Better Sooner More Convenient Primary Care - New Zealand Doctor

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Goal 5. Better: Improving co-ordination of care between general practices, hospitals and community providers Objectives Key activities Associated projects More co-ordinated care from the wider multidisciplinary team Co-ordinated support for high needs patients with LTCs Integrated mental health Better access to the range of services for frail older people Closer links with Māori providers Closer links with NGOs Closer links with pharmacy Shared information MDT clinically focused meetings in each IFHC and satellite clinic Lay navigators Clinical nurse specialists based in or linked with IFHC Allied health providers based in or linked with IFHC One entry point to primary and secondary care Establishment of co-ordinator roles Primary care involvement in discharge planning, shared care arrangements Community mental health workers and psychiatrists see patients in IFHCs Free primary care checkups and flu vaccinations Care link in IFHCs Pathways of care Case management with key clinical workers and heath navigators Processes for referrals to and from Shared approach to LTC – CVD screening Regular monthly forum at each IFHC Newsletters Locum prescribing guide Medication reviews Written My Shared Health Record for patients with LTCs Web based patient record, eg. MedTech Manage My Health portal ED access to general practice notes General practice access to Health Views Improved referral and discharge information Shared electronic clinical notes across all providers based in IFHCs Integration: DHB community based services Integration: DHB community based services Mental health Frail older people Long term conditions Long term conditions Integration: DHB community based services IFHC facilities Goal 6. More convenient: community based care in integrated family health care Objectives Key activities Associated projects IFHC established All community based services located in 3 integrated family health centres, IFHCs facilities Business case EoI V38 AC 25Feb10 Page 68
Devolved community based services with satellite clinics for more remote areas Community nursing, allied health, Care Link devolved to primary care Integration: DHB community based services Devolved specialist services Direct access to secondary services Move some First Specialist Assessments (FSAs) follow-ups to IFHC when workforce issues solved Expand direct access to radiological investigations Health pathways Improved access to diagnostics Remote clinical support Telemedicine Acute care Goal 7: Greater clinical leadership Objectives Key activities Associated projects Clinical engagement in leading change Shared training Ensuring staff spread across IFHCs maintain professional relationships Clinical leaders planning workshops Enhanced practice Quality Improvement (QI) teams Training centre for rural excellence providing multidisciplinary education Peer support and development for each professional group Core general practice redesign Integration: DHB community based services Workforce Integration: DHB community based services Goal 8: Living within available funding Objectives Key activities Associated projects Return DHB owned and operated practices to profitability Return other DHB owned & operated services to profitability Engage clinicians within practices in identifying the problems & owning the solutions Reduce unnecessary and/or duplicated management layers Transfer practices to NGO (PHO) ownership(?), and apply private sector disciplines Engage clinicians within services in owning the problem and identifying the solutions Reduce unnecessary and/or duplicated management layers Transfer services to NGO (PHO) ownership(?), and apply private sector disciplines Governance, ownership, management Governance, ownership, management Cost effective prescribing Analyse current spend for laboratory Referred services Business case EoI V38 AC 25Feb10 Page 69
Page 1 and 2:
Business Case Better, Sooner, More
Page 3 and 4:
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
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: Expanded pharmacy roles Improving a
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
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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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