Better Sooner More Convenient Primary Care - New Zealand Doctor
Better Sooner More Convenient Primary Care - New Zealand Doctor
Better Sooner More Convenient Primary Care - New Zealand Doctor
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The<br />
Community<br />
Health<br />
System<br />
Delivery System<br />
Design<br />
Clinical<br />
Information<br />
Systems<br />
Equity in<br />
Health<br />
together to meet the health needs of the population. While full version of this runs to many<br />
pages, the key aspects are summarises in the following diagram:<br />
Chronic conditions management – the WCDHB<br />
framework,<br />
The Patient’s Journey<br />
Environment<br />
Healthy<br />
At Risk<br />
Acute<br />
Event<br />
Initial<br />
management<br />
Long term<br />
clinical and<br />
Self<br />
management<br />
End of Life<br />
<strong>Care</strong><br />
Healthy public<br />
policy and<br />
creation of<br />
supportive<br />
environments<br />
Non-italics=<br />
existing service<br />
Italics= proposed<br />
service<br />
Healthy<br />
Schools;<br />
Smoke free;<br />
HEHA:<br />
Community<br />
events;<br />
Breast feeding;<br />
Men‟s health;<br />
Green Rx;<br />
Health<br />
promoting<br />
practices<br />
CVD and<br />
diabetes<br />
screening,<br />
follow up<br />
for those at<br />
highest risk<br />
Smoking<br />
cessation<br />
Diagnosis,<br />
hospital<br />
admission<br />
Pre-hospital<br />
fibrinolysis<br />
Diabetes<br />
Pulmonary<br />
rehabilitation,<br />
Cardiac<br />
rehabilitation,<br />
Arthritis and<br />
diabetes<br />
education/<br />
support<br />
groups<br />
PHO LTC: Focus on,<br />
CVD, diabetes ,<br />
COPD: clinical and self<br />
management support<br />
<strong>Care</strong>Link and AT&R<br />
assessments and MDT<br />
review for more<br />
complex<br />
Cancer<br />
navigators<br />
Palliative<br />
care<br />
funding in<br />
primary<br />
care<br />
UNDERPINNED BY THE WEST COAST‟S 7 PILLARS OF CHRONIC CONDITIONS MANAGEMENT<br />
The PHO Long Term Conditions programme (as it is now)<br />
The programme is both based on the Wagner Chronic <strong>Care</strong> model 1 (self-management support,<br />
community support, delivery system redesign, clinical information systems and decision support)<br />
and the Kaiser Triangle stratified care approach 34 . The programme meets the National Health<br />
Committee‟s objectives 35 of providing effective chronic care management and co-ordination<br />
through using a population health approach to care delivery, based on level of need, both clinical<br />
need and need for self management support. There is a focus on those with conditions that are<br />
frequent or severe, and these are addressed by national evidence based clinical guidelines and<br />
are responsive to enhanced primary care management, and have outcomes that can be tracked<br />
over time to measure improvement (Cardiovascular Disease (CVD), Diabetes, and Chronic<br />
Obstructive Pulmonary Disease (COPD)).<br />
34 World Health Organisation Innovative <strong>Care</strong> for Chronic Conditions: Building Blocks for Action: Global Report 2002<br />
WHO document no. WHO/NMC/CCH/02.01.<br />
35 National Health Committee People with Long Term Conditions A Discussion Paper National Health Committee<br />
Wellington May 2005<br />
Business case appendices V12 AC 25Feb2010 Page 39