Better Sooner More Convenient Primary Care - New Zealand Doctor

% 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 Care 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