Better Sooner More Convenient Primary Care - New Zealand Doctor

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Appendix Five: Long term conditions 1. Aspirational statement: Every patient with a long term condition will have the clinical care and support they need to achieve good health outcomes. 2 Project overview The West Coast Long Term Conditions (LTC) Management Strategy was developed in 2006 by the West Coast District Health Board i(WCDHB) in collaboration with the West Coast Primary Health Organisation (WCPHO), Community & Public Health (CPH) (the local public health provider), NGOs and Māori and consumer representation. This strategy is underpinned by Wagner‟s Chronic Care Model 32 and the Continuum of Care approach. The LTC Steering Group continues to meet regularly and oversees the implementation of the various aspects of the framework by each of the contributing organisations. As part of that strategy the PHO redesigned all its LTC programmes (Care Plus, Diabetes Annual Review, Cardiovascular Annual Reviews, Diabetes Self Management Education groups, Coast Quit smoking cessation) into one overall LTC management programme in 2008. Implementation of this programme began in 2009, assisted by Ministry of Health funding to use the Institute for Healthcare Improvement (IHI) Breakthrough Series 33 approach to quality improvement. This project builds on the work already done, particularly in regards to enhancing the integration of care for those with high complexity LTCs and to providing extra health navigation support services. 3 Background and Problem definition DHB wide strategy The DHB strategy contains a framework that incorporates all DHB, primary care and NGO activity around LTCs and is updated on an annual basis to ensure that all groups are working 32 Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4 33 Wagner - find Wagner E, Austin B, Davis C, Bonomi A., Provost L, McCulloch D, Carver P, Sixta C. Quality Improvement in Chronic Illness care: a Collaborative approach. J Q Improvement 2001; 27(2):63-80. 33 Business case appendices V12 AC 25Feb2010 Page 38
The Community Health System Delivery System Design Clinical Information Systems Equity in Health together to meet the health needs of the population. While full version of this runs to many pages, the key aspects are summarises in the following diagram: Chronic conditions management – the WCDHB framework, The Patient’s Journey Environment Healthy At Risk Acute Event Initial management Long term clinical and Self management End of Life Care Healthy public policy and creation of supportive environments Non-italics= existing service Italics= proposed service Healthy Schools; Smoke free; HEHA: Community events; Breast feeding; Men‟s health; Green Rx; Health promoting practices CVD and diabetes screening, follow up for those at highest risk Smoking cessation Diagnosis, hospital admission Pre-hospital fibrinolysis Diabetes Pulmonary rehabilitation, Cardiac rehabilitation, Arthritis and diabetes education/ support groups PHO LTC: Focus on, CVD, diabetes , COPD: clinical and self management support CareLink and AT&R assessments and MDT review for more complex Cancer navigators Palliative care funding in primary care UNDERPINNED BY THE WEST COAST‟S 7 PILLARS OF CHRONIC CONDITIONS MANAGEMENT The PHO Long Term Conditions programme (as it is now) The programme is both based on the Wagner Chronic Care model 1 (self-management support, community support, delivery system redesign, clinical information systems and decision support) and the Kaiser Triangle stratified care approach 34 . The programme meets the National Health Committee‟s objectives 35 of providing effective chronic care management and co-ordination through using a population health approach to care delivery, based on level of need, both clinical need and need for self management support. There is a focus on those with conditions that are frequent or severe, and these are addressed by national evidence based clinical guidelines and are responsive to enhanced primary care management, and have outcomes that can be tracked over time to measure improvement (Cardiovascular Disease (CVD), Diabetes, and Chronic Obstructive Pulmonary Disease (COPD)). 34 World Health Organisation Innovative Care for Chronic Conditions: Building Blocks for Action: Global Report 2002 WHO document no. WHO/NMC/CCH/02.01. 35 National Health Committee People with Long Term Conditions A Discussion Paper National Health Committee Wellington May 2005 Business case appendices V12 AC 25Feb2010 Page 39
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Business Case Better, Sooner, More
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1 Caveats/status This business case
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Current situation By three years Wa
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staffed on a capacity model - in wh
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support from DHBs, specialist clini
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10.4 Key milestones................
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Annual government health funding pe
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Ambulatory Sensitive Hospitalisatio
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The base populations of the three d
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Māori/Pacific Not Māori/Pacific D
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4.7 West Coast region service deliv
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5 Future model of care 5.1 The desi
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support them. Help with understandi
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LEVERS VISION Better, sooner, more
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providing the majority of care). Th
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The Community Health System Deliver
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To better integrate the support pro
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5.5 Enablers A key aspect of this b
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Two rounds of meetings with front l
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While doctor-nurse substitution has
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Nick Goodwin, Kings Fund 14 , in hi
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Quality domains Each new initiative
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Preventative Acute LTC management R
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Preventative Acute LTC management R
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The core services are provided or p
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Total required FTEs for the Grey IF
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7 Governance, Ownership & Managemen
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Option D: PHO/DHB jointly owned Pri
Page 57 and 58: The IFHS will need the ability to b
Page 59 and 60: Of note, a large proportion of the
Page 61 and 62: The DHB delegates decision making o
Page 63 and 64: Limited integration of community se
Page 65 and 66: 10.4 Key milestones The table below
Page 67 and 68: Expanded pharmacy roles Improving a
Page 69 and 70: Devolved community based services w
Page 71 and 72: Appendices Appendix One: Health Equ
Page 73 and 74: ongoing GP shortage creating an env
Page 75 and 76: 10. What are the unintended consequ
Page 77 and 78: It is common for people with an acu
Page 79 and 80: Outcome measures Indicator Baseline
Page 81 and 82: determine ratio of nurses and GPs t
Page 83 and 84: C. Extended role for pharmacists:
Page 85 and 86: 11 Engagement Working group who dev
Page 87 and 88: Appendix B: Acutely unwell adult pa
Page 89 and 90: 4 Objectives to implement nur
Page 91 and 92: Review Buller after hours arrangeme
Page 93 and 94: Year three Community education camp
Page 95 and 96: 13 Costs Budget considerations:
Page 97 and 98: established. This group now oversee
Page 99 and 100: Output measures Tobacco control / s
Page 101 and 102: Improving immunisation coverage - h
Page 103 and 104: Year three Continued joint plan
Page 105 and 106: extending health promotion activiti
Page 107: Immunisation Coverage Funder Provid
Page 111 and 112: Clinical care Practice self managem
Page 113 and 114: and increases in the numbers of pat
Page 115 and 116: Ambulatory Sensitive Hospitalisatio
Page 117 and 118: % CVD on lipid lowering drugs, beta
Page 119 and 120: Health navigators/ kaiawhina: chan
Page 121 and 122: Committee‟s objectives 41 of prov
Page 123 and 124: - lack of consistency of care betwe
Page 125 and 126: qualifications and skills. Where ca
Page 127 and 128: 6 Deliverables / activities Impleme
Page 129 and 130: “With an aging population and an
Page 131 and 132: Differences between revenue generat
Page 133 and 134: Appendix Seven: Integration - Healt
Page 135 and 136: It is expected that HealthPathways
Page 137 and 138: Year two implement the process to
Page 139 and 140: Low uptake by primary and secondary
Page 141 and 142: Appendix Eight: Improved access to
Page 143 and 144: to easily access by telephone). Oth
Page 145 and 146: Year One - July 2010 to June 2011 T
Page 147 and 148: LECG 50 evaluated whether “the im
Page 149 and 150: Appendix Nine: Referred services 1.
Page 151 and 152: them by technical errors or lack of
Page 153 and 154: Identify patients that would benefi
Page 155 and 156: • Provision of patient specific m
Page 157 and 158: 12 Organisational accountabilities
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emain under the care and management
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Service user pathways in an optimal
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Model for shared care pathways deve
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Implementation plan: to June 30 Dev
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Year two Review progress, outcome m
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10 Risk analysis Risk Probability I
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Appendix Eleven: Frail older people
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ehab and treatment programmes that
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Year one: Maintain and continue the
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Māori have a higher incidence of m
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11 Organisational accountabilities
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There are often vacancies for allie
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6 Deliverables / activities Program
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Professional development: Provide
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Mainstream arguments are concerned
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Appendix Thirteen: IFHCs - Faciliti
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A key possibility is that land at t
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This option is effectively a Greenf
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7 Westland IFHC Facilities options
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Year two Substantive-IFHC in Greymo
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12 Costs Capital costs Greymouth IF
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utilize MedTech, but via their own
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4 Objectives: To implement c
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Security An individual‟s health i
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8 Effect on inequalities The increa
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Appendix Fifteen: Project advisory
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