequences
Need to be used to supportembed change
Need to be openly and transparently applied
0 Home
0 Allied Health amp Nursing0Acute and Urgent
0Child Health 0 Investigations 0 Lifestyle0f1edical
0 Mental Health
0Older Persons Health
0 Pharmacology
0 Surgicala Womens Health
0 Breastfeeding0 Contracept ion and Sterilisatioa Gynaecology
G Abdominal Pain in Young WD Cervical Polyps0 Cervical Screening
0 Dysmenorrhoea
0 Endometrial Cancer Low Ri0 Hea or I r re ular Mense
D Hysteroscopy Outpatient Pr0 Intermenstrual andor Post
0 f1enopause0 Ovarian Cyst0 Pelvic Pain (Chronic)
0 Pipelle Biopsies
0 Polycystic Ovarian Syndrom 0 Post Menopausal Bleeding 0 Prolapse0 Ring Pessaries
0 Sub Fertility
0 Urinary IncontinenceIIVulvodynia I Superficia l Vul
DReferral to Gynaecology amp 0 Pregnancy Related Conditions DReferralto Gynaecology amp Ob0Canterbury Initiative Services
0 Resources
Heavy or I rregula r Menses
0 About heavy or irregular menses
flowchartRed Flags
Endometrial cancer I hyperplasia
Risk factors include age e 45 years or gt 35 and one or more of
Weight e 90kg
Exposure to oestrogen without progestogens
bull Nulliparit y infer tilit y PCOS
bull MaoriPac ific Islander
Assessment
1 Check the patients 0 history of the condition
2 Carry out a speculum and bimanual examinat ion
3 Check t he patients smear history and repeat if necessary
4 Consider doing endocervical and chlamydia swabs if Mirena is an option or there is a risk of infection
5 Investigations
bull test CBC and ferri t in
bull consider thyroid funct ion tests if t here are ot her signs or symptoms of thyroid dysfunc tion
bull consider tests for Polycystic Ovarian Syndrome if periods are irregular
Practice Point
Copper IUCDs can increase menstrual blood loss If the patient has no risk fac tors requiring investigation changing contrac eptive methods may be all that is required to improve menorrhagia
6 If the patient
bull is e 45 years or
bull is 0 high risk or
bull has persistent intermenstrual bleeding or failed medical treatment
ltv
Cumulative Count of Practices using ERMS
67
7882 84
8894
98 99 101 102
113 115
0
20
40
60
80
100
120
140
n b r r y n l g p t v ca a p a u u u c oJ Fe M A M J J A Se O N De
2011
Clinically Led Integration
Electronic Referral
Management System
HealthPathways 610 established clinical pathways
11000 visits a month
74000 page views a month
(Restricted to clinicians only)
We do more in the community
Acute admission avoidance programme (ADMS)
now manages 18000 people per annum in their
own home
Acute Demand Programme
Canterbury-wide Programme - established 14 years ago
Now manages over 25000 episodes per year
Common Presentations include
Cellulitis
Respiratory
Pyelonephritis
Diverticulitis
Heart failure
Deep Vein Thrombosis (DVT)
lsquoGenerally unwellrsquo
Nursing amp Medical teams
Five bedded observation unit
Acute demand liaison nursing team (Hospital based)
Close working relationships across primary secondary care amp
ambulance
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Target Audience
All health system staffAny staff interested in learning amp applying the principles of Lean Thinking amp who are seeking to be part of change in their work environment This should be viewed as an ideal programme to get teams of people linked into Lean Thinking methodology within their environment
All health system staffAny staff member that is attempting to make improvements at all levels of the health system Ideal for people who are getting frustrated at the ability to enable change or enlighten people to their point of view
All health system leadersFirstline Leaders to senior leaders (Management Clinical Operational Support) Two programmes targetted at different audiencesFour week programme Firstline leaders to middle managementOne week programme Middle management to senior leaders ndash particularly senior medical officers (SMOs)
Span of Focus Making improvements in the personrsquos immediate workplace Team orientated improvement focus
From Self to health system span of improvement From Self as a leader to health system view
Commitment 2-day course time over three months (approx) with a project to do between workshop 1 amp 2
14 hours over three separate days 8 Days plus project time
Key Learnings bullHealth system ViewbullLean Thinking basics (foundation)bull Knowing ones own personality and how this impacts on others (introduction level)bull Patient safety principlesbull Communication principles (introduction level)bull ProjectImprovement work amp Presentations
bull Health System viewbull Identify skills and attributes that will empower the individual to influence othersbull Understand the importance of the environment emotion and logic in making change through the Elephant Rider and Path work from Dan amp Chip Heathbull Knowing self and others through DISC personality with emphasis on engaging others (more depth)bull Understanding how to evaluate the worth of ideasbull Focus on key Canterbury Health system principles and testing ideas against these principles
bull Health System Viewbull DISC (introduction level)bull Consumer viewService designbull Production management principlesbull Lean Thinking basics (foundation)bull Leadership principlesbull Business support toolsbull Learning application - project
Calendar Available through LampD Calendar To be posted on LampD Calendar June 2012 August 2012 October 2012
Contact Booking Christine MacDonald PDUChristinemcdonaldcdhbgovtnz
Information Lynn Davies
Booking Bev McVicar BDU
Information Felicity Woodham
Booking Bev McVicar BDU
Information Richard Hamilton BDU
All Staff Firstline to Senior Leaders
Potential Change Agents
The Role of Funding Mechanisms
Can act as a barrier to change
ldquoyou get what you pay forrdquo
Rarely drive the right change
Can create perverse incentives
Can lead to unintended consequences
Need to be used to supportembed change
Need to be openly and transparently applied
0 Home
0 Allied Health amp Nursing0Acute and Urgent
0Child Health 0 Investigations 0 Lifestyle0f1edical
0 Mental Health
0Older Persons Health
0 Pharmacology
0 Surgicala Womens Health
0 Breastfeeding0 Contracept ion and Sterilisatioa Gynaecology
G Abdominal Pain in Young WD Cervical Polyps0 Cervical Screening
0 Dysmenorrhoea
0 Endometrial Cancer Low Ri0 Hea or I r re ular Mense
D Hysteroscopy Outpatient Pr0 Intermenstrual andor Post
0 f1enopause0 Ovarian Cyst0 Pelvic Pain (Chronic)
0 Pipelle Biopsies
0 Polycystic Ovarian Syndrom 0 Post Menopausal Bleeding 0 Prolapse0 Ring Pessaries
0 Sub Fertility
0 Urinary IncontinenceIIVulvodynia I Superficia l Vul
DReferral to Gynaecology amp 0 Pregnancy Related Conditions DReferralto Gynaecology amp Ob0Canterbury Initiative Services
0 Resources
Heavy or I rregula r Menses
0 About heavy or irregular menses
flowchartRed Flags
Endometrial cancer I hyperplasia
Risk factors include age e 45 years or gt 35 and one or more of
Weight e 90kg
Exposure to oestrogen without progestogens
bull Nulliparit y infer tilit y PCOS
bull MaoriPac ific Islander
Assessment
1 Check the patients 0 history of the condition
2 Carry out a speculum and bimanual examinat ion
3 Check t he patients smear history and repeat if necessary
4 Consider doing endocervical and chlamydia swabs if Mirena is an option or there is a risk of infection
5 Investigations
bull test CBC and ferri t in
bull consider thyroid funct ion tests if t here are ot her signs or symptoms of thyroid dysfunc tion
bull consider tests for Polycystic Ovarian Syndrome if periods are irregular
Practice Point
Copper IUCDs can increase menstrual blood loss If the patient has no risk fac tors requiring investigation changing contrac eptive methods may be all that is required to improve menorrhagia
6 If the patient
bull is e 45 years or
bull is 0 high risk or
bull has persistent intermenstrual bleeding or failed medical treatment
ltv
Cumulative Count of Practices using ERMS
67
7882 84
8894
98 99 101 102
113 115
0
20
40
60
80
100
120
140
n b r r y n l g p t v ca a p a u u u c oJ Fe M A M J J A Se O N De
2011
Clinically Led Integration
Electronic Referral
Management System
HealthPathways 610 established clinical pathways
11000 visits a month
74000 page views a month
(Restricted to clinicians only)
We do more in the community
Acute admission avoidance programme (ADMS)
now manages 18000 people per annum in their
own home
Acute Demand Programme
Canterbury-wide Programme - established 14 years ago
Now manages over 25000 episodes per year
Common Presentations include
Cellulitis
Respiratory
Pyelonephritis
Diverticulitis
Heart failure
Deep Vein Thrombosis (DVT)
lsquoGenerally unwellrsquo
Nursing amp Medical teams
Five bedded observation unit
Acute demand liaison nursing team (Hospital based)
Close working relationships across primary secondary care amp
ambulance
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
The Role of Funding Mechanisms
Can act as a barrier to change
ldquoyou get what you pay forrdquo
Rarely drive the right change
Can create perverse incentives
Can lead to unintended consequences
Need to be used to supportembed change
Need to be openly and transparently applied
0 Home
0 Allied Health amp Nursing0Acute and Urgent
0Child Health 0 Investigations 0 Lifestyle0f1edical
0 Mental Health
0Older Persons Health
0 Pharmacology
0 Surgicala Womens Health
0 Breastfeeding0 Contracept ion and Sterilisatioa Gynaecology
G Abdominal Pain in Young WD Cervical Polyps0 Cervical Screening
0 Dysmenorrhoea
0 Endometrial Cancer Low Ri0 Hea or I r re ular Mense
D Hysteroscopy Outpatient Pr0 Intermenstrual andor Post
0 f1enopause0 Ovarian Cyst0 Pelvic Pain (Chronic)
0 Pipelle Biopsies
0 Polycystic Ovarian Syndrom 0 Post Menopausal Bleeding 0 Prolapse0 Ring Pessaries
0 Sub Fertility
0 Urinary IncontinenceIIVulvodynia I Superficia l Vul
DReferral to Gynaecology amp 0 Pregnancy Related Conditions DReferralto Gynaecology amp Ob0Canterbury Initiative Services
0 Resources
Heavy or I rregula r Menses
0 About heavy or irregular menses
flowchartRed Flags
Endometrial cancer I hyperplasia
Risk factors include age e 45 years or gt 35 and one or more of
Weight e 90kg
Exposure to oestrogen without progestogens
bull Nulliparit y infer tilit y PCOS
bull MaoriPac ific Islander
Assessment
1 Check the patients 0 history of the condition
2 Carry out a speculum and bimanual examinat ion
3 Check t he patients smear history and repeat if necessary
4 Consider doing endocervical and chlamydia swabs if Mirena is an option or there is a risk of infection
5 Investigations
bull test CBC and ferri t in
bull consider thyroid funct ion tests if t here are ot her signs or symptoms of thyroid dysfunc tion
bull consider tests for Polycystic Ovarian Syndrome if periods are irregular
Practice Point
Copper IUCDs can increase menstrual blood loss If the patient has no risk fac tors requiring investigation changing contrac eptive methods may be all that is required to improve menorrhagia
6 If the patient
bull is e 45 years or
bull is 0 high risk or
bull has persistent intermenstrual bleeding or failed medical treatment
ltv
Cumulative Count of Practices using ERMS
67
7882 84
8894
98 99 101 102
113 115
0
20
40
60
80
100
120
140
n b r r y n l g p t v ca a p a u u u c oJ Fe M A M J J A Se O N De
2011
Clinically Led Integration
Electronic Referral
Management System
HealthPathways 610 established clinical pathways
11000 visits a month
74000 page views a month
(Restricted to clinicians only)
We do more in the community
Acute admission avoidance programme (ADMS)
now manages 18000 people per annum in their
own home
Acute Demand Programme
Canterbury-wide Programme - established 14 years ago
Now manages over 25000 episodes per year
Common Presentations include
Cellulitis
Respiratory
Pyelonephritis
Diverticulitis
Heart failure
Deep Vein Thrombosis (DVT)
lsquoGenerally unwellrsquo
Nursing amp Medical teams
Five bedded observation unit
Acute demand liaison nursing team (Hospital based)
Close working relationships across primary secondary care amp
ambulance
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
0 Home
0 Allied Health amp Nursing0Acute and Urgent
0Child Health 0 Investigations 0 Lifestyle0f1edical
0 Mental Health
0Older Persons Health
0 Pharmacology
0 Surgicala Womens Health
0 Breastfeeding0 Contracept ion and Sterilisatioa Gynaecology
G Abdominal Pain in Young WD Cervical Polyps0 Cervical Screening
0 Dysmenorrhoea
0 Endometrial Cancer Low Ri0 Hea or I r re ular Mense
D Hysteroscopy Outpatient Pr0 Intermenstrual andor Post
0 f1enopause0 Ovarian Cyst0 Pelvic Pain (Chronic)
0 Pipelle Biopsies
0 Polycystic Ovarian Syndrom 0 Post Menopausal Bleeding 0 Prolapse0 Ring Pessaries
0 Sub Fertility
0 Urinary IncontinenceIIVulvodynia I Superficia l Vul
DReferral to Gynaecology amp 0 Pregnancy Related Conditions DReferralto Gynaecology amp Ob0Canterbury Initiative Services
0 Resources
Heavy or I rregula r Menses
0 About heavy or irregular menses
flowchartRed Flags
Endometrial cancer I hyperplasia
Risk factors include age e 45 years or gt 35 and one or more of
Weight e 90kg
Exposure to oestrogen without progestogens
bull Nulliparit y infer tilit y PCOS
bull MaoriPac ific Islander
Assessment
1 Check the patients 0 history of the condition
2 Carry out a speculum and bimanual examinat ion
3 Check t he patients smear history and repeat if necessary
4 Consider doing endocervical and chlamydia swabs if Mirena is an option or there is a risk of infection
5 Investigations
bull test CBC and ferri t in
bull consider thyroid funct ion tests if t here are ot her signs or symptoms of thyroid dysfunc tion
bull consider tests for Polycystic Ovarian Syndrome if periods are irregular
Practice Point
Copper IUCDs can increase menstrual blood loss If the patient has no risk fac tors requiring investigation changing contrac eptive methods may be all that is required to improve menorrhagia
6 If the patient
bull is e 45 years or
bull is 0 high risk or
bull has persistent intermenstrual bleeding or failed medical treatment
ltv
Cumulative Count of Practices using ERMS
67
7882 84
8894
98 99 101 102
113 115
0
20
40
60
80
100
120
140
n b r r y n l g p t v ca a p a u u u c oJ Fe M A M J J A Se O N De
2011
Clinically Led Integration
Electronic Referral
Management System
HealthPathways 610 established clinical pathways
11000 visits a month
74000 page views a month
(Restricted to clinicians only)
We do more in the community
Acute admission avoidance programme (ADMS)
now manages 18000 people per annum in their
own home
Acute Demand Programme
Canterbury-wide Programme - established 14 years ago
Now manages over 25000 episodes per year
Common Presentations include
Cellulitis
Respiratory
Pyelonephritis
Diverticulitis
Heart failure
Deep Vein Thrombosis (DVT)
lsquoGenerally unwellrsquo
Nursing amp Medical teams
Five bedded observation unit
Acute demand liaison nursing team (Hospital based)
Close working relationships across primary secondary care amp
ambulance
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Cumulative Count of Practices using ERMS
67
7882 84
8894
98 99 101 102
113 115
0
20
40
60
80
100
120
140
n b r r y n l g p t v ca a p a u u u c oJ Fe M A M J J A Se O N De
2011
Clinically Led Integration
Electronic Referral
Management System
HealthPathways 610 established clinical pathways
11000 visits a month
74000 page views a month
(Restricted to clinicians only)
We do more in the community
Acute admission avoidance programme (ADMS)
now manages 18000 people per annum in their
own home
Acute Demand Programme
Canterbury-wide Programme - established 14 years ago
Now manages over 25000 episodes per year
Common Presentations include
Cellulitis
Respiratory
Pyelonephritis
Diverticulitis
Heart failure
Deep Vein Thrombosis (DVT)
lsquoGenerally unwellrsquo
Nursing amp Medical teams
Five bedded observation unit
Acute demand liaison nursing team (Hospital based)
Close working relationships across primary secondary care amp
ambulance
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
We do more in the community
Acute admission avoidance programme (ADMS)
now manages 18000 people per annum in their
own home
Acute Demand Programme
Canterbury-wide Programme - established 14 years ago
Now manages over 25000 episodes per year
Common Presentations include
Cellulitis
Respiratory
Pyelonephritis
Diverticulitis
Heart failure
Deep Vein Thrombosis (DVT)
lsquoGenerally unwellrsquo
Nursing amp Medical teams
Five bedded observation unit
Acute demand liaison nursing team (Hospital based)
Close working relationships across primary secondary care amp
ambulance
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Acute Demand Programme
Canterbury-wide Programme - established 14 years ago
Now manages over 25000 episodes per year
Common Presentations include
Cellulitis
Respiratory
Pyelonephritis
Diverticulitis
Heart failure
Deep Vein Thrombosis (DVT)
lsquoGenerally unwellrsquo
Nursing amp Medical teams
Five bedded observation unit
Acute demand liaison nursing team (Hospital based)
Close working relationships across primary secondary care amp
ambulance
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
ED
Ambulance
GP Teams Accident amp Medical CentresRadiology
Labs
ADMS
ADMS
24hrs
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Supporting a System
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Sub-
committees
Executive Management Team
Canterbury District Health
Board
Hospital and
Specialist Services
Operational
Management
Primary and
Community
Services
Transformation
Work
streams
Service
Level
Alliances
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Transformation ndashCanterbury Clinical Network
All clinicians are part of the Network
Work streams
Strong clinical leadership to provide guidance in
an area of health and social services for a defined
population
Service Level Alliance
Design plan and monitor the delivery of a service
or a group of services within a defined scope and
a defined budget
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
How it works
Confidence that the DHB through its Planning and
Funding function honours the process and implements
the agreed outcomes
Confidence that if it is the right thing to do the funding
will be found
Enabled by and enabling of
HealthPathways
Project Chain (Shared Care)
ERMs
Shared Care Record View (eSCRV)
Aligned funding models
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Opportunity
Population
Health
StableAim
At risk
Acute Unstable
Aim
End of life
Align the model of care across the systemMulti-disciplinary care continuum
Align the funding and functions to support the model of care
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
The New ChallengeThe New Challenge
ldquoThe trouble with the future is that itusually arrives before wersquore ready for itrdquo
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
ur health system demonstrated a remarkableresilience
We could react redesign how services could
be delivered in the community in the hospital
on the Park develop new models and deliver
break through innovations that the rest of the
country can benefit from
In the space of hours we were organised and
connected across Canterbury in the space of days we
had the whole system back on its feet and delivering
free care to people in their communities
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Post-Disaster
February 2011 dealt the Canterbury Health
System a huge blow
We lost people our people lost people we lost
buildings and like everyone else we lost access to
roads power water and sewerage
But we didnrsquot lose the health system
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Post-Disaster
We had a plan
We had a shared vision of where we were going
and we have a system that is built on a foundation
of trust and good relationships that we work at
hard in the easier times and certainly works for us
when we are challenged
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Post-Disaster
Our health system demonstrated a remarkableresilience
In the space of hours we were organised and
connected across Canterbury in the space of days
we had the whole system back on its feet and
delivering free care to people in their communities
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
ED attendance with Resp disease
(gt85 admitted)
0900 ndash 1700
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Primary Care
lsquoBlue Cardrsquo
Identification of 1500 lsquoat
riskrsquo patients
Flu vaccinations winter health check nurse assessment
CCMS Shared Care Plan
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Strong links with ED
Respiratory Physicians
Prevention and Early
Treatment of Exacerbation
Acute Demand Liaison in ED AMAU Wards
The Whole System
Increasing Acuity at 24 Hour Surgery
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Ambulance DiversionJuly 2012 ndash Jan 2014
0
20
40
60
80
100
120
140
160
180
200
Kept at Home
GP
24 Hour Surgery
ED
05
1015202530354045
In Primary Care
In Primary Care
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Count of COPD Admissions (month)
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Hospital
deconditioning
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Frail Older Peoples ED Presentations
Aim ndash Reduce attendances for 0ver 80 year olds to 600 or less per month by 31st May 2014
Process ndash Frailty pathway in Acute Demand Acute Frailty clinics etc
Balancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Frail Older Peoples Acute Admissions From ED
Aim ndash Reduce ED conversions to admits over 80 year olds to 110 or less per week by 31st May 2014
Process ndash Frailty identification in ED Community CGA rate for ED discharges
Balancing ndash ED re-attendance and admits in 7 and 28 days
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
In-Patients aged 75 and over with LOS 14
days or more ndash the Stranded PatientAim ndash Reduce IP aged 75 and over with LOS 14 + by end August 2014 to mean of 100Process ndash Early identification of at risk group CGA early supported discharge schemesBalancing ndash no increase in institutional care ndash aim for a reduction in over 75s in Long term Care
Why 1000 days matters
Our Health System
is based on trusted
relationships
Why 1000 days matters
Our Health System
is based on trusted
relationships
Our Health System
is based on trusted
relationships