Better Sooner More Convenient Primary Care - New Zealand Doctor

More documents

Recommendations

Info

Each provides support and education to clinicians within primary and secondary settings, as well as education and self management support to patients within the hospital and home settings, some examples are: Breathe easy groups have been happening sporadically according to staff resourcing cardiac rehabilitation have two formal programmes: phase 2 cardiac rehabilitation, a six week outpatient programme based at the DHB physio gym in Greymouth and a modified programme at Buller hospitals Heart Guide Aotearoa, a home based programme designed to improve access to rehabilitation for West Coasters. Allied health comprises physiotherapy, occupational therapy, social work, dietician, speech language therapy, all with work components crossing secondary and primary care. These services are utilized within all levels of care as required, preferably sooner than later within the patient journey, this will ensure patient and family supports are put in place earlier before crisis point is hit. Pharmacist support This is related to levels of care, people would tend to move to more „intensive‟ care over time. Patients managing well – prescription dispensing, brief counseling/education as medicines added or adjusted, eg. take with food, side effects to watch for, inhaler/spacer technique, self care cards, adherence support, referral onto other team members as required. Supporting self management – as above but likely to be seen more often as receiving more medicines and more presentations to pharmacy, increased likelihood of medicines-related problems, medication reviews, compliance aid provision as necessary. Integration – as above, likely weekly compliance packaging – picked up or delivered to home or sometimes district nursing, reminders to visit GP for 3 monthly prescription, liaison with hospital and GP practice at discharge, follow-up if (blister-packed) medications not collected. Scope for comprehensive medication review at this level. General support – pharmacists are involved with various support groups, eg. cardiac and respiratory as speakers and are accessible to those with questions, presenting for Over The Counter (OTC) products or wanting their weight or blood pressure measured. Smoking cessation services are offered. People are referred as necessary, eg. to diabetes nurse specialist or general practice team. Ambulatory sensitive hospitalisations for those aged 45–64 are helpful in indicating whether LTC management is keeping people out of hospital. 39 39 Included are angina, MI, CHF, pneumonia, asthma, diabetes, stroke, epilepsy Business case appendices V12 AC 25Feb2010 Page 44
Ambulatory Sensitive Hospitalisation ISDR - ages 45 to 64 years (12 months to 30 Sep 2009) Indirectly Standardised Discharge Rate per 1,000 Māori Pacific peoples Other West Coast Actual ASH rate 8 n/a 152 ISDR value for Year to Date 35.1 n/a 90.4 West Coast DHB overall total discharge rates per 1000 for ambulatory sensitive hospitalisations, while below the average of 100, does not vary significantly from the overall national rates at the 99% confidence interval. Current issues Areas where there is still room for improvement include: total numbers of patients enrolled in LTC percentage of patients meeting clinical KPIs, e.. target lipid, BP, HbA1c levels closing of inequality gaps, eg. smoking levels integration of care for Level 3 patients (who have high hospitalisation rates), with a focus on preventing acute exacerbations and avoiding hospital admissions more support for those Level 3 patients who have difficulty accessing the health and social systems and would benefit from kaiawhina and/or health navigator assistance closer co-ordination and greater consistency of care between clinical nurse specialists (CNS) and medical centres and allied health and medical centres more support for patients self care is required . 4 Objectives To increase implementation of the programme so that over 70% of all patients with COPD, CVD and/or diabetes have an annual review followed by a timely package of care appropriate for their level of need. Development of a Māori team within each Integrated Family Health Centre (IFHC) who will focus on improving access and health outcomes for Māori. To review the management of Level 3 patients and enhance the integration between general practice care and AT&R, <strong>Care</strong> Link and nurse specialist care and allied heath. To enable and empower people in the community to obtain process and understand health information and services needed to make appropriate decisions about their health. To develop health navigator support services for Level 3 patients who have difficulty accessing health care and social services. Business case appendices V12 AC 25Feb2010 Page 45
Page 1 and 2:
Business Case Better, Sooner, More
Page 3 and 4:
1 Caveats/status This business case
Page 5 and 6:
Current situation By three years Wa
Page 7 and 8:
staffed on a capacity model - in wh
Page 9 and 10:
support from DHBs, specialist clini
Page 11 and 12:
10.4 Key milestones................
Page 13 and 14:
Annual government health funding pe
Page 15 and 16:
Ambulatory Sensitive Hospitalisatio
Page 17 and 18:
The base populations of the three d
Page 19 and 20:
Māori/Pacific Not Māori/Pacific D
Page 21 and 22:
4.7 West Coast region service deliv
Page 23 and 24:
5 Future model of care 5.1 The desi
Page 25 and 26:
support them. Help with understandi
Page 27 and 28:
LEVERS VISION Better, sooner, more
Page 29 and 30:
providing the majority of care). Th
Page 31 and 32:
The Community Health System Deliver
Page 33 and 34:
To better integrate the support pro
Page 35 and 36:
5.5 Enablers A key aspect of this b
Page 37 and 38:
Two rounds of meetings with front l
Page 39 and 40:
While doctor-nurse substitution has
Page 41 and 42:
Nick Goodwin, Kings Fund 14 , in hi
Page 43 and 44:
Quality domains Each new initiative
Page 45 and 46:
Preventative Acute LTC management R
Page 47 and 48:
Preventative Acute LTC management R
Page 49 and 50:
The core services are provided or p
Page 51 and 52:
Total required FTEs for the Grey IF
Page 53 and 54:
7 Governance, Ownership & Managemen
Page 55 and 56:
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 and 108: Immunisation Coverage Funder Provid
Page 109 and 110: The Community Health System Deliver
Page 111 and 112: Clinical care Practice self managem
Page 113: and increases in the numbers of pat
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
Page 163 and 164: Model for shared care pathways deve
Page 165 and 166:
Implementation plan: to June 30 Dev
Page 167 and 168:
Year two Review progress, outcome m
Page 169 and 170:
10 Risk analysis Risk Probability I
Page 171 and 172:
Appendix Eleven: Frail older people
Page 173 and 174:
ehab and treatment programmes that
Page 175 and 176:
Year one: Maintain and continue the
Page 177 and 178:
Māori have a higher incidence of m
Page 179 and 180:
11 Organisational accountabilities
Page 181 and 182:
There are often vacancies for allie
Page 183 and 184:
6 Deliverables / activities Program
Page 185 and 186:
Professional development: Provide
Page 187 and 188:
Mainstream arguments are concerned
Page 189 and 190:
Appendix Thirteen: IFHCs - Faciliti
Page 191 and 192:
A key possibility is that land at t
Page 193 and 194:
This option is effectively a Greenf
Page 195 and 196:
7 Westland IFHC Facilities options
Page 197 and 198:
Year two Substantive-IFHC in Greymo
Page 199 and 200:
12 Costs Capital costs Greymouth IF
Page 201 and 202:
utilize MedTech, but via their own
Page 203 and 204:
4 Objectives: To implement c
Page 205 and 206:
Security An individual‟s health i
Page 207 and 208:
8 Effect on inequalities The increa
Page 209:
Appendix Fifteen: Project advisory
show all

Better Sooner More Convenient Primary Care - New Zealand Doctor

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?