Better Sooner More Convenient Primary Care - New Zealand Doctor
Better Sooner More Convenient Primary Care - New Zealand Doctor Better Sooner More Convenient Primary Care - New Zealand Doctor
Outcome measures Indicator Baseline Target – Yr 1 Rate of admission for falls-related fracture, for people aged 75+ years, over 3 year rolling period Average length of stay in specialist Health of Older People (AT&R) service Rates of re-admission to acute hospital care over a 6-month period for people aged 75+ Rate of „frequent fliers‟ (6+ acute hospital admissions per year) for people aged 75+ Rate of admission to permanent rest home level care per capita of people aged 75+ years Rate of ambulatory sensitive admissions 45-74 years Carer stress as measured by average years duration of employment for carers TBC TBC TBC TBC 5.98% (July-Dec 2009) TBC Not yet measured. Same as baseline Same as baseline Same as baseline Same as baseline Year 2 Year 3 5% reduction on baseline 5% reduction on baseline 5% reduction on baseline 5% reduction on baseline 5.75% 5.5% 5.0% Same as baseline 5% reduction on baseline 5% reduction on baseline 10% reduction on baseline 10% reduction on baseline 10% reduction on baseline 5% reduction on baseline Baseline Baseline 5% reduction on baseline 5 Deliverable / activities Implementation plan: To June 30 Identify the process, timeframe, resources and accountabilities for establishing a single shared patient record that is available to all appropriate primary, community, hospital and residential care staff. Introduce clinical protocols whereby stroke patients and frail older people admitted to Grey Hospital are routinely referred to the specialist Health of Older People Service (AT&R), with their primary health teams and case managers being alerted electronically Progress the planned changes to a restorative model of homecare that have already started, aligning with similar work by Nelson Marlborough and Canterbury DHBs Complete implementation of InterRAI at Care Link and ensure read-only access to at least other DHB services Set up a robust budget management system for the long-term support services accessed through Care Link, and a plan for linking InterRAI data to volumes and expenditure data Business case appendices V12 AC 25Feb2010 Page 104
Year one: Maintain and continue the initiatives up to June 30 and also: Identify patient pathways for older people, especially those disabled by frailty and medical conditions. Create a simple, easy-to-use process for all health and support workers to access community and primary services, including primary health services, community nursing and allied health, palliative care, clinical nurse and allied health specialists, and needs assessment/service coordination for short term and long term support services, including mental health support services. Extend InterRAI read-only access to non DHB health and support services, including primary health teams, home support agencies and residential care facilities. Set up a case management function for complex older clients by linking Care Link NASC staff more closely to each primary care team to provide expert multidisciplinary needs assessment and to ensure each client has a key worker to coordinate the treatment, rehabilitation and support provided at home. This would work closely with the Chronic Conditions Programme – „frail complex older people‟ treated as one more Chronic Condition. Set up a medical and geriatric nurse specialist rotation among primary health teams, Care Link and specialist Health of Older People service (AT&R) Reconfigure AT&R service to enable greater input to primary health teams, community services and residential care facilities Set tight criteria for access to long term support services, based on reliable data and ongoing consultation with all stakeholders Change relevant protocols and contractual arrangements to allow greater allied health and nurse specialists input to home support agencies and residential care facilities Explore the best way of providing step-down beds in the main centres for admission avoidance, convalescence and slow stream rehabilitation (in the light of the experience at Waikato and Wairarapa DHBs). Prepare a Carer Support Strategy and Action Plan that identifies needs, proposes service changes and allocates funding for services to support carers. Pharmacist support: - for patients managing well – prescription dispensing, brief counseling/education as medicines added or adjusted; - supporting self management – Medication Utilization reviews and compliance aid provision as necessary; - for those requiring integrated services: compliance packaging – picked up or delivered to home or sometimes District Nursing, reminders to visit GP for three monthly prescription, liaison with hospital and GP practice at discharge, follow-up if (blister-packed) medications not collected. Scope for comprehensive medication review at this level; - General support – pharmacist involvement with various support groups, eg. cardiac and respiratory, answering patient questions, providing smoking cessation services, referral of patients to other providers, eg. diabetes nurse educator or general practice. Business case appendices V12 AC 25Feb2010 Page 105
- 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 and 172: Appendix Eleven: Frail older people
- Page 173: ehab and treatment programmes that
- 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
Year one:<br />
Maintain and continue the initiatives up to June 30 and also:<br />
Identify patient pathways for older people, especially those disabled by frailty and<br />
medical conditions. Create a simple, easy-to-use process for all health and support<br />
workers to access community and primary services, including primary health services,<br />
community nursing and allied health, palliative care, clinical nurse and allied health<br />
specialists, and needs assessment/service coordination for short term and long term<br />
support services, including mental health support services.<br />
Extend InterRAI read-only access to non DHB health and support services, including<br />
primary health teams, home support agencies and residential care facilities.<br />
Set up a case management function for complex older clients by linking <strong>Care</strong> Link NASC<br />
staff more closely to each primary care team to provide expert multidisciplinary needs<br />
assessment and to ensure each client has a key worker to coordinate the treatment,<br />
rehabilitation and support provided at home. This would work closely with the Chronic<br />
Conditions Programme – „frail complex older people‟ treated as one more Chronic<br />
Condition.<br />
Set up a medical and geriatric nurse specialist rotation among primary health teams,<br />
<strong>Care</strong> Link and specialist Health of Older People service (AT&R)<br />
Reconfigure AT&R service to enable greater input to primary health teams, community<br />
services and residential care facilities<br />
Set tight criteria for access to long term support services, based on reliable data and<br />
ongoing consultation with all stakeholders<br />
Change relevant protocols and contractual arrangements to allow greater allied health<br />
and nurse specialists input to home support agencies and residential care facilities<br />
Explore the best way of providing step-down beds in the main centres for admission<br />
avoidance, convalescence and slow stream rehabilitation (in the light of the experience<br />
at Waikato and Wairarapa DHBs).<br />
Prepare a <strong>Care</strong>r Support Strategy and Action Plan that identifies needs, proposes<br />
service changes and allocates funding for services to support carers.<br />
Pharmacist support:<br />
- for patients managing well – prescription dispensing, brief counseling/education<br />
as medicines added or adjusted;<br />
- supporting self management – Medication Utilization reviews and compliance aid<br />
provision as necessary;<br />
- for those requiring integrated services: compliance packaging – picked up or<br />
delivered to home or sometimes District Nursing, reminders to visit GP for three<br />
monthly prescription, liaison with hospital and GP practice at discharge, follow-up<br />
if (blister-packed) medications not collected. Scope for comprehensive<br />
medication review at this level;<br />
- General support – pharmacist involvement with various support groups, eg.<br />
cardiac and respiratory, answering patient questions, providing smoking cessation<br />
services, referral of patients to other providers, eg. diabetes nurse educator or<br />
general practice.<br />
Business case appendices V12 AC 25Feb2010 Page 105
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