Better Sooner More Convenient Primary Care - New Zealand Doctor

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5.4.3 Future well child service model Currently well child service provision is fragmented between Plunket, primary care, Māori health NGO providers, LMCs and Community nursing services. The advent of IFHCS creates the opportunity to bring these carers together, so that care is streamlined, information is shared and families get the right level of follow up. Initial discussions with NGO service providers indicate a willingness to collaborate in order to achieve better health outcomes and better use of resources. More detailed discussions and project planning will occur in year one of the implementation phase. 5.4.4 Future mental health service model [NB. The Mental Health component of this plan was written on the basis of funding being available to employ Mental Health Co-ordinators in each IFHC. It became apparent on 23 rd February that this funding was not going to be available. While aspects of this plan may still be able to be implemented within existing resources and funding, this will require discussion with, and support from, clinicians from community mental health services, primary mental health services and primary care. Given the time now available a revision to this plan was therefore not attempted; this review will done by June 30, 2010.] Significant changes are proposed for mental health services. Most secondary mental health services provided by the West Coast DHB are, in fact, community based. Over time it is proposed that these will increasingly be based in IFHCs to enhance the connection with core primary care. This process will commence in 1 July 2010 with the devolution of funds for three primary care based primary mental health co-ordinators who, over time, will conduct almost all Business case EoI V38 AC 25Feb10 Page 30
The Community Health System Delivery System Design Clinical Information Systems Equity in Health assessments for patients with mental health conditions, irrespective of whether patients are then referred for primary or secondary mental health interventions. Currently, there is one assessment role in primary care, and it only assesses patients for entry to brief intervention counselling provided by the primary mental health team. This devolution will reduce the separateness of (and associated stigma that typically goes with referral to) secondary mental health services, prevent patients falling through the 'gap' between primary and secondary mental health services, and further strengthen the provision of mental health services in primary care settings. After year two, provided developmental milestones are achieved, it is anticipated that mental health services will be fully devolved to the PHO/community provider, to enable further integration of service delivery. 5.4.5 Future management of long term conditions The WCPHO and DHB have invested significantly in development of a best practice framework for management of long term conditions (LTCs). The developments to date, and future targets are detailed in „Appendix 5 Long Term conditions‟. The framework is summarized in the schematic below. Chronic conditions management – the WCDHB framework, The Patient’s Journey Environment Healthy At Risk Acute Event Initial management Long term clinical and Self management End of Life Care Healthy public policy and creation of supportive environments Non-italics= existing service Italics= proposed service Healthy Schools; Smoke free; HEHA: Community events; Breast feeding; Men‟s health; Green Rx; Health promoting practices CVD and diabetes screening, follow up for those at highest risk Smoking cessation Diagnosis, hospital admission Pre-hospital fibrinolysis Diabetes Pulmonary rehabilitation, Cardiac rehabilitation, Arthritis and diabetes education/ support groups PHO LTC: Focus on, CVD, diabetes , COPD: clinical and self management support CareLink and AT&R assessments and MDT review for more complex Cancer navigators Palliative care funding in primary care UNDERPINNED BY THE WEST COAST‟S 7 PILLARS OF CHRONIC CONDITIONS MANAGEMENT Business case EoI V38 AC 25Feb10 Page 31
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: providing the majority of care). Th
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:
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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
Page 103 and 104:
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
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Ambulatory Sensitive Hospitalisatio
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% CVD on lipid lowering drugs, beta
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Health navigators/ kaiawhina: chan
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Committee‟s objectives 41 of prov
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- lack of consistency of care betwe
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qualifications and skills. Where ca
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6 Deliverables / activities Impleme
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“With an aging population and an
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Differences between revenue generat
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Appendix Seven: Integration - Healt
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It is expected that HealthPathways
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Year two implement the process to
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Low uptake by primary and secondary
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Appendix Eight: Improved access to
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to easily access by telephone). Oth
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Year One - July 2010 to June 2011 T
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LECG 50 evaluated whether “the im
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Appendix Nine: Referred services 1.
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them by technical errors or lack of
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Identify patients that would benefi
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• Provision of patient specific m
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12 Organisational accountabilities
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emain under the care and management
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Service user pathways in an optimal
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Model for shared care pathways deve
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Implementation plan: to June 30 Dev
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Year two Review progress, outcome m
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10 Risk analysis Risk Probability I
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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
Page 207 and 208:
8 Effect on inequalities The increa
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Appendix Fifteen: Project advisory
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