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Speech: Healthcare and the Super Utiliser Program

Speeches in Parliament
Lee Rhiannon 24 Nov 2015

Lee discusses the benefits of the Nuka System in fixing a fragmented and beaurocratic healthcare system. This program and other super utiliser programs integrate medical, dental, behavioural and other types of support services to reduce unnecessary hospital care, increase social benefits, and provide truly universal healthcare.

Senator RHIANNON (New South Wales) (21:53):

On another matter, in New South Wales and around the world, health systems are fragmented and bureaucratic. This creates dissatisfaction amongst patients and healthcare professionals alike. Good clinicians go to work every day at good hospitals, yet the overarching system impedes their ability to provide coordinated care. Health policy experts agree that greater coordination of services is necessary to develop a more effective and sustainable health system in New South Wales. The New South Wales State Health Plan has some remarkable features. They are very admirable, including the aim to develop new models of integrated care. I would like to outline two innovative, evidence-based approaches to integrated care that could be used to guide this vital work and improve health services across our state.

The Greens have stressed the need for improved primary care services, including dental care, to keep people healthy and reduce their need for expensive hospital care. A greater focus on primary care is absolutely essential to reducing health system expenditure, and this is especially important due to the increasing number of people with chronic health conditions requiring ongoing, long-term treatment. What we need to do is imagine a health system where people are well and hospitals are empty, and develop strategies to help us move towards that vision. This is where the idea of integrated care becomes so critical. Effective models of integrated care can assist people's journeys towards better health, and reduce the number of people requiring episodic emergency treatment for acute illnesses. The question is one of how we can redesign the NSW health system to enable integrated care. While there are some Australian examples of how this could be achieved, our efforts could also be guided by models of effective integrated care from the United States.

Alaska's Southcentral Foundation recently won the highest award for healthcare quality in the United States for its model of integrated care: the Nuka System. The Nuka System has been described by Dr Donald Berwick, the former administrator of the Centers for Medicare and Medicaid Services, in the United States, as an internationally leading example of effective health care redesign. The Nuka System of Care provides integrated medical, dental, behavioural and other types of support services to around 60,000 people. It aims to support wellness in the community rather than solely addressing sickness. The approach involves multidisciplinary teams providing ongoing support to individuals in primary care centres and also in the community. The aim is to help people self-manage their health and journey as necessary through different parts of the health system. This is combined with a broader approach to improving community wellbeing, which aims to tackle domestic violence and other problems through education and community engagement.

The overarching principle is that care should be delivered by a healthcare team, not by individual professionals working in comparative isolation. Relationships between people and the multidisciplinary teams that care for them are at the forefront of their work. There is recognition that people control their own healthcare decisions, so ongoing engagement is necessary to encourage positive decisions that promote improved health and decreased need for hospital care.

The Nuka system has produced stunning results, including 25 per cent fewer admissions to hospital emergency departments, producing significant cost savings. It has also led to a decrease in family violence, showing that a holistic, integrated model of care can produce social benefits beyond the traditional indicators of health system effectiveness.

A second innovative model of integrated care was developed by the Camden Coalition of Healthcare Providers in the United States, led by Dr Jeffrey Brenner. The program aims to reduce the amount of unnecessary hospital care for people whose complex physical, behavioural and social needs are not well met through the fragmented US healthcare system. These people, known as 'super utilisers', often move from emergency department to emergency department, from inpatient admission to readmission, receiving chaotic, costly and ineffective treatment.

While there are clear differences between the US and Australian health systems, super utilisers are equally problematic in New South Wales and, I imagine in other parts of the country. For example, during 2011-12, two per cent of the New South Wales population attended an emergency department three or more times, accounting for 35 per cent of all emergency department attendances. These figures highlight the potential implications of Dr Brenner's approach in the New South Wales context.

Super utilisers often lack financial resources and an understanding of how to use the healthcare system effectively. Many have no source of regular, coordinated medical and social support services-which are the very thing they need for stable health. To address these issues, super utiliser programs provide intensive care management to these high-need, high-cost patients outside hospital settings. The heart of the approach is a patient management program to improve the transition of super utilisers from the hospital to outpatient care and ensure they continue to get the medical and other services they need so that they do not end up back in hospital.

A multidisciplinary care management team visits the patient in the hospital, conferring with doctors and nurses and helping plan the discharge. Team members visit the patient at home immediately after discharge and provide ongoing support, including connecting them to a GP, accompanying them to appointments and helping line up needed social services. The goal is to leave patients with the ability to manage their own health-surely what should be central to our approach to our health system.

The results were interesting. The first 36 patients averaged a total of 62 hospital and emergency room visits per month before the intervention compared to 37 visits per month afterward. Their hospital bill total fell from a monthly average of $1.2 million to just over half a million dollars. If results of this magnitude could be obtained in New South Wales, the reductions in health system expenditure would be significant.

The Nuka System of Care and the super utiliser program both demonstrate the feasibility and potential benefits of innovative models of integrated care. Both involve the same groups of healthcare professionals that we also have in New South Wales but coordinate their activities more effectively to help them deliver better care. As such, these two models would likely be well received by doctors, nurses and allied health professionals in New South Wales, who are currently frustrated by the fragmentation of our health system.

The Nuka System of Care and the super utiliser program are applicable to New South Wales and could be trialled and refined to support the state government's objectives, as detailed in the New South Wales health plan. Trials should occur at the local health district and Primary Health Network level. The two approaches outlined today have the potential to provide best practice models of integrated care that could be scaled up to a state or national level over time.

The Greens are in agreement with the government that change is needed to address the impending challenges facing the New South Wales health system. This change will require us to redefine our traditional conceptions and place effective models of integrated care at the centre of our future health system. The approaches I have outlined today I believe provide practical, evidence-based templates to help guide these important efforts.

Senate adjourned at 22:12


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