Better Sooner More Convenient Primary Care - New Zealand Doctor

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Participate in the development and review of change proposals to improve discharge planning across the continuum of care, including examination of models of good practice which exist elsewhere, and support implementation of changes. Undertake consultation with staff groups being represented by members to ensure that all those involved in the discharge planning process are adequately engaged in the development and implementation of service changes. Promote internal and external multi disciplinary team working and communication. Promote continuous improvement of discharge planning activities to all staff. Self management/health literacy support: group diabetes self management programme: 4 sessions per year continue support for and referrals to Arthritis Foundation group self management support programme develop data analysis and reporting systems for measuring changes in Flinders self management score, produce first reports training session for health providers on health literacy publicise health navigator patient self management website – for providers and community, eg. pamphlet in prescription bags create link to Community & Public Health website on PHO website restart pulmonary rehabilitation programme, and create referral pathways from Green prescription increase referrals to other NGOs providing educational support support pharmacist to complete accreditation for medication utilization reviews develop a whanau focused approach to health literacy and self management. Year one Link PHO LTCM programme in with relevant HealthPathways Implement IT support for integration: create health views link from all practice and outpatients, wards and hospital pharmacy link into MedTech investigate use of shared electronic record. Medication reviews: develop funding stream for medications utilization reviews done by hospital and community pharmacies. Māori health team: develop a dedicated team that includes a Māori nurse and kaiawhina to build and strengthen relationships across the health care sector and with a key focus on the disengaged and hard to reach Māori within the West Coast community. Business case appendices V12 AC 25Feb2010 Page 48
Health navigators/ kaiawhina: change cancer navigator processes and criteria to include helping those with LTCs provide training in LTCs for health navigators and kaiawhina health literacy training for kaiawhina/navigators align health navigators and kaiawhina with IFHCs refine patient pathways between navigators/kaiawhina, in close relationship with Māori nurses within the IFHCs develop and implement pathway to follow-up frequent LTC emergency department (ED) attendees/admissions so that they understand how to access and navigate the primary care system. Self management/health literacy support: scope MedTech Manage my Health portal as a tool to improve self management review transport issues and develop plan to address these. Integrated community nursing and allied health in IFHCs: regular multidisciplinary meetings with clinical nurse specialist and allied health placing of CNS and allied health in IFHCs investigate use of shared electronic record. Decreasing repeat attendances at ED for LTC patients: work with ED to create a pathway to refer these people to either CNSs, health navigators or core general practice team. <strong>Care</strong> Link integration (see Appendix Eleven: Frail older people for more information) InterRAI assessments done in IFHCs/practices include <strong>Care</strong> Link in MDT meetings in IFHCs align LTC and frail elderly pathways. Data and reporting: review prevalence estimates and Read coding for West Coast, particularly for COPD review appropriateness of reports provided to IFHCs Year two more integrated community nursing and allied health working in IFHCs, (see EOI community and allied workstream plan) packages of care for patients with deteriorating medical condition/social situation, enabling faster access to a greater range of home/community support services. Year three review outputs, outcomes and the implementation of this plan, revise this plan as required. Business case appendices V12 AC 25Feb2010 Page 49
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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
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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 and 116: Ambulatory Sensitive Hospitalisatio
Page 117: % CVD on lipid lowering drugs, beta
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
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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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