Better Sooner More Convenient Primary Care - New Zealand Doctor

The DHB and the Ministry of Health both approved the content of the LTC management
programme in late 2008, including giving permission to allocate all LTC funds (Diabetes Annual
Review, Care Plus, some Section J contract lines and some SIA funding) into a global budget for
this programme.
The programme is based on all patients with diabetes, CVD or COPD having an annual review
from the time of diagnosis, and then based on their clinical condition and ability to self manage,
a decision is made as to the level of care they require for the following year as shown in the
diagram below:
Patient enters system
Package of care
discussed
with patient,
package provided
for following year
Annual assessment
carried out of
patient's clinical
condition & ability
to self manage
Decision made as to
which level of
care is most
suitable for patient
Patient may
exit following
annual
assessment of
care
There are three packages of care, with increasing intensity and support as shown in the
following three tables:
Level One Care: Annual Reviews
Patient LTC Diabetes ±
Cardiovascular Disease
(CVD)
Target group
Only CVD or
Diabetes or
COPD patients:
Meets diagnostic
criteria for diabetes.
Assessed to be self
managing well –
informally or formally
Cardiovascular
Disease
(If risk only, use CV
Screening
programme)
Established
cardiovascular
disease
Assessed to be self
managing well
Chronic Obstructive
Pulmonary Disease
(COPD)
Confirmed diagnosis of
COPD: Spirometry
showing FEV 1 /FVC