Evaluation of Care Plus Programme

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

The Care Plus programme provides funding for primary health organisations to give better care to people who use high levels of care because of chronic conditions or terminal illness. Evaluation of the programme indicates that Care Plus is regarded positively by both patients and providers. However uptake has been slower than expected and the programme may be not the best method for improving access for some patients who need intensive care over a short period.

Recent developments

The Care Plus programme was rolled out nationally from July 2004 following an evaluation of three pilot projects. The Ministry of Health commissioned an independent review of implementation of the programme. This review was undertaken from November 2004 to May 2006.

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

Public (and possibly also provider) visibility of this programme has been somewhat lower than was perhaps expected or hoped. The overall impact on the system is therefore likely to be rather marginal.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Providers

• Patients, Consumers

• Civil Society

Stakeholder positions

In general, diverse stakeholders are very supportive of the concept of Care Plus although they have different views of the purpose of the programme. At Ministry and District Health Board level, Care Plus is an attempt to improve chronic care management, reduce inequalities, improve primary health team work, and reduce the cost of services for high-need primary health users.     

Care Plus is viewed by some primary health organisations (PHOs) as an alternative to enhance the patient-practice relationship and as a basic model for services for chronic care patients, whereas other PHOs perceive it as a low-cost access to GP services for chronic care patients. There were relevant differences in the implementation process. The PHOs which strongly supported Care Plus as a new model for chronic care assigned high priority to the transfer of High User Health Card patients onto Care Plus. Others reported that it had not been a high priority relative to other initiatives and they had not actively encouraged the transfer.

Actors and positions

Providers
Primary Health Organisations	very supportive		strongly opposed
Independent Practitioner Associsation Council	very supportive		strongly opposed
Patients, Consumers
Patients	very supportive		strongly opposed
Civil Society
Ministry of Health	very supportive		strongly opposed
District Health Boards	very supportive		strongly opposed
current    previous

Actors and influence

Providers
Primary Health Organisations	very strong		none
Independent Practitioner Associsation Council	very strong		none
Patients, Consumers
Patients	very strong		none
Civil Society
Ministry of Health	very strong		none
District Health Boards	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

Care Plus was introduced on 1 July 2004 (for details, see Survey No (4)2004). By April 2006, 64 out of the then 81 PHOs had commenced the programme delivering services in some or all of their practices. 75 percent of all registered patients in New Zealand were enrolled in a PHO that had started Care Plus and within these PHOs, 39 percent of the estimated eligible patients were enrolled.

According to the independent reviewers, the concept of Care Plus is supported by most practitioners (GPs and nurses), PHOs and District Health Boards. The services are equally likely to be delivered by doctors and nurses and 87 percent of patients in the programme are given a Care Plan by practitioners. Significant resources are needed for setting up Care Plus to identify eligible patients and to establish clinical and business processes, both within a practice and at the PHO level. All PHOs receive funding according to the national agreement but there are variations in the financial support models employed by these organisations.

Monitoring and evaluation

 

The Ministry of Health commissioned an independent review of implementation of the programme from November 2004 to May 2006.

Key findings of this evaluation were:

• The programme is regarded positively by most PHOs, practices, practitioners and patients and fills a gap in the range of subsidised services that have been offered at the primary care level.
• Even in practices that have been delivering Care Plus for some time, enrolment growth has been much slower than expected. Two reasons are the relative complexity of care delivery (written Care Plans and changes in practice processes) and difficulties managing cash flow experienced by some PHOs. 
• Care Plus is being targeted at patients with chronic high need but may not be well suited to patients who need intensive interventions.
• Care Plus is generally not being used as a replacement for the High User Health Card (which entitled high users of primary care services to higher subsidies) although this was an early Ministry of Health expectation.
• Limited funding per patient, and limited space, time and nursing staff, may be reducing the potential uptake and impact of Care Plus.
• Care Plus seems to work best when linked to a Chronic Care Management programme.
• Care Plus patients felt their care had improved. Their consultation rates increased by an average of four visits per annum and hospital admissions rose 40 percent, increases that may have been due to improved monitoring of conditions and/or the natural history of certain chronic illnesses.
• Many practices felt that Care Plus is administratively complex, not flexible enough and under-funded.

Response to the evaluation

In response to the evaluation report, the Ministry of Health noted that Care Plus in its current form may not be well suited to patients needing intensive primary health care interventions over a short period of time, such as those with mental health problems and the terminally ill. The Ministry will consider all the issues and recommendations noted in the report.

Expected outcome

Overall, the concept of Care Plus has been positively regarded by different actors like government, GPs, primary health organisations and patients. However, the fact that the uptake has been slower than expected may suggest that its implementation depends significantly on the approach of PHOs to the programme and on their decision and motivation to put it into action. Successful implementation requires that the government promote the programme not only in those PHOs where it has been developed slowly but in all PHOs nationally. The evaluation indicates that some changes to the programme are necessary. Given the support of the government towards the programme and their positive attitude towards its evaluation, it seems likely that some suggestions will be followed-up.  

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

References

Sources of Information

• The full evaluation report (Review of the Implementation of Care Plus, CBG Health Research Limited, 2006: Ministry of Health) is available on: www.moh.govt.nz/moh.nsf/pagesmh/5567?Open  
• An overview of Care Plus (Care Plus: an Overview, Ministry of Health, 2004: Ministry of Health) is avilable on: www.moh.govt.nz/moh.nsf/pagesmh/3499?Open  
• Ministry of Health Media Release (Evaluation of the Care Plus Programme, December 2006: Ministry of Health) is available on: www.moh.govt.nz/moh.nsf/pagesmh/5571?Open  
• Details of Care Plus programme can be found on: www.moh.govt.nz/moh.nsf/indexmh/phcs-projects-careplusservice  

Reform formerly reported in

Care Plus: Primary care for high needs patients Process Stages: Implementation

Author/s and/or contributors to this survey

Gomez, Diana and Toni Ashton

Suggested citation for this online article

Gomez, Diana and Toni Ashton. "Evaluation of Care Plus Programme". Health Policy Monitor, April 2007. Available at http://www.hpm.org/survey/nz/a9/5