出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Faced with rapid demand growth for acute hospital care, Counties Manukau Health (CMH) has integrated care across services and the entire population to improve outcomes and lower costs. Description : The model is multi-faceted and represents a ‘whole of system’ change across multiple dimensions: a. Primary care clusters within four geographic localities have been created, bringing together hospital and community clinicians and managers charged with operationalising the new model of care as well as growing shared vision, goals, and values for integrated care (normative integration). b. Aliancing and contractual agreements between the hospital, community and primary care providers with a collective responsibility to manage unplanned acute hospital care demand (financial integration). c. Early identification, multi-disciplinary care planning, and care coordination for patients at risk of unplanned hospital admissions and/or poor outcomes, supported by electronic shared care plans and pathways (clinical integration). d. Reshaping hospital, specialist and community services around the primary care clusters to support them with activating patients through the new model of care, including participation in improvement and innovation collaboratives to test new approaches (administrative integration). Impact : Initial benefits realised include: over 30,000 acute bed days saved through reduced hospital admissions and shorter length of stay; improved clinical outcomes as measured through standard indicators such as A1C levels, better population health outcomes including reduced smoking rates and improved immunisation and screening, widespread clinical engagement; and improved capability to self manage chronic conditions as meassured through the Partners in Health scales. Discussion : 30,000 Counties Manukau patients have now benefited from integrated care. Shifting from the siloed structures of the past to the inter-professional and inter-organizational approaches required for integrated care is challenging, however, the CMH experience is that better outcomes can be acheived at lower overall cost.
