Better Sooner More Convenient Primary Care - New Zealand Doctor

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Appendix Six: Integration - DHB community based services 1. Aspirational statement: West Coasters with complex health needs will receive co-ordinated and consistent care from their health providers working together as an integrated health team. 2 Project overview This project establishes integrated health teams inclusive of general practice based primary health practitioners and non general practice based community health nurses 42 and allied health staff, to ensure the provision of integrated and co-ordinated multi disciplinary care and a holistic approach to meeting the populations' needs. 3 Problem definition Traditional medical centres, or general practices, care for their enrolled populations. Some of those same patients are cared for by district nurses, and other community based nursing and allied health professionals, both as hospital inpatients and post discharge, sometime for an extended time period. But the two systems of care are not routinely or systematically well connected together. They operate to a large extent as parallel systems of care. When the two systems do intersect, it may be purposeful, eg. a GP refers a patient to district nursing, or it may occur by accident, eg. one individual is employed as both a practice nurse and a clinical nurse specialist, or a district nurse and a GP happen to know each other and have a working relationship. This work stream aims to better connect these two significant health care workforces, and to do so systematically and fundamentally, to ensure patients will benefit from co-ordinated and consistent care. Key issues identified as a result are: Lack of co-ordination of care across the different systems of care and difficulties for the patient navigating through the system: - communication gaps between primary and secondary health providers (referral, discharge, treatment) - duplication of care, and consequent unnecessary costs 42 "community health nurses" is defined broadly; it is taken to include: district nurses, public health nurses, rural nurse specialists, neighbourhood nurses, immunisation coordination & outreach nurses, Well Child & Plunket nurses and clinical nurse specialists (cardiology, respiratory, oncology, palliative, diabetes etc) Business case appendices V12 AC 25Feb2010 Page 52
- lack of consistency of care between providers; inconsistent information given to patients by different providers Inequalities in health outcomes: - poorer health status for Māori and deprived populations through lower access rates to services Lack of continuity of care: - seeing a different health provider each visit - lack of a single patient record system across health care providers - providers working in silos and not „joining up‟ episodes of care. Problems in accessing services: - services not co-located in some areas, making it particularly difficult for the frail elderly or those without transport who need to see several health care providers - referral system for care outside core primary health team inefficient and unwieldy. Workforce shortages. The patient numbers and, in particular, the patient demand on the health system, relevant to the possible intersection of these two workforces, are significant. An analysis of West Coast PHO enrolled patients and visit numbers for 2009 shows the following: Business case appendices V12 AC 25Feb2010 Page 53
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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
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Expanded pharmacy roles Improving a
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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 and 118: % CVD on lipid lowering drugs, beta
Page 119 and 120: Health navigators/ kaiawhina: chan
Page 121: Committee‟s objectives 41 of prov
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
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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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Better Sooner More Convenient Primary Care - New Zealand Doctor

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