“You’re trying to solve the simple and… you’re probably better to solve in the complex.” - Dr Christine HowardBrown
INSIGHTS Provider Rehabilitation System Workshop Testing some underpinning concepts for the future state journey Meeting: 01 November 2023
Concepts – our focus Know Me This concept focusses on information relating to client complexity being captured, accessed and aggregated early in a structured way to understand risk and need at the client level.
Improved diagnostics Appropriate and early diagnosis is an important step in a Kiritaki recovery journey as it provides a sense of clarity and allows for clearer expectations to be set around a recovery plan and timeframes to desired outcomes.
Recovery network A trusted network of people to collaborate and work with the kiritaki to lead their journey.
Navigator A lead carer or navigator of care that is determined by the kiritaki. This Lead carer or navigator will be the key person guiding and supporting the kiritaki along the recovery path that is best for them.
Best Practice Recovery Pathways Commissioning best practice recovery pathways. Includes alignment of incentives towards kiritaki outcomes at a client and scheme level.
The Recovery Plan A singular plan driven by kiritaki recovery outcomes and informed by clinical input and others.
We asked you… For each concept, from your perspective:
What do you think success will look and feel like? (what will you see and how will you feel if this is successful?)
What steps do you think we will have to take to get there? (how will we know we are progressing towards success?)
What do you think the key enablers for this are? (what do we need to be successful?)
What do you think the biggest barriers to its success might be? (what might get in the way of success?)
Know Me
You told us…
Know Me
“Is it understand me?” – Rangi Pouwhare
“Te Whare Tapa Wha could be a model used for Ko Wai Au” – Dr Christine Howard-Brown
Flexibility & trust Success would look like flexibility in the system allowing health practitioners to get to know kiritaki on a case-by-case basis (e.g may need to know more about people with complex injuries, or new patients etc). Trusting that providers know their kiritaki and understand their circumstances using that information in the client's best interest rather than challenging and restricting health practitioners.
Whanaungatanga Success would look like the system supporting health practitioners to have time for the rehabilitation team to build trust and have whanaungatanga with each other, the kiritaki and their whānau.
Clarity Success would look like a system that supports a joined-up approach with clarity and shared understanding within the rehab team. And helps facilitate a line of sight for the rehab team (providers, kiritaki & whānau) on where they are on their journey, what has been done, what needs to be done and what is being done right now.
Information Success would look like a system that only asks for information relevant to the claim, that provides clarity on why they are asking for certain information, where it will be going and what it is used for. A system where kiritaki & providers do not need to repeat their stories and information to ACC and other agencies they are working with.
Know Me
Our providers said…
“it’s really disingenuous isn’t it that you have somebody getting to know somebody, working out the exact right plan for them and then you have ACC cutting across it saying no like goals aren’t smart enough or 60 hours becomes 40 hours or do another assessment or no, we don’t think that’s injury related. - Dr Christine Howard-Brown
“It’s a privacy issue too… why would I? Who am I telling my story to? Why am I telling my story to them? So there has to be a huge push on why, a push on what you’re going to do, what ACC, for example, or who is collecting the information, what are they going to do with it? What are they trying to achieve? The trust has to work that way to. The kiritaki has to understand why that’s what they need to tell you about… all about the interrelationships in my life… how will that help me get my recovery outcome, why am I telling this, where is the information going?” - Mary Morrissey
“It’s making sure you have the trusting relationship and that takes time… 2 hours or 5 hours, 15 minutes doesn’t cut it, which is what we do now.” - Rangi Pouwhare
“health professionals as a whole, are pretty good at getting to know their clients. The problem is we get to know them, but then we get limited by the system and being able to actually use that information to help people recover. So, from my perspective success looks like the system supports us to spend time with our clients, get to know them, but then use that information, and we’re not being restricted by it in some way… ACC has a tendency to restrict all the way through this process, whether it’s delays in getting people seen by specialists or not responding quick enough to actually get people the help that they need in a timely manner.” - Matthew Manderson
“the shift into ‘know me’ has to come with a trust me because so often it’s felt like the questions have come once there is a movement into conflict with the client around their status as opposed to as a genuine inquiry to be able to help.” -Dr Luke Bradford “Transparency and clarity. We need to see a clear pathway, where people are on it, and how a decision’s been made, where they’re being made and where they’re stepping too next.” - Dr Luke Bradford
“how do you mix in complexity with faculty?... You don’t want a rigid process that says I must go through all of that, even though it’s not going to affect what I do, but at the same time, we can’t let everybody just do what they always did, there’s got to be ways in which we trigger change in the way people think and act. So, there’s nuance here to be practical but also move us forward” - Paul Roseman “I keep going back to that trauma [when I have to repeat my story/information]” - Rangi Pouwhare
“the ‘know me’ is important [and] that the clients and the providers are all on the same page and can see the same things and conceive a journey that the patient’s been on rather than constantly reassessing and constantly having to ask the questions and look for it. It’s important that we know what’s important and what success looks like to the patient and it’s important to avoid the weaponization. But it’s important to scale this, because if someone’s just, you know, sprained ankle… we don’t need to be wrapping around two days' worth of bureaucracy to that process. - Dr Luke Bradford
Improved Diagnostics
You told us…
Improved Diagnostics
What this might look and feel like
“it would just mean a more streamlined service, people wouldn’t be waiting, we wouldn’t be scanning six months down the track and picking up something that should have been picked up or was picked up by a physio, but we couldn’t get a scan. It would just mean a better overall treatment planning process without the delays and a greater outcome… what we do see is clients will say I’ve been walking around on my broken leg or whatever for weeks and weeks in pain, being told there’s nothing wrong with me and we lose all our credibility, and they get angry with ACC. So, if it was all working, we would have less of those experiences.” - Matthew Manderson
Improved Diagnostics
Our providers said…
Timely access to services for health practitioners, kiritaki, and their whānau across the motu is needed “location and access to services, [in Taranaki] we have some great services, but we don’t have some of the services that are available in say Auckland, or Wellington or Christchurch.” - Mary Morrissey “It’s about access and ensuring that people across the motu can get services close to home and easily.” - Dr Luke Bradford
A broader number of people able to order diagnostics may enable more timely access to services
Visibility, transparency, and clarity across the rehab team would be enabling
“if we go back four or five years here in Taranaki, there was one radiology firm, we now have I think 3 or 4, but we can’t get them in there because we need to get ACC sign off and go through a specialist for certain types of images… the small number of people that can order imaging for our client group means that people are waiting often months, when they don’t need to, so it’d be good to see that change.” - Matthew Manderson
“There has to be visibility and information sharing, so between, for example, the radiology service, the current provider, the general practice, possibly the surgeon, whoever else it might need to be involved, so it’s connected and it’s easy.” - Dr Christine Howard-Brown
Education is an important enabler
Part-charges are a barrier “there’s a lot of services out there that we know aren’t available and surely it’s not that hard [e.g. steroid injections]” -Andrea Pettett
Trust & balance is an enabler “what we do at the moment… we’re worried that you might make some bad [decisions], so we won’t let you make any. What we say is we think mostly you’ll make good decisions, so we’ll see if we can find the bad ones and improve on them for next time… it’s those kind of approaches that I think would enable this to happen.” - Paul Roseman
“also, part-charges, particularly radiology part charges… they’re a big barrier [e.g. trying to take a patient from a public to a private pathway].” -Andrea Pettett
“No part-charges… trusting the relevant clinicians to determine what diagnostics are actually required on the basis that you would expect them to be available… then you can have a seamless process to go forward… no part charges circling back.” - Dr Christine Howard-Brown
“we’d really like to see quality management naturally included so that we actually spend time educating… we don’t want people afraid of using the right investigation, but we do want them to know when they haven’t used the right one and to change their behaviour.” - Paul Roseman
“We need to make sure that the training is there in interpretation of the reports coming back.” - Dr Luke Bradford
Improved Diagnostics
Capturing the conversation on a broader range of people able to order the diagnostics and the GPMRI programme
“we need to enable a broader range of people to order the diagnostics… [and] you need a system that makes sure that that broader range of people that are ordering diagnostics are making good clinical decisions to do that… poorly ordered diagnostics clog up the capacity and delay access for people who need them, but I think we’ve proven that it’s possible to do that with things like the GPMRI programme… we’ve got some really nice, clear pathways for what good looks like… clear enough that we’d be actually able to structure the referral so that we’re naturally capturing the things that you need to know… ” - Paul Roseman [Andrea responded with some thoughts on this] “experience overseas had shown that [the GPMRI programme] led to a huge number of diagnostic referrals leading to some asymptomatic issues raised with very anxious patients needing to be reassured that they didn’t have more problems than they thought they had. But we have been quite pleasantly pleased with how it had, how it did roll out… I think one of the things that didn’t work well was I don’t think surgeons and GPs were brought together very well to have trusted conversation about how to do it and how to do it well… so I think we can do that better and I think it comes back to trusted relationships and conversations” - Andrea Pettett [Dr Luke Bradford also commented on this] “I am in support of the broader access by different clinicians to request, I think that the MRI thing for knees, shoulders, neck and backs has gone well. I think there is scope for further, certainly CT heads following TBI’s is a no brainer, you know waiting for a general surgeon to say oh yeah, that person should probably be scanned is a waste of everyone’s time” - Dr Luke Bradford
The Recovery Plan
You told us…
The Recovery Plan
Our providers told us…
Expectations of provider vs whānau/client Success will look like understanding what everyone’s role in the Recovery Plan will be. Ensuring that the client and their whānau/support network know where everyone fits and knows what is expected of them to achieve their outcomes. Language and communication That there is clear communication around what is expected of the client, ensuring that the language used is non-clinical at all levels and at all stages. Integrated technology and data We need to ensure that there are digital tools available to record the outcomes and measure against them for both the provider and the client. There needs to be integration across the systems for the client, ACC and the delivery of health services to allow connection and ensure that all involved are telling the same story.
Whānau focused Ensure that the clients whānau or support network is included in the Recovery Plan and it doesn’t just include clinical goals. The Recovery Plan needs to consider all aspects of a person's life, and what matters to them and their recovery, not just the injury. Workforce capabilities Addressing workforce capabilities, capacity and training will enable this concept to be successful.
The Recovery Plan
Our providers said…
“A clear understanding of the steps to get there… a lot of people will not understand what it is they need to do and how they're going to get there” – Lloyd McCann
“when we talk about a recovery plan, [it] really needs to create a context for the whānau to live within it as well and have the ability to express what it is that they want to do.” – Charmeyne Te Nana-Williams
“when [providers] become involved, they get to understand [and] see what happened [for the client] preinjury. They get to get the whole picture [and] where this person is coming from or where they want to go” - Charmeyne Te Nana-Williams
“Looking at the [client], understanding what their journey and the outcomes are. I think it's key that they understand their role. And I think [that] can vary for two different people with the same conversation. One doesn't understand it and one may not just have the ability to interpret it or to deliver that to achieve it.” – Geraint Emrys
“I think that would suggest that then one of the key enablers based is good, clear communications at all levels at all stages.” – Maura Thompson
“So, to me a really critical component of that is language and the use of language. Nonclinical language that expresses what good outcomes looks like for me or my whānau” – Lloyd McCann
“I think that there needs to be a dual focus both on the patient but also the support around that person because they will become quite key about reinforcing and/or clarifying [outside of the appointment]” – Richard Whitney
The Recovery Plan
What steps do you think we will have to take to get there?
“I wouldn't underestimate the importance of getting alongside the regulators and the educators of workforce. Current discussions would just reinforce the fact that they are very slow and sluggish about recognising need to change and while they don't change the impact on the abilities to look at the scope of practise, their abilities to address workforce constraint aspects, their willingness to think out-of-the-box is constrained and by default we just inherent the rigidness and blind spots.” – Richard Whitney
Navigator
You told us…
Navigator
Our providers told us…
Valuing the navigator role A navigator doesn’t need to be a health professional, they could be someone who has the expertise through their lived experience. But ensuring that they are remunerated is key in valuing their function within the system. Culture change That a big barrier in terms of the navigator role being successful, there needs to be a big shift in how health professional’s value the navigator role. Access Navigation needs to be accessible for all clients Data tools and integrated systems Building the navigation ‘tool’ into the system to become a meta-capability. There is potential to build into the system when a navigator might be needed to pre-emptively for when there is often difficulties for other clients with similar injuries.
Navigator
Our providers also told us that..
Pre-empting Navigating needs in the system There is potential to build into the system when a navigator might be needed based on data that ACC holds of similar injury types and where there has been issues historically in those journey’s
“And I think one of the key things [removed for
clarity] is about timing. People sometimes think well I need an [XYZ] or you say well you will need that, but what you need now is this. So, it's about having the skills [to] put somebody on the right part of the journey at the right time and that
people then don't get the wrong expectations about why didn't I get my MRI when I first went to the GP? You know, if only I'd have got that and so we can sort of manage those ‘if only’ questions..” – Geraint Emrys
How do we know when it's right to have a navigator versus when it's not needed. How do we know the difference?
“this is this is where I think again the data set ACC sits on top of is pretty useful if there is a correlation on the basis of complexity analysis, on the basis of presentation type, all of that type of thing where you can draw out the relationship between navigation in versus not then it can be used. We talked about a ‘flag’ around if somebody's on a specific pathway and they're faltering, triggering an alert on the basis of that. I think this is something where some upfront analysis and intelligence is actually quite useful. So, we understand in this cohort of people these presentations, even though it might seem linear, there's some speed bumps over here. So, putting that investment in up front helps us get to the end point and the outcome a little bit more quickly and a little bit more efficiently and the outcome is better. ” – Lloyd McCann
Navigator
Our providers said…
“If somebody's got lived experience of the system, then often they might be well placed to assist with navigating. Equally it could be a professional who understands and knows the system well.” – Lloyd McCann
…”navigation almost needing to become a meta capability within the system. So, there’s navigation through the system rather than you navigating in the system” – Lloyd McCann
“…my observation would be that the health system generally is not well placed or familiar with providing navigation tools.” - Richard
“I think there is potential for pushback in relation to acceptance of the importance of this type of role from within, professions and within the provider community itself.” – Lloyd McCann
“Context specific for the patient. Two individuals with the same injury, at baseline aren't going to be equal by virtue of their backgrounds, their context, the social support that's around them, etcetera. So even though the process itself might be quite simple actually adding in some navigation for one of those individuals might again drive a better outcome” – Lloyd McCann
“I think a lot of the barriers in the space will be cultural barriers and barriers in terms of professions” – Lloyd McCann
“we just need to recognise and enable some urgency around culture change. We are talking about funders to providers, but we're also talking about providers across various sectors. And then we're talking about subgroups within one sector required to be on the same game plan and on the same empowerment part of this or a reasonable amount of it, I think it is about key individuals letting go, whether it is around the scope of practise, whether it's around It's not on my watch, it's on someone else’s…. But there has to be a first step made in actually there has to be some consequences for noncompliance around joining the journey.” – Richard Whitney
Navigator
What do you think the key enablers for this are?
“This function needs to be remunerated because quite often what occurs is that this is like a voluntary activity, and so that time and that effort that helps to generate an awesome outcome for the individual or the whanau, we don't pay [the navigators for] that. So, I think success actually is going to be very closely aligned to placing some monetary value on that function and that role within the system.” – Lloyd McCann
Recovery Network
You told us…
Recovery Network
Our providers told us…
[success would look like] “the system not dominating a person’s healing journey” - Catherine
Whānau-centric The whānau collective should be the first port of call for a trusted network
Scalable & Flexible There needs to be scalability, we don’t want to over think or over cook the simple injuries that are currently for the most part being handled well between the whānau and clinician, (while flagging that ‘know me’ and ‘initial assessment’ are very important in making sure that a simple injury isn’t part of something more serious such as domestic violence). We do want to scale it so that medium-complex injuries are able to have networks appropriate for them, building in flexibility and adaptability for different and changing circumstances. And flexibility built in for kiritaki to be able to lead their recovery, communicate what they need and what they want.
Trust, Onboarding & taking time Going from a low-trust model to a high-trust model would be highly valuable but also takes onboarding, training and time. We should be prepared for things to go wrong, for resource hungry people to take more than they might need initially due to the previous low-trust model, this doesn’t mean that it doesn’t or that it won’t work. People need to learn what they can expect and what it means to be in a hightrust model.
Recovery Network
“Right people, right time” – Chris Gregg
I come back to concentric rings. The centre ring is the patient and their whānau. So, if it’s a simple injury, it might be to reassure the mother that actually the scar will not be that bad or the skin glue will not hurt the child as opposed to sutures. But as you go up the scale of severity, we bring in the wider primary care, we bring in diagnostics, we bring in secondary care, either public or private we bring the social aspects, you know, the wider social, the community, and that increases in complexity. I don’t think we need to overthink the simple injuries, but I think we need to put more energy as we go up that scale.” – Murray Tilyard [But] “some simple injuries are caused by come very major problems like domestic violence… on the face of it, it might look like a sprain, or it might look like a child that’s got a bit of glass… that, you know, got infected. But, you know, it we’re not realising that the glass is from a window that got smashed by the parents fighting… it is about that initial assessment and really not just taking it at face value sometimes.” – Anne Huriwai
“there’s a whānau collective that should be the first board of call [as part of that trusted network]” - Anne
“enough flexibility for the actual kiritaki to be saying this is what I need… it’s not decided by what information ACC is providing to them… in the holistic world, this is what I need and then it’s up to the navigator… to bring in all the people to make that happen for them. That’s how you build a trusting relationship.” – Anne Huriwai
“success would be that it’s integrated. It’s whānaucentric this choice, there’s trust, strong engagement, strong teamwork, it’s linked, it’s scalable for the need, it’s holistic… it’s weighted heavily at the front in terms of assessment and has flexibility to adapt.” – Chris Gregg
“I think some sort of highly connected IT platform that everyone has access to sharing of information… that’s not restricted, all services are available in open and free to use based on patient need” – Mark Quinn “it may well be that things are flagged as being sensitive and that if you want to know more you get the clients consent… if we can guarantee that interactive kind of open portal also has some caveats and some really clear lines, especially if you start adding into it emotional history… personal or family history.” – Catherine Gallagher
“There is an assumption that people know what they need, i.e. they have health literacy, so there is a piece probably before this. I think we need to consider what that looks like… how do people know what is right and… when to access, what that looks like?” – Amy Tyson
“if you work for a workplace and there’s low trust, then you can kind of be a little bit resource hungry because you don’t know when you next bit’s going to come… it may well be that if people are coming out of a low trust environment where you better get the resources if they’re on offer because you might not know when you’re next one’s going to come along…trust is actually something that has to be learnt, and how do we operate in a high trust model needs to be learnt... if you kind of say right, we’re choosing to trust and then there’s some people [who take more than they need] that doesn’t mean the system doesn’t work, it just means that actually there’s going to be a few people who might do that. But also this takes time to establish a trust system.” - Catherine Gallagher
Best Practice Recovery Pathways
You told us…
Best Practice Recovery Pathways
Our providers told us…
Digital Solutions Utilise IT platforms that providers and clients can use to measure their progress. The digital tool can be used to determine if a client is needing any other supports for their rehabilitation. Frameworks and flexibility Provide frameworks that will set kiritaki up the best outcomes while enabling providers to be flexible within the pathway to deliver what is needed. Equity of Access All clients should have access to quality care. Ensure that those living in rural communities have access to all the treatment/support options. Incentives Consideration around what ‘incentives’ might look like and how these might influence outcomes for a client's recovery. (e.g. there were concerns that depending on what the incentives are, it can create ‘cherry picking’ from providers of who they have as their clients)
Best Practice Recovery Pathways
Our providers said…
“If it is successful, clients come into a care pathway that delivers the most appropriate and effective best practise support that's needed for their circumstance…so its success is that it provides a pathway to give you the best chance of success. But it's adaptable to meet your specific needs” – Chris Gregg
“spending time and having some scaffolding around what does good goal setting look like and it's not just going for optimal, it's going for realistic because then you can actually set that up against the idea that we're having realistic success and success that's relevant for that particular client.” – Catherine Gallagher
“[Have] commissioning services that enable providers and clients to make choice around how to appropriately use funding to get the best outcome” – Chris Gregg
“There needs to be some sort of digital accuse or guides that are available to help with the pathways. That's one important part of it. With key check points highlighted in decision making components. Not overly complicated, I think if these things are really overly prescribed, they remove the clinician's ability for clinical reasoning or for people to make decisions, and it becomes harder and harder to tailor it so providing a framework but enabling clients and providers to still be able to have some flexibility in how they achieve the outcome.“ – Chris Gregg
“I think that the IT platform has been really helpful for clinicians, but I think can also help patients see and track their journey and give them a good idea of the progress and reward them for doing well, going from A to B and making progress that they feel it. But patients are really excited by seeing a graph and seeing their improvement, [it’s] a real motivator” – Mark Quinn
“In rural communities we're not given all the options. [When we are] talking ‘best practise recovery pathways. It's about giving the whānau all the options. Even if one option costs $1,000,000. Don't assume that the whānau [don’t want or can’t afford] these treatments out there. I think the best practise recovery pathway is giving all the options available.” – Anne Huriwai
“You should have the same access to quality care.” – Murray Tilyard
“This piece [concept] really flows through to so many of all of the other bits that we've been talking about. So, if we don't get this bit right, it feels like so many of the other feeder components will fall over.” – Amy Tyson
Best Practice Recovery Pathways
What do you think the key enablers for this are?
“Enabling those pathways to be flexible and holistic so that it's broader around how it addresses the issues for the client, it shouldn't just be [the injury, if] something else is going on your life, it should address that and support it. That's a very important part, I think of the model.” – Chris Gregg
If these concepts are embedded the system will be/have…
Clarity
Trusting
Flexible
Timely
Scalable
Access & Equity
Holistic
Whānaucentric
Education & Training
Responsible Information & Data management