If our next NHRA doesn’t address the fact our hospitals continue to operate as islands of acute, fragmented and episodic care, largely disconnected from community-based care, then a lot of good work around continuity of care and technical interoperability will be for nought.
At their structural core, Australian hospitals still largely function with a narrow focus on episodic and acute episodes of care.
Once a patient is admitted, they’re managed within a hospital’s own, often bespoke, and mostly siloed, network of care teams, EMRs, IT and admin systems.
The only significant development in connectivity thinking so far from the states, who manage our public hospital networks, is for public hospitals within a state to talk to each other better via projects like NSW’s single digital patient record, or Victoria’s statewide hospital HIE (notably, neither are working that well so far).
No serious focus or effort has been made by any of the states so far to get their hospital networks to talk meaningfully to community-based care networks.
Yet every key policy document and healthcare review (state and federal) of the last decade points to only one way forward if we are to address our impending chronic care crisis which is threatening system collapse: the rapid integration of the tertiary and primary care sectors – data and patient fluidity between the two sectors.
There’s been a lot of talk on the part of state planners, and on the part of the Department of Health, Disability and Aged Care over the years, about creating this connection, but little effective action.
Hospitals remain largely siloed from critical external community-based care services such as GPs, home care, aged care, and mental and allied health care providers.
When patients discharge to home from a hospital, transfer to aged care, or need ongoing GP follow-up, the transition is hit and miss, uncoordinated, and often even hazardous.
The federal government has embarked on a significant program over the last few years to lay the foundations for a new national digital health infrastructure designed to facilitate far better technical interoperability between hospitals and community care. This is the “sharing by default” program, lots of plans of which are in play already.
The ability to achieve technical interoperability is, of course, an important foundational element of integrating the two sectors, but in the end the integration of hospitals seamlessly to community-care networks is not just a technology problem.
It’s a cultural, political and funding problem with its problematic roots in our federated model of system management: states run hospitals, the commonwealth runs most community-care networks and until now, little actual effort has been given to the integration of the two.
With technical system interoperability plans in place and actually being built out, we now need to urgently turn our attention to the relationship between how the money flows from the commonwealth to the states to fund hospitals.
Specifically, the money needs to flow to incentivise and fund integrated system care and continuity of care transition, not to hospitals alone.
So far, the states and hospitals have not been incentivised in any meaningful way to share system management responsibility with, or integrate into, any of the federally run community provider groups.
But without much more fluidity across our federal and state jurisdictions, particularly in respect to hospitals, seamless coordination of transitions of care will continue to be elusive and system transformation of the sort needed to properly shift system focus to better manage our rapidly burgeoning chronic care problem will not occur.
Related
Technological disconnection reinforces hospitals as institutional silos
The federal government through DoHDA has and is doing a lot of work to build out much better national infrastructure for digital interoperability and connected care across Australia – think Health Connect Australia, 1800 Medicare, a properly connected and atomised My Health Record, telehealth integration, and plans for a national HIE that won’t just connect hospital networks to each other.
But all this work has as a fundamental flaw if we really want to connect hospitals into our integrated care vision – hospitals all use legacy IT systems that don’t communicate with primary-care software, aged-care platforms, or standard digital health tools and standards.
While the states are talking “cooperation” in the key interoperability program of Sparked (a CSIRO-run initiative to equalise clinical coding as a preparation for software development standardisation), they can still choose to do what they want to do when they want to do it.
The big problem with the states is that politics runs far deeper into their management of health than it ever has at the federal level.
Hospitals are key chess pieces in elections. And outside of elections everything that goes wrong in health reverberates far harder for the politicians because hospitals and their mistakes are so big and visible.
This has meant that over time the technological isolation of hospitals has begun to mirror their organisational isolation from the rest of the system in a manner that has become so systemic the status quo is very hard to perturb.
If Australia is to move meaningfully on its healthcare system transformation, policy makers must address the problem of fragmented digital hospital systems limiting meaningful data flow and continuity of care as a key point of focus, not just in its national infrastructure plans but in its key existing funding and policy plans as well.
Today we are seeing a lot of innovative web-based models of care breaking down some of this systemic build-up of institutional and technical barriers to hospital integration – things like new web-based e-referral networks and cloud-based EMR platforms.
The system is begging to apply new web-sharing technologies to facilitate integration.
But without coordination of the opportunity of this new technology work both with the national interoperability program and with new “transition of care” funding signals, a lot of this innovation could end up creating more system complexity and inefficiency, not less.
The problem with disconnected hospitals
In most of our hospitals today, patients leave without any proper continuity of handover.
Things like gaps in medication lists, missing referrals, hit and miss GP contact, and the absence of formal care plans that connect all points of the system into the community and back to the hospital, are done very poorly.
As a result, patients and their families struggle significantly to coordinate post-hospital support. It’s hardly patient-centric.
This lack of connectivity to community services means follow-up falls through the cracks, leading to unnecessary, or in the worst case, emergency readmissions and a lot of resource duplication. Appointments are repeated, records relayed multiple times, and tests are duplicated, all because each sector is working from its own isolated data sets.
Again, this is not just a technology problem.
Providers have to be incentivised to use interoperability technology as it comes on board in our system.
All of this complexity and duplication of course amplifies our already bad workforce problems.
Clinicians across both the hospital and community settings are currently charged with plugging all our continuity gaps manually.
It means more admin and less time with patients. It’s hugely inefficient but worse, all this additional admin and paperwork is a significant contributor to provider burnout both in hospitals and in primary care.
Everyone loves to talk about co-design and patient-centred design.
None of this is.
Patients have no information or reasonable navigation resources to empower them to improve their healthcare journeys. If they do, the system will likely gain an additional level of efficiency, as patients will do much of the work healthcare providers are having to do now.
In addition to building out new funding signals and better data-sharing infrastructure, both state and federal governments need in the near term to think far more carefully about how to create meaningful joint governance between hospitals and the community sector.
Clinical integration of the sort required to connect hospitals properly to the community requires a proper power balance in the executive and system-level leadership of both the state-run hospitals (eg, LHDs, HHSs) and the federally run community-care provider organisations (eg, PHNs).
Work on this sort of joint governance arrangement has been ad hoc to date. It has been promoted by various champions of “joint commissioning” but if you look around the states today, a lot of that enthusiasm has evaporated post-covid and amid the rapidly growing day-to-day logistical issues of simply keeping a busy hospital running.
Without embedding such governance within a federal and state agreement, and somehow incentivising it properly with funding, it is not likely to ever be a serious initiative.
Outdated funding models
Hospitals are measured and paid in large part based on inpatient metrics – length of stay, bed occupancy, throughput and in-patient procedure efficiency and cost. These existing models include virtually no signals for post-discharge continuity of care within the community.
Without such system-funding balance the emergence of properly connected out of hospital management and community care is unlikely to ever occur.
Culture
Each sector (hospitals, GPs, aged care, community health) have their own wants and needs, their own processes, terminologies, governance, and decision-making processes, and their own lobby groups.
Our federated system has served us well over the years, but it has created an intensely tribal culture among the various healthcare sectors.
The tribes – GPs, pharmacists, nurses, specialists, hospital doctors, and so on – are not directed or incentivised in any meaningful way to join in peace talks and work for the greater good of the patient.
Funding and policy from the federal level down, can no longer ignore this problem.
It’s possibly the hardest one to overcome in a short amount of time but it is a big key to system change.
Our next NHRA must be brave and bold, but is it?
This is what the government says the main goal our National Health Reform Agreement is on the current DoHDA website:
“The NHRA is an agreement between the Australian government and all state and territory governments.
“It commits to improving health outcomes for Australians, by providing better coordinated and joined up care in the community, and ensuring the future sustainability of Australia’s health system.” [our emphasis]
So far, the NHRA has achieved none of this. Hospitals are hospitals, GPs are GPs and mostly, never the twain shall meet.
It’s not entirely surprising.
The NHRA’s immediate previous incarnation was called the National Health and Hospitals Network Agreement, which roughly translated means, how much the commonwealth is going to pay each state to run hospitals for the next five years.
It was always a transactional and financial negotiation, not a strategy negotiation between the commonwealth and the states.
It needs now to pivot to strategy big-time.
In essence, not a lot has yet changed between the NHRA and the NHHNA despite the community integration concept and the new goals being developed for this vital funding deal being introduced 14 years ago now.
That means we’ve had two NHRA agreements since we intended to make system and strategy changes to this funding deal to encourage system change and integration with no effect so far.
The first agreement after the change you could maybe understand.
The second was a missed opportunity. It remained a financial agreement, not a national healthcare plan with money to back it up, which is what it should be.
The third agreement is due by the end of this year.
But we all may have a problem.
There is a lot of secrecy and opaque process surrounding how the current NHRA is unfolding. It is obviously a highly sensitive negotiation from a political perspective.
But it seems to have become Secret Policy People Business. High-level political and policy people’s eyes only.
Surely that’s a dangerous way to run a process on which the future transformation or not of our healthcare system depends.
Apparently our current NHRA was on some sort of track to delivering a pivot somewhat in the direction this article suggests we now need.
But word is, state and commonwealth negotiation has broken down following a lot of discontinuity within the various states and territories at the decision-making level.
According to some people, the process, ironically for what this agreement says it is designed to achieve, and for what the country needs it to achieve, has lost continuity.
Things are currently either stalled or back to it being mainly a financial hospital deal … apparently.
We know that the people in place federally to negotiate this deal haven’t lost continuity and want to push for some systemic change to create much better incentives for the hospital sector to integrate with their communities.
But it’s hard to tell where this vital negotiation is at. The whole process remains shrouded in politics and secrecy.
For those in state policy positions, and everyone around them who could influence their positions in the next NHRA, take note.
If we end up with yet another financial deal between the feds and the states on hospitals, we can kiss all the good work everyone is doing around interoperability, and connected care, goodbye for the foreseeable future.
The NHRA needs to be an ambitious and bold new strategy play that synchronises all the infrastructure work going on, into incentivising the hospital sector and the states to seriously start concentrating on integrating their bricks-and-mortar vote-winning palaces of acute care into local community care provision.
The following are some of the basics that need to change in our next NHRA – this of course may be a naïve list that others need to add to or edit, but it’s enough hopefully to give everyone who is thinking this through an idea.
Mandate continuity-based KPIs for hospitals and primary care
Rather than bed turnover and procedure volumes only, hospital performance frameworks should be balanced to include measures for post-discharge follow-up and continuity, including seamlessly starting to work with GPs, specialists and allied care in the community, and for hospitals themselves to be able to better manage a lot of their patients directly in the community via new virtual care programs.
Tie funding to care transitions
The NHRA should pave the way for developing shared budgets to specifically incentivise hospital-community transitions. A significant element of this should be addressing joint commissioning models, bundled payments, or discharge-to-care agreements.
Create conditions for proper collaborative governance between the sectors
Money should be set aside to incentivise and build joint leadership structures by region (defined probably by PHNs and their local overlapping hospital networks) where hospitals, primary care groups, PHNs, aged care facilities, patient groups and mental health community providers jointly use local population research and then design and build out local digital continuity between all the stakeholders.
This would mean adjusting how care continuity and care pathway innovation is delivered and funded by regional (patient) needs.
Such groups might ideally start managing a single regional heatlhcare budget which incorporates all the funding of all the elements of the stakeholders at the table. This idea is probably too far for an NHRA now, but the states and the commonwealth should pick some advanced regions and maybe pilot the idea.
Incentivise and organise for better patient data, analytics and engagement strategies
The next agreement should imbed the collection and analysis of regional patient data to help local health management develop specific regional strategies for deployment of connected care services.
The AIHW should probably be built into this model as it’s doing a pretty good job already with data and analytics.
Everyone should imagine that AI might significantly enhance this initiative.
Using this data, the joint provider leadership teams should then be measured and incentivised to build out digital solutions that promote better localised patient experience, promote increasing patient engagement and participation in the provision of their local community-based care and facilitate hospital to community patient transition (both ways).
A key objective of the connected-care revolution that is unfolding around us (and around the world) is reimagining the patient experience as a continuous, seamless, person-centred journey from community to hospital and back – sometimes never to the hospital ideally.
Today – not six months or so away from our next NHRA – hospitals in Australia remain mostly bricks-and-mortar and digital health islands lost to a series of disconnected community care provider services – GPs, aged care, mental health, allied health and so forth.
The commonwealth’s interoperability work is going to lay the rails for being able to make information flow seamlessly between providers and providers and patients in both sectors soon.
But without institutional, policy and funding reform – something that a well-constructed NHRA can start us down the track on – our much hoped-for healthcare system transformation will almost certainly continue to stall.
True connected care will come when hospitals anchor themselves within integrated systems—shifting focus from their four walls to the lived experience of each patient out in the community.
This transformation requires alignment of funding, governance, technology, culture, and clinical practice – a deep and proper integration of hospitals into the ecosystems they ultimately serve.
Our best chance of kick-starting this change seriously is our next NHRA.
Note: If you’re interested in canvassing some of the latest models of connected care being used in hospitals, including case studies, and the sort of funding alignment changes and political will that might be needed to expedite hospital connectivity and transformation, then maybe have a look at our upcoming summit: New Models of Care Reshaping the Future of Hospitals, October 16, Aerial Centre, UTS, Sydney, HERE. Use this code – FUTURE20 – for a one off 20% off our Early Bird Tickets. If you have any queries on the summit, content or sponsorship you can contact greta@healthservicesdaily.com.au