Grosvenor Independent Monitoring And Evaluation CVC Program Final Report

Aside from the CVC Program’s impact on health system outcomes, there area number of opportunities for improvement of the CVC Program’s design,delivery and management as well as lessons learnt for other programs.1. Impact on health system outcomesThe CVC Program was originally expected to deliver savings in health careexpenditure to DVA through the reduction of unplanned hospital admissionsfor enrolled Gold Card holders. While the anticipated savings have not yetbeen achieved, there is evidence that suggests savings could arise furtherinto the future with long term enrolment in an appropriately focusedprogram. As expected, anticipated savings are likely to arise from slowerincreases, and perhaps decreases, in hospital admissions among enrollees.However, savings may be difficult to realise given the current average age ofthe enrollees and the length of time before savings arise.Further analysis was performed to determine which CVC enrollees have thestrongest potential to deliver savings and was based on the estimatedlikelihood of an enrollee being hospitalised in the year following enrolment.This is referred to as a risk rating and can be represented as a percentileband for both genders. The risk rating range from the 80th to 95th percentileis the band that shows the strongest evidence of potential savings, and the60th to 80th percentile band has similar results. For these groups, enrolmentin the CVC Program immediately increases health service outlays byapproximately 50% (primarily due to the initial CVC payments to GPs), butfuture costs slowly decrease. In contrast, costs continue to graduallyincrease for those not enrolled in the program.It will take approximately 3 (female) to 8 (male) years after enrolment forthe expected cost of an enrollee and a never enrolled Gold Card holder toequalise. Further years are required to offset the additional costs occurredprior to equalisation, and yet more time to achieve savings.The extended period before achieving savings leads to a practical problem.Even among the most responsive population groups, clients would need tobe enrolled on the CVC Program for many years in order to achieve overallsavings. As the target population is predominantly elderly, it is likely that asignificant proportion would enter residential aged care or die before thesesavings were realised.It was expected that Gold Card holders at higher risk of hospitalisationwould be most likely to experience decreased unplanned hospital admissionsand produce savings when enrolled in the CVC Program. There is someevidence to support this expectation, with the 80th to 95th percentile riskband showing a decrease in costs of hospitalisation following enrolment.However, Gold Card holders in that risk percentile band who did not enrol inCVC also showed such a decrease. Furthermore, analysis of the hospitalepisodes by average length of stay and type of episode showed no clearpatterns that can be attributed to CVC enrolment.The results mirror the shift in the literature, which has shown somemovement away from the premise of care coordination resulting in savingstowards a focus on the quality of care and cost neutrality. Where results ofcost savings have been reported in the literature, the analysis has oftenbeen critiqued in terms of the quality and completeness of data resulting inDepartment of Veterans’ Affairsgrosvenor management consulting7

the relatively poor evidence base for achieving savings through carecoordination.The data available for analysis in this evaluation is more complete and ofhigher quality than for many of the previous care coordination programs.However, while the statistical evidence of savings potential is reasonablystrong and consistent, the relationship extrapolates beyond the timeframesof the existing data and may not continue once more years of data arecollected.2. Benefits for Gold Card holders and general practicesGeneral practices are confident that the additional level of support isbeneficial to Gold Card holders, making it easier for them to manage safelyin their homes and giving them confidence to continue to do so. Generalpractices and Gold Card holders are able to provide many constructiveexamples of benefits and outcomes as a consequence of participating in theCVC program.The survey and interview results emphasise cases of improved: health status and quality of life health literacy and ability to self manage social connectedness avoided hospitalisations.CVC participants acknowledged feeling secure, having peace of mind as wellas a greater ability to navigate the healthcare system.In addition, general practices have indicated that involvement in CVCProgram delivery has enhanced their capability and capacity to delivercoordinated care.Enhanced capability has been demonstrated through training uptake andother self-reported indicators such as improved knowledge of carecoordination and effectiveness of the Nurse Coordinator role. The Programhas also built capability through increasing importantly collaboration withingeneral practice and between general practice and other health providers.Positive changes within general practice such as employing additional nurseresources or extending existing nurse hours has meant additional capacity.In the 2014 survey 55.9% of respondents reported that their generalpractice had employed additional nurse resources or extended the hours ofexisting nurse resources. A small proportion of general practices alsoreported increases to capacity by employing additional GPs, or increasing thehours of existing GPs.Another key benefit identified through the qualitative analysis is theincreased time spent with CVC participants allows for a more holisticunderstanding of their condition and needs. Nurse coordinators havereported the additional time has also enabled a greater trust and openDepartment of Veterans’ Affairsgrosvenor management consulting8

relationship to facilitate effective care coordination and health outcomes forthe person.The CVC Program’s funding model is successful in incentivising practiceparticipation in the program, as demonstrated by service provider feedbackthat remuneration is a key consideration for deciding to deliver CVC Programservices. The vast majority (over 90%) of survey respondents also reportthat their practice plans to continue to deliver the CVC Program.3. Lessons learnt and opportunities for improvement of programdesign, delivery and managementThe lessons learnt and opportunities for improvement of the CVC Program’sdesign, delivery and management are outlined below and in more detail insection 10.3:1.Existing practice business models have been noted as a barrier toincreased capacity within general practices, as some business modelsdo not support DVAs intent of the CVC funding model that was toenable general practice to fund additional Practice Nurse resources.These issues are driven by individual business decisions and by thebroader Medicare Benefits Schedule fee for service model. As such, theCVC Program has a limited ability to influence these issues.2.The retrospective claiming model for quarterly care payments is notedby some general practices as being one of the most frustrating aspectswhen establishing the program within their practice. However, thesedifficulties are often resolved once the practice has embedded thebilling process in its administrative processes.3.While the eligibility criteria and recruitment activities have shapedenrolment on the CVC Program to some extent, the current flexibilityin the eligibility criteria has contributed to diluting the overalleffectiveness of CVC. The eligibility criteria could be further narrowedto increase enrolment of those Gold Card Holders with the strongestevidence of potential savings. Changes to the eligibility criteria shouldbe implemented using a robust change management approach.4.There are indications that condition flags produced from theDepartment’s Management Information System (DMIS) dataset andused for targeting and Patient Treatment Report (PTR) purposes areproducing false positives and false negatives. Exploratory work toestablish the error rate and refine the algorithms may be warranted,but may be limited by the nature of the DMIS dataset which isprimarily administrative. The extent to which this is contributing to lowaccess rates of PTRs through the Health Professional Online Servicessystem and increases in the survey rating of PTRs as ‘not very useful’should also be explored.5.There is opportunity to improve service quality and obtain assurance ofcompliance by further leveraging the better practices of CVC Programhigh performing general practices and enhancing the complianceregime for the CVC Program. The prevalence of general practices whoare categorised as either ‘CVC requires improvement’ or ‘existingChronic Disease Management (CDM) general practices’ may haveDepartment of Veterans’ Affairsgrosvenor management consulting9

impacted on the results achieved to date. If this explanation is correct,a greater proportion of ‘CVC Program high performer’ general practicesshould improve the results.6.General practices required substantial support and had a strong desirefor training and practical support and resources during implementation.The availability of the training modules continues to be relevant fornew practices commencing delivery of the program as well ascontinuing service providers who experience turnover or require thetraining material for reference.7.The uptake of CVC Social Assistance services has been consistently lowacross all years of the evaluation. Based on the information availablethe need for the services is unable to be accurately assessed.Exploratory work to establish the need should be considered, andinform decisions about the service design and future.Grosvenor Management Consulting notes that a detailed service delivery andimplementation study of the CVC Program in general practice is currentlybeing undertaken by the Flinders University of South Australia. The study isdue to be completed in August 2015 and will provide further insight to thehow CVC is working in general practice. The findings will assist DVA inunderstanding how general practice interpret, apply and implement CVC andwill inform future opportunities for improvement along with this report.Ideas for improvementThe following suggestions are made in relation to the CVC Program’s design,delivery and management: Place greater emphasis in relevant training/educations material on theclaiming model for the CVC Program and the need to keep additionalservice date records, over and above typical general practiceprocesses. Narrow the eligibility criteria to increase enrolment of Gold Cardholders in the target percentile risk bands that show the strongestevidence of potential savings from reduced hospitalisations (60th to95th percentile). Use robust change management processes to effectively implementchanges to the CVC Program’s eligibility criteria. Undertake exploratory work to establish the error rate in the PTRs andtheir value to general practices. The exploratory work should informwhether: -no action is required,-refinement should be undertaken to improve accuracy, or-PTRs should be discontinued on the basis they do not representvalue for money.Consider the results of the Flinders University study into theimplementation of CVC in general practice in the future programdesign.Department of Veterans’ Affairsgrosvenor management consulting10

Enhance the CVC Program’s audit and compliance regime to drivecontinuous improvement and further assure appropriate claimingpractices. Continue provision of the online training modules. Undertake exploratory work to establish the usefulness, service designand value of CVC Social Assistance services into the future.Department of Veterans’ Affairsgrosvenor management consulting11

2Introduction2.1BackgroundThe Coordinated Veterans’ Care (CVC) Program aims to provide coordinatedcare for eligible Gold Card holders with chronic conditions and complex careneeds, and who are at risk of being admitted or readmitted to hospital.Grosvenor Management Consulting (Grosvenor) was engaged by theDepartment of Veterans’ Affairs (DVA) as the Independent Monitoring andEvaluation Provider in March 2011 to conduct a three year evaluation of theCVC Program that monitors consistency of its overview and aim.2.2ScopeThis report is the third and final of the three annual reports which have beenproduced as part of the evaluation activities for the CVC Program.This report brings together the results of the quantitative and qualitativeanalyses undertaken between September—November 2014 building on thefindings in the previous reports and covers: an update of the evidence for coordinated care enrolment demographics for financial year 2012/132 analysis of service delivery assessment of patterns of care and service utilisation under care plans,including any changes in hospitalisation rates for enrolled Gold Cardholders analysis of program costs.The conclusions in this report are a summary of the key findings and themesthat have emerged between May 2011 and November 2014. This report alsoincludes Grosvenor’s observations and recommendations for enhancementsto the CVC Program.This is as a result of the lag issues associated with hospitalisation data. Please refer to section9.1.1 for further detail.2Department of Veterans’ Affairsgrosvenor management consulting12

3Coordinated Veterans’ Care Program3.1Overview of the CVC ProgramThe CVC Program was a 2010-11 Federal Budget initiative. The CVC Programreceived funding to improve access to community based support for eligibleGold Card holders with chronic conditions and complex care needs at risk ofunplanned hospitalisation. The CVC Program is now considered a business asusual program for DVA.The CVC Program commenced 1 May 2011 and provides ongoing, plannedand coordinated primary and community care, led by a general practitioner(GP) with a Nurse Coordinator3, to eligible Gold Card holders. These includeveterans, war widows, war widowers and dependants, who are Gold Cardholders with chronic conditions and complex care needs, and who are at riskof being admitted or readmitted to hospital.The CVC Program uses a proactive approach to improve the management ofparticipants’ chronic conditions and quality of care. It provides newpayments to GPs for initial and ongoing care.General practices, which decide to be involved in the CVC Program, arerequired to prepare for the program, enrol participants in the program, andprovide ongoing care.The CVC Program primarily targets Gold Card holders with the followingchronic conditions: congestive heart failure coronary artery disease pneumonia chronic obstructive pulmonary disease diabetes.At program commencement there were an estimated 170,000 Gold Cardholders living in the community. About 10% or 17,000 individuals wereexpected to participate in the CVC Program.The uptake of the program has exceeded expectations. As at 8 January2015, there were 21,276 active participants enrolled on the CVC Program4.Note active enrollees are those participants who have not entered aresidential aged care facility or passed away or who have exited CVC foranother reason.The terms Nurse Coordinator, Practice Nurse and nurse are used interchangeably in this report.Nurse Coordinator is the term used by DVA in the CVC Program guidance material and refers toeither a Practice Nurse, Aboriginal Health Worker or a DVA contracted community nurse.34Figures sourced from BHD mo

Independent Monitoring and Evaluation of the Coordinated Veterans' Care (CVC) Program . Figure 21: Change in one year service expenditure, medical services . 69 Figure 22: Change in one year service expenditure, broad type of service, targeted 80th . This report is the third and final of the three annual evaluation reports which