Better Sooner More Convenient Primary Care - New Zealand Doctor

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PHO/Community self care support Electronic clinical decision support Targets Referral to Diabetes SME group, cooking skills for life, Living a Health Life, Kaiawhina, community support groups, green prescription, pulmonary or cardiac rehabilitation, pharmacist support Diabetes form Flinders Questionnaire National PMP targets EDGE CVD form Flinders Questionnaire National PMP targets COPD Advanced form Flinders Questionnaire 15 % smokers 85% flu vaccination Flinders Questionnaire Decrease in Flinders score Capped numbers Capped at 950 across whole PHO Cap of 25% of 950 Level Three Care: Integration (level two care, plus the following) Patient with long term conditions – not managing, clinical Patient with long term problems (+/- social problems) conditions – not managing well due to social problems Assessed by GP: Needs level 3 Long Term Conditions Care Refer for inpatient AT&R assessment Referred to Care link asking for AT&R assessment Referred to Care link asking for NASC assessment Has AT&R assessment – inpatient or outpatient Has NASC assessment by needs assessor Plan written Referrals to allied health, mental health, secondary care (physicians, nurse specialists), pharmacy medication utilization reviews, home care, community support groups, as required Copy of plan to GP Followed up by AT&R nurse in community Followed by Care Link service co-ordinator 3 monthly reports to GP, until discharge from ongoing co-ordination Practice puts patient onto level 3 LTC care Receives funding for extra hour of GP time and extra hour of nurse time for either quarterly 30 minute GP assessments or quarterly 15 minute assessments plus home visit Full Flinders assessment with quarterly follow up by nurse and My Shared Health Record Funding available for GP or nurse to participate in case conference with AT&R nurse or Care Link service coordinator or clinical nurse specialist At one year GP reassesses and decides whether : - Goes back to Level 2 care - Or continues on Level 3 with ongoing service integration/AT&R nurse - Or continues on Level 3 and referred for another AT&R or NASC assessment Capped at 190 patients each year for the whole PHO Implementation of the programme has gone well in 2009 using the IHI Breakthrough Series methodology. A recent evaluation 37 of the implementation showed high acceptance by practices 37 North D, Tracey J. Evaluation of the IHI Breakthrough Series Project for West Coast PHO. Jan 2010. Business case appendices V12 AC 25Feb2010 Page 42
and increases in the numbers of patients with LTCs managed in a proactive and planned manner as shown in the following table: Enrolment Comparisons December 2008 December 2009 Care Plus enrolments 51% 80% Level 1 enrolments 0 1061 Level 2 enrolments 0 300 Level 3 enrolments 0 27 COPD enrolments 0 74 CVD annual reviews 558 675 Diabetes annual reviews 55 Māori reviewed 35% Māori smoking 61 Māori reviewed 26% Māori smoking Cardiovascular risk and diabetes screening Active screening is in place for both cardiovascular risk and for diabetes, with follow-up management and support. The programme can profile and monitor cardiovascular risk assessments where people have a greater than 15% risk of having a cardiovascular event within the next 5 years. These identified patients are closely followed up with interventions to reduce their risk, and provide patients with the individual supports they require for self management and risk reduction. Cancer navigators The PHO has had pilot funding from the Ministry of Health to provide a Cancer Lay Navigator service for three years, finishing in June 2010. Programme evaluation reports have shown that the navigators have developed excellent skills in supporting predominantly low socio-economic and Māori people to access the health care and social support systems they need in order for their condition to be appropriately managed. There is growing international support for the use of lay navigators to support patients with LTCs 38 and opportunity to expand the role of this workforce to include LTCM. Clinical nurse specialists and allied health The clinical nurse specialist‟s are experienced clinicians in their respective fields of cardiac, respiratory, diabetes, oncology, urology, palliative care and AT&R. This specialised group of nurses provide clinical management to people with sometimes very complex needs. Some nurses work across two specialty areas like cardiac and respiratory which proves as a great advantage to continuity of care and management of these patients. 38 Improving access to cardiac care report: http://www.libin.ucalgary.ca/documents/news/Libin-2008-07-23.pdf . accessed 14 Jan 2010 Business case appendices V12 AC 25Feb2010 Page 43
Page 1 and 2:
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
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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 and 110: The Community Health System Deliver
Page 111: Clinical care Practice self managem
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
Page 161 and 162: 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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