Better Sooner More Convenient Primary Care - New Zealand Doctor

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5 Benefits and gains Output measures Indicator Baseline Target – Yr 1 Year 2 Year 3 Percentage of health centres with monthly (or more frequent) regular clinical full MDT meetings 25% 67% 100% 100% Development of single health assessment Shared electronic health record Patient timeframe to move through system - average time from new routine service request to patient being seen: - district nurses - rural health nurses - clinical nurse specialists - allied health Not in place Not in place TBC In place Partially in place In place Outcome measures Indicator Baseline Target – Yr 1 Year 2 Year 3 ASH rates See LTC paper % people with LTCs meeting clinical targets, eg. HbA1c, lipids and BP See LTC paper Annual No. re-admissions per year 8.21% (2009) No. patients with more than 6 ED TBC attendances per year No. patients with more 2 or more 199 admissions for 5 or more bed days (2009) per year 43 8% 7% 6% 190 180 170 43 Definition borrowed from the Counties Manukau project: Roseman, P. (2003). "Frequent Adult Medical Admissions Final Report." Retrieved 15 December 2008, 2008, from http://www.cmdhb.org.nz/Funded- Services/CCM/documents.htm. Business case appendices V12 AC 25Feb2010 Page 56
6 Deliverables / activities Implementation plan: to June 30 Establish MDT meetings: allied health, district nursing and clinical nurse specialists will meet with core health centre staff in each health centre to plan the care of specific high complexity patients. <strong>More</strong> sharing of information about patient needs for care will ensure more effective management of these patients. Guidelines for conducting these meetings will be developed. Identify extent and nature of overlap between medical centre frequent attenders cohort and community nursing/allied health clients; conduct review of care provided to patients common to both cohorts; examine systems and/or performance issues identified by this review and rectify/optimize. Review nature and type of home based nurse assessments with a view to developing standardised assessment procedure. Plan for assignment of community nursing and allied health clinicians to practice populations. Identify a professional grouping/team(s) and locations to be the first centre for implementation of the integrated model. Pilot, refine, spread. Develop common, integrated service specifications (break down barriers created by the existing specs). Consolidate and reduce reporting requirements where possible. To achieve this outcome, communication with the Ministry of Health needs to commence this year. Year one: Develop and implement a pathway for nurse care for different patients groupings, eg. post surgery, long term condition, frail elderly, palliative (covering the various nursing groups/specialties) and for wound care, across clinic and home settings. Examine better linking of home based care with district nursing. Develop IT and administration systems that enable closer integration, including those that enable data capture in the home/at the bedside. Review current referral systems, considering potential role of <strong>Care</strong> Link, and change to 'within-system-request-for-assistance/booking'. Monitor workload and waiting times and develop new priority and entry criteria as required. Identify the requirements for sharing clinical notes on MedTech in a single clinical file used by all health providers in the IFHC. Develop specifications for new system and fund implementation. Work with the current health centre that does not currently use MedTech to determine the barriers and facilitators for change. Develop a plan for better integration of well child services. Business case appendices V12 AC 25Feb2010 Page 57
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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
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Appendices Appendix One: Health Equ
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ongoing GP shortage creating an env
Page 75 and 76: 10. What are the unintended consequ
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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 and 122: Committee‟s objectives 41 of prov
Page 123 and 124: - lack of consistency of care betwe
Page 125: qualifications and skills. Where ca
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Page 131 and 132: Differences between revenue generat
Page 133 and 134: Appendix Seven: Integration - Healt
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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
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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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Page 175 and 176: 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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