Better Sooner More Convenient Primary Care - New Zealand Doctor

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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
Clinical care Practice self management support PHO/Community self care support Electronic clinical decision support Targets Annual review of clinical management by GP team according to national guidelines Recall for annual review and annual flu vaccination Plus ongoing usual clinical care Refer to CNSs and allied health as required My Shared Health Record 36 provided or updated at annual review, used at all consultations, smoking cessation (Coast Quit programme) if required Referral to Diabetes self management group, cooking skills for life, Living a Healthy Life, Kaiawhina, community support groups, green prescription, pharmacist support Diabetes advanced EDGE CVD form COPD Advanced form form (this includes CVD) National Practice Performance Programme (PMP) targets for Diabetes and CVD 15% current smokers and 85% flu recall for COPD Numbers Enroll all COPD, CV Disease and Diabetes pts – estimated number 2000 Level Two Care: Annual reviews and quarterly follow-up to support self management LTC Diabetes CVD COPD Other Patient will benefit from extra level of care Patient gives consent Capped numbers for each practice Target group New diagnosis of diabetes OR HbA1c> 8 AND/ OR Flinders PIH assessment shows person is not self managing well New diagnosis of CVD OR BP>150/90 TC >6mmol/l Worsening symptoms AND/OR high Flinders Score New diagnosis OR FVC 1 < 60% (moderate – severe COPD) Smoker AND/OR high Flinders score Two or more long term conditions (but not COPD, CVD or Diabetes) AND High Flinders score Clinical care Practice Self Management Support Quarterly half hour reviews by GP Team of clinical management according to national guidelines Recall for quarterly appointments and annual influenza vaccination Timing to coincide with need for regular script Focus on continuity of care – same provider for regular visits Other care as required Refer to clinical nurse specialist and allied health as required My Shared Health Record developed at annual review, used at all consultations, Full Flinders assessment, smoking cessation (Coast Quit programme), referral as required to PHO Mental Health Programme 36 This includes goal setting, medication card, list of health problems, educational material Business case appendices V12 AC 25Feb2010 Page 41
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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
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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 and 108: Immunisation Coverage Funder Provid
Page 109: The Community Health System Deliver
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
Page 159 and 160: 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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Better Sooner More Convenient Primary Care - New Zealand Doctor

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