Co-designing a new approach to delivering integrated services to chronically ill patients within existing funding constraints – Victoria’s HealthLinks trial

Background: In the context of increasing demand and constrained funding, delivering holistic, effective and efficient models of care that reduce reliance on hospitals without increasing service costs is a priority.

HealthLinks: Chronic Care uses funding to encourage innovative patient centric approaches to chronic disease management. Activity based funding is substituted for a capitation payment, determined using an analytical model which predicts the number of patients that will present to hospital with a range of risk factors, and the average service consumption for this cohort over 12 months. Payments can be used flexibly to deliver a mix of services in different settings to meet patient needs. Four health services are participating in the trial and a range of interventions are being trialled.

A co-design approach has been adopted to inform the initiative. Health services have engaged patients in the design of the interventions, and are working collaboratively to share learnings about the impact and challenges of different intervention models.

Aims and Objectives: Stimulate a discussion on funding and policy approaches to stimulate alternative models of care for people with chronic and complex health conditions.

Share implementation early results and learnings.

Discuss data science techniques to identify and stratify patients with multiple complexities.

Format: Denise Ferrier, Director, Policy and Planning: ‘Engaging central government and health sector co-design’ (10min)

Chris Hamilton, Manager, Health Modelling & Forecasting: ‘Developing a prediction model’ (10min)

Donald Campbell. Service Director, Community Medicine and HealthLinks: ‘A health service response’ (10min)

Audience discussion (30min)

Target audience: Policy makers. Health care practitioners.

Learnings/Take away: Well-designed funding levers combined with community based chronic disease management can deliver cost effective, integrated services that improve patient outcomes.

Adopting a co-design methodology is challenging but can improve program and policy effectiveness.

A capitation funding model can incentivise health services to develop a more sophisticated understanding of patient characteristics and risk profiles and stream patients into cost-effective, appropriate levels of care.

Identifying patients at qualification rather than the start of a financial year enrols more patients, at a more meaningful time in their healthcare.

Hospital readmissions are driven by a broad range of factors. Prior utilisation is the strongest predictor of future utilisation, but social factors and anxiety can exacerbate other issues and lead to hospital admissions. These are rarely coded.

Patient centeredness is contextual. Interventions will benefit from strong patient engagement in the design process.

High-users of hospital services cluster into four dominant patient personas: frail older patients; patients experiencing a significant acute event; patients with anxiety; and patients with a combination of mental health and substance issues.

Providing earlier support and preventive services to patients who are deteriorating can reduce the risk of readmission of these patient groups. Social and behavioural supports develop patient resilience moving from coping to thriving skills.

Interventions are demonstrating early success in reductions in readmissions and shorter lengths of stay in hospital.

Patient experience is improved through the provision of more preventative and integrated services and supports to navigate a complex health system.