Better Sooner More Convenient Primary Care - New Zealand Doctor

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To better integrate the support provided to patients by CNSs, allied health and medical centres, eg. through better communication and information sharing. To link with the activities described in the health promotion workstream. 5 Benefits and gains Output measures Indicator Baseline Target – Yr 1 Year 2 Year 3 % <strong>Care</strong> Plus enrolments 80% 83% 85% 88% Numbers in level 1, 2, 3 All Māori 1061/300/27 35/24/2 % estimated CVD coded* All 21.5% Māori 25% % estimated diabetes coded* All 69% Māori 72% 1410/500/80 75/45/6 70% 70% 73% 74% 1880/750/120 100/65/12 80% 80% 77% 77% 2000/950/190 150/75/15 90% 90% 80% 80% % diabetes (coded) annual reviews* All 57% 65% 75% 80% % of diabetes reviews with retinal All 73% >85% >85% >85% screening Māori 67% Number CVD annual reviews YTD All 577 Māori 28 Number COPD annual reviews All 75 Māori 4 % eligible popn screened for CV risk/diabetes* All 33% Māori 31% 627 35 200 30 51% 51% 677 40 300 45 65% 65% 720 45 400 60 80% 80% No. pharmacy medication reviews 0 100 200 300 % of those hospitalised with angina 49% 55% 62% 70% or MI receiving cardiac rehabilitation 79 YTD to Sept 09 % of those hospitalised with COPD 0 20% 30% 40% receiving pulmonary rehabilitation % patients admitted who are offered smoking cessation support* 70% 75% 80% 85% Outcome measures – for all and for Māori Indicator Baseline Target – Yr 1 Year 2 Year 3 % diabetes HbA1c80% 80% 70% 70% % CVD LDL
% CVD on lipid lowering drugs, beta blockers ACE aspirin* % diabetes with microalbuminuria on ACE* Māori 67% 70% 75% 80% 73% 49% 49% 73% All 84% Māori 89% 80% 55% 55% 80% 86% 89% 85% 65% 65% 85% 88% 90% 90% 70% 70% 90% 90% 90% % COPD on flu recall All 84% 86% 88% 90% % COPD not smoking All 73% 77% 81% 85% Average number exacerbations in 2.6 2.4 2.2 2 last year/patient % decrease in Flinders score TBC LTC ASH rates: ISDR (aged 45- 64yrs) includes: Diabetes, MI/angina, Pneumonia, CHF, Stroke 90.4 89 87.5 85 *Current or proposed PHO Performance Programme indicators and National Health targets 6 Deliverables / activities Implementation plan: to June 30 Increase participation: continue to employ a practice nurse facilitator to support practices to identify and enrol new patients into LTCM assist practices to adopt texting or use of Dr Info IT package for recalls. Level 3: review the implementation of level 3 care to date work with AT&R and <strong>Care</strong> Link, specialist nurses and allied health to develop processes to increase co-ordination and integration with primary care in a case management style approach within the IFHC environment, (overlap with workstream on community based nursing and allied health integration) implementation of regular meetings with cardiac, respiratory, diabetes nurse specialists within practice teams to plan level 3 patient care/management. Discharge planning: This is a stand-alone project being managed by the DHB Patient Journey Improvement Co-ordinator that aims to provide advice around service changes and identify opportunities to enhance discharge planning processes at WCDHB. It will be completed by June 2010 and encompasses the following objectives: Provide advice on clinical service and business process changes related to discharge planning to enhance outcomes and efficiencies. Business case appendices V12 AC 25Feb2010 Page 47
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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
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Of note, a large proportion of the
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The DHB delegates decision making o
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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 114: and increases in the numbers of pat
Page 115: Ambulatory Sensitive Hospitalisatio
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
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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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