Better Sooner More Convenient Primary Care - New Zealand Doctor

More documents

Recommendations

Info

Underdevelopment of support for carers – local voluntary agencies are barely sustainable as the Coast population is not large enough to support services that would be available in bigger centres, (eg. age concern befriending, continence education, dementia support). Carer burnout contributes to the relatively high rate of rest home entry. Many health and support workers and many clients still hold to a traditional dependency and entitlement model for rest home and home support services and there is limited implementation of a restorative model as yet. Very limited availability of allied health staff for community based work, (eg. supervising home carers in home based rehabilitation programmes, responding to GP referrals), reflected in high rate of inpatient admission to AT&R ward. Residential aged care facilities (in Greymouth) have had limited access to general practitioner services, reflected in a relatively high rate of referrals to the acute services. Primary health care received by residential care residents is sometimes suboptimal and would benefit from greater input from medical staff with specialist knowledge of older peoples health, including dementia. A number of residential aged care facilities have had a continued shortage of registered nurses, which has repeatedly compromised quality of care. 3 OBJECTIVES Set up a clear pathway for accessing primary and community services. This would include: A hub of shared client information available to all health and support services – GPs, practice nurses, district nurses, Care Link, ward staff, allied health, residential care, home care agencies etc. This includes InterRAI and other assessments. A triage function for logging all cases and sending simple routine cases directly to the appropriate service while ensuring complex cases receive multidisciplinary assessment, case management through Chronic Conditions Programme and/or Care Link, and/or referral to specialist services Clear, agreed protocols for accessing services Co-locate Care Link with the Integrated Family Health Centres (IFHC), and link staff to specific primary health teams, thereby giving those teams easy access to expert assessment (InterRAI), community-based support packages and a case management function for people with long-term disabling conditions. Set up a restorative home-based support service based on need, accessed through Care Link and closely linked to primary and community health services: Home care workers having close connection to primary health services, community nursing and allied health, in some cases working under supervision to help clients do the Business case appendices V12 AC 25Feb2010 Page 102
ehab and treatment programmes that occupational therapists, physios, GPs etc have prescribed. All relevant health and support workers (in primary, hospital, community and residential services) trained in a restorative goal based model of care that focuses on the client being helped to regain and maintain their function and on proactively preventing illness and injury (eg. falls prevention, flu immunisation, timely equipment, active continence management and other ways of preventing carer burnout). Include a strong focus on supporting carers to prevent/reduce care burnout – Care Link will use long term funding for carer support more flexibly to support carers and voluntary patient support agencies. Make best use of specialist Health of Older People (AT&R) resources: Set up clear pathways to ensure timely transfer to specialist services for frail older people and anyone with a stroke. Set up step-down/admission avoidance beds in the main centres A greater proportion of AT&R staff time available for consultation and support for primary health services, home care services and residential care. 4 Benefits and gains Output measures Indicator Baseline Target – Yr Year 2 Year 3 1 Percentage of stroke patients Nil 25% 100% 100% transferred to specialist stroke team Pathways implemented for the appropriate care of frail older people admitted to medical/surgical wards No Yes Yes Yes Number of people with high falls risk receiving ACC-funded falls prevention programmes (55+ years Māori, 65+ years non-Māori) Shared client record can be accessed by all appropriate staff working in primary health, community, hospital and residential care services Percentage of people receiving NASC assessment within the appropriate timeframe Single point of entry and clear pathway exists for access to all community services 30 in Greymouth & Hokitika in 2009-10 75 throughout Coast 100 throughout Coast No Partially Partially Fully 90% 100% 100% 100% No Partially Partially Fully 100 throughout Coast Business case appendices V12 AC 25Feb2010 Page 103
Page 1 and 2:
Business Case Better, Sooner, More
Page 3 and 4:
1 Caveats/status This business case
Page 5 and 6:
Current situation By three years Wa
Page 7 and 8:
staffed on a capacity model - in wh
Page 9 and 10:
support from DHBs, specialist clini
Page 11 and 12:
10.4 Key milestones................
Page 13 and 14:
Annual government health funding pe
Page 15 and 16:
Ambulatory Sensitive Hospitalisatio
Page 17 and 18:
The base populations of the three d
Page 19 and 20:
Māori/Pacific Not Māori/Pacific D
Page 21 and 22:
4.7 West Coast region service deliv
Page 23 and 24:
5 Future model of care 5.1 The desi
Page 25 and 26:
support them. Help with understandi
Page 27 and 28:
LEVERS VISION Better, sooner, more
Page 29 and 30:
providing the majority of care). Th
Page 31 and 32:
The Community Health System Deliver
Page 33 and 34:
To better integrate the support pro
Page 35 and 36:
5.5 Enablers A key aspect of this b
Page 37 and 38:
Two rounds of meetings with front l
Page 39 and 40:
While doctor-nurse substitution has
Page 41 and 42:
Nick Goodwin, Kings Fund 14 , in hi
Page 43 and 44:
Quality domains Each new initiative
Page 45 and 46:
Preventative Acute LTC management R
Page 47 and 48:
Preventative Acute LTC management R
Page 49 and 50:
The core services are provided or p
Page 51 and 52:
Total required FTEs for the Grey IF
Page 53 and 54:
7 Governance, Ownership & Managemen
Page 55 and 56:
Option D: PHO/DHB jointly owned Pri
Page 57 and 58:
The IFHS will need the ability to b
Page 59 and 60:
Of note, a large proportion of the
Page 61 and 62:
The DHB delegates decision making o
Page 63 and 64:
Limited integration of community se
Page 65 and 66:
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 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 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: Appendix Eleven: Frail older people
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
show all

Better Sooner More Convenient Primary Care - New Zealand Doctor

Create successful ePaper yourself

Delete template?

Save as template?