Better Sooner More Convenient Primary Care - New Zealand Doctor

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The programme is both based on the Wagner Chronic Care model 1 (self-management support, community support, delivery system redesign, clinical information systems and decision support) and the Kaiser Triangle stratified care approach 4 . The Programme meets the National Health Committee‟s objectives 5 of providing effective chronic care management and co-ordination through using a population health approach to care delivery, based on level of need, both clinical need and need for self-management support. There is a focus on those with conditions that are frequent or severe, and these are addressed by national evidence based clinical guidelines and are responsive to enhanced primary care management, and have outcomes that can be tracked over time to measure improvement (cardiovascular disease [CVD], diabetes, and Chronic Obstructive Pulmonary Disease [COPD]). The DHB and the Ministry of Health both approved the content of the long term conditions (LTC) management programme in late 2008, including giving permission to allocate all LTC funds (diabetes annual review, Care Plus, some Section J contract lines and some SIA funding) into a global budget for this programme. The programme is based on all patients with diabetes, CVD or COPD having an annual review from the time of diagnosis, and then based on their clinical condition and ability to self manage, a decision is made as to the level of care they require for the following year, based on clinical need and self management competency. Implementation of the programme has gone well in 2009 using the IHI Breakthrough Series methodology. A recent evaluation 6 of the implementation showed high acceptance by practices and increases in the numbers of patients with LTCs managed in a proactive and planned manner – now 1419 in Care plus, 1061 in level 1, 300 in level 2 and 27 in level 3. The key objectives of the next stage of LTC management are: To increase implementation of the programme so that over 70% of all patients with COPD, CVD and/or diabetes have an annual review followed by a timely package of care appropriate for their level of need. Development of a Māori team within each IFHC who will focus on improving access and health outcomes for Māori. To review the management of Level 3 patients and enhance the integration between general practice care and AT&R, Care Link and nurse specialist care and allied heath To enable and empower people in the community to obtain, process and understand health information and services needed to make appropriate decisions about their health. To develop health navigator support services for Level 3 patients who have difficulty accessing health care and social services 4 World Health Organisation Innovative Care for Chronic Conditions: Building Blocks for Action: Global Report 2002 WHO document no. WHO/NMC/CCH/02.01. 5 National Health Committee People with Long Term Conditions A Discussion Paper National Health Committee Wellington May 2005 6 North D, Tracey J. Evaluation of the IHI Breakthrough Series Project for West Coast PHO. Jan 2010. Business case EoI V38 AC 25Feb10 Page 32
To better integrate the support provided to patients by CNSs, allied health and medical centres, eg. through better communication and information sharing. To link with the activities described in the health promotion work stream. The expected outcomes from this programme are set out in the table below. Outcome measures – for all and for Māori Indicator Baseline Target – Yr 1 Year 2 Year 3 % diabetes HbA1c
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: The Community Health System Deliver
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
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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:
Page 97 and 98:
established. This group now oversee
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Output measures Tobacco control / s
Page 101 and 102:
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
Page 109 and 110:
The Community Health System Deliver
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Clinical care Practice self managem
Page 113 and 114:
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
Page 127 and 128:
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
Page 187 and 188:
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
Page 197 and 198:
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
Page 209:
Appendix Fifteen: Project advisory
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