Process Evaluation of Northland Neighbourhood Healthcare Homes – the First Year of Implementation

Abstract

November 2017 and February 2018. Four interviews were with key stakeholders in the Northland district, and 21 with staff from four of the six practices in the first tranche of NHH implementation. The evaluation noted marked differences between district stakeholders and those working in primary care practices regarding the equity aims of NHH. Stakeholders regarded reduction in inequities of access and health outcomes between Maori and non-Maori as the ‘number one priority’ of NHH, over and above improved efficiency and primary care practice capacity, and enhanced quality of care. However, staff from practices emphasised efficiency and quality, but did not identify reducing inequities as an aim of NHH. The four key questions that the evaluation sought to answer were: 1) How are practices and patients responding to the Northland Neighbourhood Healthcare Homes initiative? 2) Are these changes consistent with, or divergent from the expectations and behaviours envisaged in the Neighbourhood Healthcare Home model? 3) What are the enablers and barriers to successful adoption of the Neighbourhood Healthcare Home model? 4) What lessons from early-stage implementation are transferrable to other primary care practices embarking on NHH? Overall, the effects of NHH on participating primary care practices and their staff were positive. 3 i. The NHH programme is being implemented ‘as intended’ in the four primary care practices we researched, following a clearly staged series of activities. Not all the components of the programme could be addressed in the first year. ii. There were a number of teething problems experienced by practice staff. Most of these were overcome successfully in the first few months of implementation, due to persistence and willingness to learn of staff in implementing practices. iii. NHH has had a highly positive impact on the quality of communication between staff in primary care practices, with morning huddles the key mechanism. iv. For the most part, NHH resulted in improved job satisfaction and reduced stress. Many staff were clear that they would not want to return to a ‘traditional’ model of primary care practice. v. Implementing practices (and sponsors) need to be attuned to the experiences and needs of administrative staff. They are crucial to successful implementation, but there is potential for them to experience additional workload pressures. Our research does not directly examine the impact of NHH on patients and the Northland population. However, we were still able to make some important observations based on interviews with practice stakeholders about the capacity of NHH to improve patient experiences and reduce inequities of access to services and health outcomes. vi. Patient response to NHH appears to be positive overall. However, it will be important to hear the patient voice more directly. vii. Some patients and whānau living in isolated, rural areas may not be well-placed to adapt to, and benefit from many NHH components, specifically those that require access to telephones and internet. viii. NHH requires patients to learn new ways of interacting with their practices. Practices and sponsors need to be proactive in order to ensure that NHH does not adversely affect patients for whom this learning process is more challenging ix. It is not yet clear whether (and how) implementation of NHH will lead to reductions in inequities between Māori and non-Māori. This component of the initiative requires more detailed work, resourcing and support for practices. The key implications of this evaluation are that NHH looks to be a promising vehicle for reconfiguring primary care practice in order to meet many contemporary challenges. All practices showed resilience and progress, and the capacity to work through the initial implementation difficulties. Research into HCH in other parts of New Zealand suggests that it takes 3-5 years to begin to see clear indications of improved health outcomes. Practices beginning the NHH journey in future can learn from the experience of the early adopters in Northland. A staged approach to implementation makes it more manageable, and the improvements in communication within practices generated by NHH has a wide range of positive effects. The DHB and the PHOs support for NHH is well-targeted and much appreciated by practices. However, if equity is to be the number one priority of the initiative, the DHB and PHOs will need to continue to develop more practical and detailed strategies and develop clear processes of support for practices.