Better Sooner More Convenient Primary Care - New Zealand Doctor

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Year one: Co-ordinator role: three co-ordinators appointed and based in Buller, Greymouth and Westland two monthly review steering group sessions to review and refine processes and roles. Discharge planning process: set up mental health discharge planning process, levering off the generic project develop a plan for change consult widely among primary and secondary care providers and consumers revise plan put new processes in place review six months later. Shared care: establish a planning group that includes consumer, whanau and Māori representation review current contracts and funding models develop model and processes for shared care, ie. reviews; agreed role boundaries; clinical accountability and responsibilities consult widely among primary and secondary care providers and consumers revise plan pilot processes in one region review and revise pilot processes transition of support workers to primary care. Brief intervention: review age group covered by primary care youth counsellor (14 – 18). Improving integration: allocate a secondary mental health team member liaison person for each practice/IFHC where facilities allow co-locate secondary mental health team in IFHCs. Addressing physical health needs: develop and implement annual health checks for long term mental health patients at their IFHC fund and encourage flu vaccinations for long term mental health patients. Extending kaupapa Māori Mental Health service: kaupapa Māori mental health services include service provision for Māori clients in primary health settings. Business case appendices V12 AC 25Feb2010 Page 96
Year two Review progress, outcome measures and adapt plan Alcohol and Drug: review the patient pathway for alcohol, drug and other addictions. Integration: develop shared patient record systems review the ownership, management and organisational accountabilities for primary and secondary mental health services to consider whether both should be merged with IFHCs (some service will need to be district wide, eg. Child and AdolescentMental Health Services). Professional development activities: integrate activities across the services. Shared care: review pilot processes and refine process for shared care roll out across the region. Support for patient self care: further up-skilling of staff in self management education review availability of self management education and support and consider establishment of group self management education. Year three Review progress, outcome measures and adapt plan. 7 Capability and capacity Current configuration of adult secondary care community mental health into three teams will align well with the IFHC model and provide the capability and capacity required to deliver services to each of the three IFHCs. Current primary mental health services are delivered within general practices, and will in the future be delivered from IFHCs. Greater involvement of GPs and primary care nurses in shared care and discharge planning are dependent on current workforce issues being addressed. Business case appendices V12 AC 25Feb2010 Page 97
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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
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10. What are the unintended consequ
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It is common for people with an acu
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Outcome measures Indicator Baseline
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determine ratio of nurses and GPs t
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C. Extended role for pharmacists:
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11 Engagement Working group who dev
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Appendix B: Acutely unwell adult pa
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4 Objectives to implement nur
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Review Buller after hours arrangeme
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Year three Community education camp
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13 Costs Budget considerations:
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established. This group now oversee
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Output measures Tobacco control / s
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Improving immunisation coverage - h
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Year three Continued joint plan
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extending health promotion activiti
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Immunisation Coverage Funder Provid
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The Community Health System Deliver
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Clinical care Practice self managem
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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 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: Implementation plan: to June 30 Dev
Page 169 and 170: 10 Risk analysis Risk Probability I
Page 171 and 172: Appendix Eleven: Frail older people
Page 173 and 174: ehab and treatment programmes that
Page 175 and 176: Year one: Maintain and continue the
Page 177 and 178: Māori have a higher incidence of m
Page 179 and 180: 11 Organisational accountabilities
Page 181 and 182: There are often vacancies for allie
Page 183 and 184: 6 Deliverables / activities Program
Page 185 and 186: Professional development: Provide
Page 187 and 188: Mainstream arguments are concerned
Page 189 and 190: Appendix Thirteen: IFHCs - Faciliti
Page 191 and 192: A key possibility is that land at t
Page 193 and 194: This option is effectively a Greenf
Page 195 and 196: 7 Westland IFHC Facilities options
Page 197 and 198: Year two Substantive-IFHC in Greymo
Page 199 and 200: 12 Costs Capital costs Greymouth IF
Page 201 and 202: utilize MedTech, but via their own
Page 203 and 204: 4 Objectives: To implement c
Page 205 and 206: Security An individual‟s health i
Page 207 and 208: 8 Effect on inequalities The increa
Page 209: Appendix Fifteen: Project advisory
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