Better, sooner, more convenient health care in Midlands

MihimihiKo te amorangi ki muaKo te hapai o ki muriA clear vision and direction aheadA strong and dedicated team to give substance to those dreamsTena koutou nga karangaranga, a whānau, a hapu, a iwi huri noa i to tatou rohe, te iwi e tiaki nei i ngaahika i te Taihauāuru ki te Tairawhiti.Greetings to all, to families, to groups, to communities, throughout our area, the people who keepthe home fires burning from the West to the East.E mihi ana ki te ropu kua ngaro nei i te kitenga kanohi, te hunga kua huri atu ki tua o Te Arai, tehunga kua eke nei ki roto ki te okiokinga whakamutunga mo tatou mo te tangata. Ko ratou te hungawairua kia ratou, moe mai, moe mai, moe mai, ko tatou nga whakatipuranga e whai atu nei i o ratoutapuwae, tena koutou, tena koutou, tena koutou katoa.We remember those who we can no longer see, those who have crossed the great divide, those whoentered into the last resting place for mankind. To those of the Spirit World we say sleep and rest inpeace, for us the generations following in their footsteps, we say greetings.I te tau e rua mano ma iwa, i puta te wero a Te Kawana kia ara ake nga kai whakaruruhau a tenarohe, a tena rohe ki te whakaaroaro i nga mahi hauora tuatahi hei engaringari. I te Taihauāuru ki teTairawhiti, i runga i tera whakaaro ka whakahonoa nga mahi a Hauora Maori me nga takuta otena rohe.In 2009 Government challenged districts and communities in New Zealand to take charge of theirown health issues by thinking about how to improve primary care. From the West to the East, thechallenge was taken up between Maori Health Providers and Medical Practitioners of that area.The Midlands Network strives to achieve excellence in designing and delivering effective primarycare services within their area. As the majority of the people living in Midlands are enrolled with ourPHOs, this provides a diverse range of priorities including geographic, age, gender, ethnicity anddeprivation boundaries.Ahakoa he uaua te huarahi e whaia nei e te Midlands Network, engari, ko te wawata ka puta eneikaupapa hauora ki nga iwi o enei rohe, no te mea, ko te nuinga o nga iwi kua rehita i raro i ngawhakahaere hauora o enei ropu. Ka taea e ropu te kawe enei kaupapa hauora ki nga tangata katoae noho nei i roto i nga rohe, ahakoa kei whea e noho ana, ahakoa pehea te pakeke, ma i ngamokopuna tae atu ki nga kaumatua, ahakoa maori, ahakoa iwi ke, tae atu ki te hunga rawakore.The Midlands Network looks forward to the future, secure in the knowledge that it has beenbuilt on the successes of the past, coupled with the need to continually improve. The MidlandsNetwork welcomes the opportunity of working with you to improve the health and well being ofour communities.Kei te marama te huarahi kei mua ia Midlands Network, no te mea i tipu ake tenei kaupapa hauorai runga i nga mahi aatahua o nanahi nei me te whai atu i nga taumata o enei momo mahi. He mihiatu nei tenei kia koutou, nga iwi o Taranaki, Waikato, Tuwharetoa me Turanganui a Kiwa hoki. Ko tetumanako, ko te wawata, kia noho ora ai koutou me a koutou whanau, ki o koutou nohoanga, ki okoutou kainga, ki o koutou marae, huri noa te rohe o iwi katoa.Acknowledgements:The organisations involved with the Midlands Network wish to thank Wirangi Pera raua ko Libby Kerr(Turanganui a Kiwa) for their valuable contribution in the area of translation.Ahakoa he iti, he pounamuAlthough it is small, it is of greenstone4

Index5. Community – A focus on health literacyA focus on Health Literacy - Self-management supportHealth literate patients will:A Health Team informed of and actively addressing health literacy needsA Network committed to improving their Health Literacy standardsScope of planned Initiatives6. Our network – a focus on workforce knowledge, skills and attitudePutting primacy back into primaryMedical PAs, Flow Teams and Patient AdvocatesCentralised and Coordinated Education TeamIT systems and trainingDevolution within General Practice – (legal and social status)7. Delivering on health targetsMaternity and Child healthHealth targetCurrent performanceNeeds projectionsRegional PromisesWhat needs to changeHow we will implement that changeKPIsRelationships that will make it happenSmoking and LifestyleHealth targetCurrent performanceNeeds projectionsRegional PromisesWhat needs to changeHow we will implement that changeKPIsRelationships that will make it happenCardiovascularHealth targetCurrent performanceNeeds projectionsRegional PromisesWhat needs to changeHow we will implement that changeKPIsRelationships that will make it happen6

Index cont.DiabetesHealth targetCurrent performanceNeeds projectionsRegional PromisesWhat needs to changeHow we will implement that changeKPIsRelationships that will make it happenMental healthHealth targetCurrent performanceNeeds projectionsRegional PromisesWhat needs to changeHow we will implement that changeKPIsRelationships that will make it happenOlder PeopleHealth targetCurrent performanceNeeds projectionsRegional PromisesWhat needs to changeHow we will implement that changeKPIsRelationships that will make it happen8. Funding requirements9. Performance measuresQualityPeriodic Service Review10. Letters of Support7

Executive Summary1Executive SummaryThis Expression of Interest represents a regionalapproach combining the thinking, efforts and consensusopinion of a wide range of parties in the MidlandsRegion, a region which covers the four midland DHBareas of Gisborne, Lakes, Waikato and Taranaki.This document outlines how we believe we can reduce acute demand in our region through theongoing provision of better, sooner, more convenient primary healthcare.This is an action plan.In almost all instances National Frameworks exist, Midlands strategies have been formulated,guiding principles agreed – in short the bureaucracy surrounding health delivery has done whatbureaucracies do – write. What it has failed to do is deliver. That is where this document will differfrom those it follows.It pulls together the various well-intentioned and cleverly formulated statements of intent andactually plugs them in to deliver better, sooner, more convenient Healthcare.We have identified 6 key areas and $65.8 million worth of services that are currently purchased andmanaged by the Midlands region’s DHBs and their provider arms.The majority of these services are community based and the Midlands Integrated Family HealthNetwork believes that by bringing the purchasing and management of these services closer to thepatient we can create radically better outcomes for our community in the form of better, sooner,more convenient healthcare.We are not adding another level of bureaucracy, our plan commits to being Management andAdministration FTE neutral. We will add resources where they can deliver to our community – not tothe fiefdoms of health industry administration.We are proposing moving to a one-plan regional environment. A plan that delivers superior healthoutcomes to 499,995 New Zealanders living in the Midlands region.It will not cost the Government one additional cent. It will however require a change in the way theexisting funding is distributed.10

Devolution becomes aby-product of what needs to happenrather than the focus of the discussion.Services will be located where theybenefit our communities, fundingwill be allocated to where it willhave the most positive outcome forour communities.11

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22. IntroductionA model for better, sooner, more convenient primaryhealth care in MidlandsDevolution becomes a by-product of what needs to happen rather than the focus of the discussion.Services will be located where they benefit our communities, and funding will be allocated where itwill have the most positive outcome for the people of the Midlands region.Therefore the approach that underpins our response is to:1. Evaluate outcomes as they currently occur in our region.2. Explore areas of failure, or areas where we are underperforming.3. Recommend pathways to improve health outcomes for the people in the Midlands region.4. Establish funding and resource requirements to make it happen.This is a considered response to the optimum role primary health can play in the Midlands region,and an indication of the funding required to provide better, sooner, more convenient primary health.Population Served 499,995Our regionThe Midlands region encompasses the four midland DHB areas of Gisborne, Lakes, Waikato andTaranaki containing a population of almost 500,000 people. With the largest number of people livingin towns with a population of 10,000 or less than any other region in the country, our region faces arange of challenges relating to service provision, access and workforce.The unique demography of our region adds to the challenge facing primary health. With a highproportion of Maori, and their generally poorer health status, coupled with the ageing of themajority Pakeha population, the Midlands region will have to face greater increases in workload thanare likely to occur in many other regions of New Zealand.14

2IntroductionA model for better, sooner, more convenient primary health care in MidlandsNetwork GP Consultations2006 2016 2026AnnualNumber ofGP Consultsin theNetworkProportionAnnualNumber ofGP Consultsin theNetworkProportionAnnualNumber ofGP Consultsin theNetworkProportion0-4 yrs 142,175 13.0% 127,183 10.7% 126,087 9.8%5-14 yrs 99,749 9.1% 88,137 7.4% 82,086 6.4%15-24 yrs 88,427 8.1% 84,174 7.1% 73,827 5.7%25-44 yrs 186,651 17.1% 178,392 15.0% 185,063 14.4%45-64 yrs 268,837 24.7% 303,225 25.6% 281,869 21.9%65-84 yrs 262,029 24.0% 338,670 28.6% 447,240 34.7%85+ yrs 42,524 3.9% 66,441 5.6% 92,595 7.2%1,090,393 1,186,222 1,288,766Network FTEs: 2006 - 2016CurrentWorkforce(2006)Estimated %Change inAnnual GPConsultationsby 2016Number ofNew RecruitsRequired toCompensateEstimatedIncrease inConsultationWorkloadTotalWorkforceNeeded toMaintainCurrentLevels ofServiceNo. that willpotentiallyretire at age65 yearsPotentialNumber tobe recruitedby 2016GPs 28425 309 57 82+ 8.8%PNs 349 31 380 64 95Network FTEs: 2006 - 2026CurrentWorkforce(2006)Estimated %Change inAnnual GPConsultationsby 2026Number ofNew RecruitsRequired toCompensateEstimatedIncrease inConsultationWorkloadTotalWorkforceNeeded toMaintainCurrentLevels ofServiceNo. that willpotentiallyretire at age65 yearsPotentialNumber tobe recruitedby 2026GPs 28452 336 181 23318.2%PNs 349 63 412 206 26915

IntroductionA model for better, sooner, more convenient primary health care in Midlands2These complex shifts in the age and ethnic composition of our population make the provisionof better, sooner, more convenient primary health essential for the Midlands region. Both toensure access to primary health and to help a shift to a healthier population through improvedpreventative healthcare, without which our secondary services will be overwhelmed withpreventable chronic disease.Social Report Indicators National MidlandsLife expectancy (years, 2000-2002, male) 76.5 75.6Life expectancy (years, 2000-2002, female) 81.4 80.7Cigarette smoking (%, 2005) 22.5 24.5Suicide (rate per 100,000, 2001-2005) 13.7 14.0Participation in early childhood education (%, 2007) 99.3 97.6School leavers with higher qualifications (% NCEA Level 2 or higher, 2007) 66.2 59.1Educational attainment of the adult population (%, 25-64 years, 2007) 76.0 73.8Unemployment (%, 2007) 3.6 3.5Employment (%, 2007) 75.4 77.7Median hourly earnings ($, 2007) 18.0 17.0Workplace injury claims (rate per 1,000 FTEs, 2006) 126.6 153.6Population with low incomes (%, 2006) 18.0 19.4Household crowding (%, 2006) 10.5 9.4Voter turnout – Local authority elections (%, 2007) 43.0 41.2Representation of women in local government (%, 2007) 35.8 34.5Maori language speakers (%, 2006) 21.3 24.9Language retention (%, 2006) 55.6 49.4Participation in physical activity (% 5-17 years, 2001) 68.4 71.8Participation in physical activity (%, 18+ years, 2001) 67.7 66.9Drinking water quality E. coli compliance (% of population, 2006/2007) 78.7 67.2Drinking water quality Cryptosporidium compliance (% of population, 2006/2007) 66.9 34.8Recorded criminal offences (rate per 10,000 population, 2007) 1008.5 1030.6Road casualties (Injuries per 100,000 population, 2007) 375.0 432.3Road casualties (Deaths per 100,000 population, 2007) 10.0 20.5Telephone access in the home (%, 2006) 94.2 93.5Internet access in the home (%, 2006) 63.8 59.416

2 IntroductionA model for better, sooner, more convenient primary health care in MidlandsThe Duty of Care modelWhat it looks likeThe Duty of Care principle focuses on the experience of the patient and their journey through thehealth system.Duty of Care in action is a patient never feeling unsupported on their journey through thehealth system.It is a patient receiving the right information, in the right place, at the right time, in a format theyunderstand. It is a workforce being acutely aware of the points in the healthcare system wherepatient care is transferred and not letting that patient slip through the cracks.It relies on having solutions focused staff who understand that when things go awry, patients andtheir families need both answers and advice quickly. It is staff who understand that the health systemcan be complicated, scary and intimidating and who work to find ways to make it less so.It means if you are lost we will help you find your way.How it worksDirect, Consistent and Managed Communication between Health Team and the PatientFor the Midlands Integrated Family Health Network to achieve true Duty of Care for their populationan entirely new level of patient engagement is required.In an increasingly technologically savvy world where a large percentage of people now haveaccess to a mobile phone or the internet, very rarely do we even look to record our patients’ emailaddresses yet alone use them in any meaningful manner. Our enrolled population, through thingslike online ticketing and banking, now has some base level expectation that these high priority itemscan, and will, be managed by the person themselves in an online and secure environment.Patient expectation of their healthcare system is that they should be able to communicate with usby email and yet the reality is often very disappointing and certainly not secure. The IntegratedFamily Health Centre must take responsibility for communicating with their enrolled population viathe medium that their enrolled population prefers. With the appropriate communication methodsharnessed a programme of wellness screening can begin.The process will be patient centred with a focus on self-management. The underlying goal howeveris improved patient understanding of healthcare situations where lack of comprehension can havevery real consequences.In the Integrated Family Health Network communication at a generic level will be managed centrally.The network will carry the responsibility for managing relationships at a regional level while theIntegrated Family Health Centre retains responsibility and communication milestones at a patientinformation level.A focus on wellness and preventative care in order to reduce acute demand on secondaryservices.“The burden of preventable chronic disease on the patient and his or her carer, family and whanau,the community and the nation is minimised through optimisation of processes of prevention, earlydetection, self-management support, clinical treatment and coordination and end of life support.”17

IntroductionA model for better, sooner, more convenient primary health care in Midlands2Duty of Care has a particular focus on the preventative care end of the primary care servicespectrum. It works from a base assumption that the more connected people are to their healthoutcomes, the more self aware they become of their own bodies and the need to care for them.Providing points of engagement with the Integrated Family Health Network that are well focusedinstead of sickness focused means more opportunities for patient engagement and awareness.Patients will receive a “birthday” reminder as an opportunity for the patient to reflect on theirengagement with the health system over the past year and key milestones that require screening inthe year ahead. The patient has the opportunity to update their own wellness record (either online,by mail or over the phone depending on patient profile). Enabling patients to reflect on their ownlifestyle changes in the past year and their wellness profile also gives them control and the ability toself-manage their own health.A baseline set of data on all patients can flag for the practice -• areas that need attention for the individual patient• trends that could be addressed in the first instance through group visits• non-engaged v engaged patients - those who do not engage in an online forum• those who are unable to be contacted via any medium whatsoever.A whanau ora based approach to the goal of self-management in the community is vital to theoperation of the Integrated Family Health Network. Self-management for the individual is supportedby a family, whanau, hapu and community approach to keeping everyone well. Training of unpaidcaregivers and whanau is a crucial part of the model. Creating social connectedness through thesetypes of activity has the added side effect of creating communities and families who are active in themanagement of their own and other’s health outcomes. Greater awareness and education results in awell community with a well focus.Patients will be encouraged to pro-actively manage their own health, initiate their own non-urgentand screening appointments and re-fill their own prescriptions. The theory behind this being thatthese type of patient interactions can be managed in a more effective fashion.Moving toward the goal of self-management for those with chronic conditionsTo reduce the overall health burden we will work to empower patients to move toward the goalof self-management. Where a patient has been identified as being “at risk” or of having a chroniccondition, all interactions between the Health Team and the patient will focus on the goal of selfmanagement.Health Teams will provide a level of service to a Network wide series of service standards ensuring aNetwork wide level of consistency. Mobile and Community Health Care Teams will be specific to theirlocale and community however. A team may be based in an area specific to the Integrated FamilyHealth Centre population that requires significant support (Older Persons), a geographic location orcommunity, a cultural or hapu based group or a specific ethnic community.Strategies to achieve self-management will include:• Support visits.• Group Visits.• Lifestyle reassessment and goal setting.• Whanau and Household Management.• Education sessions for family, whanau, caregivers in supporting self-management.Key to the concept of self-management is the issue of understanding and overall health literacyof our patient population. All Integrated Family Health Centres will be involved in screening for a18

2 IntroductionA model for better, sooner, more convenient primary health care in Midlandslevel of Health Literacy - information will be delivered accordingly and with the right combination ofsupport people or materials in place. All members of the Health Team will adopt use of the “CUT”method when communicating with their patients.Improvements in patient outcomes will be measured by movements in the following indicators:• Increase in access to appropriate care.• Reduction in disparities in health outcomes.• Increase in overt patient satisfaction.Focus on finding and reconnecting with our disengaged populationFor many people health milestones simply drop off the radar. In some cases people simply don’tknow they should have been keeping up to date with specific health milestones while in otherspeople don’t want to engage with the system. This may be because of a poor previous experience orwhere the element of trust between Primary Care and patient has been broken.Duty of Care means the Integrated Family Health Centre accepts responsibility for its entireenrolled population. Resource will be dedicated to locating and re-engaging with those patientswho have become disengaged from the system. It will be the Integrated Family Health Networkthat manages the engagement and that carries the risk of a disengaged population achieving poorhealth milestones.This means that where a patient has disengaged, the Integrated Family Health Network will takeresponsibility for pinpointing the appropriate method of re-engaging the patient with their corehealth milestones. More often than not this is about keeping records current and staying in touchwith a range of different systems and points of contact. The Duty of Care approach acknowledgesthat there are a range of reasons that patients become disengaged from their practice and the rangeof solutions to re-engagement can be just as diverse.Where there is low engagement with screening - the Flow Team will have access, via the CommunityReferral Centre to specialist outreach services.Development of Points of contact and “pathways in” for Social ServicesInteragency Collaboration is the buzz word of todays Public Service environment. While SocialService environments are quick to acknowledge and include health services as a core part of theirdelivery model (and vice versa) real and tangible examples of the two working together appear to befew and far between. This has been one of the very real examples of “failure to care”.Interfaces between services where the information is lost; the patient is asked to repeat their ownstory over and over again on a number of fronts. Fixing this problem is a significant issue for thespectrum of social services. The Integrated Family Health Network will work to address this issuein the first instance by working with Social Service agencies in the region so that there is awarenessaround who to contact when they need health information. They will aim to have a better everydayworking relationship between Health and Social Services as well as increasing the level of trustbetween the two.The core Flow Team will work to become experts at re-engagement strategies with the first goalbeing re-engagement with screening. This may be a strategy that begins through communitymembers or opinion leaders, it may be through the Kaiawhina or Patient Liaison role. The FlowTeams will hold open and active relationships with their communities.19

IntroductionA model for better, sooner, more convenient primary health care in Midlands2Old WayNew WayMum and Dad remember seeing something in the Well Childbook about a 3 month immunisation but they have lost thenumber of their Well Child Nurse. Dad rings the family doctorbut asks about the Well Child nurse and is told that Well Childisn’t run from the practice.John has had a sudden and unplanned stay in hospital. Thehospital team let him know it is time to go home. Discharge isto be managed by John and his family. John has a prescriptionand a discharge letter as a guideline. He does not know who tocall if he needs help. No one in John’s family owns a car.Kylie has seen the ads on TV about breast screening andcervical smears. Her maternal grandmother died of breastcancer but she googled breast cancer and it said it onlymattered if breast cancer was in the paternal side of the family.The Integrated Family Health Centre manages the milestonesof every patient. If a patient has become disengaged (forwhatever reason) from the health system the Flow Team at theIntegrated Family Health Centre work to locate the child andre-engage them and their family with the goal of achievingtheir core health milestones.The Regional Referral Centre coordinates the discharge andliaises with both the family and the Integrated Family HealthCentre to ensure all parties know what follow up care Johnrequires. A Integrated Family Health Centre CommunityHealth Team member visits John in hospital and identifiesthat transport home for John will be an issue. The CommunityHealth Team coordinates travel arrangements and ensures theright level of support is provided for John once he is home.Kylie receives a piece of communication on her birthday thatreminds her of any screens she has had over the last twelvemonths and what she will require over the next twelve months.She completes her online screen and adds a query aboutbreast screening for the Flow Team. The Flow Team contact herthe next day and book her for a breast screening appointmentat a time that suits her.20

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The Integrated Family Health NetworkA regional focus on improving patient journeys33. The Integrated Family Health NetworkA regional focus on improving patient journeysWho are weOur 11 regional partners are:• Hauora Taranaki• Lake Taupo PHO• Peak Health Taranaki• Pinnacle Group Limited• Pinnacle Incorporated• Taranaki Primary Health Provider Inc• Tui Ora• Te Hauora o Turanganui a Kiwa• Turanganui PHO• Tuwharetoa Health Services Ltd• Waikato Primary HealthThe proposal is to formalise the relationship between our partner organisations to form what wehave called the Midlands Integrated Family Health Network. This regional approach to healthprovides the scale we require to deliver better, sooner, more convenient healthcare to the totalMidlands population.The network focuses on putting the primacy back into primary care. It focuses on the role of primarycare as being truly critical and belonging at the forefront of a patient’s healthcare.It comprises several components:• A One Plan environment.• Regional Referral Centre*.• Introducing a newly developed commissioning tool to facilitate needs analysis andservice planning.• Central Co-ordinated Education Network.• 12 Regional Promises to the Midlands Population.• A managed communication programme promoting population health outcomes*.• A strategy aimed at creating an IT ready workforce of digital dinosaurs capable of working withdigital natives.• A Periodic Service Review System.*Solutions apply to the total population of Midlands regardless of the PHO with which they are enrolled.The team who will drive the implementation of the Midlands Regional Network are:• Hauora Taranaki• Lake Taupo PHO• Peak Health Taranaki• Pinnacle Group Limited22

3 The Integrated Family Health NetworkA regional focus on improving patient journeys• Pinnacle Incorporated• Taranaki Primary Health Provider Inc• Tui Ora• Te Hauora o Turanganui a Kiwa• Turanganui PHO• Tuwharetoa Health Services Ltd• Waikato Primary HealthThese seven organisations form the Midlands Integrated Family Heath Network and are delegatedoperational authority and responsibility by the regional partners.All seven of these organisations share a common culture and approach to the delivery of healthto their respective communities. All also operate in a not-for-profit environment and all share acharitable trust legal status and ethos.Existing capabilitiesTransparent ownership and governance arrangementsHauora TaranakiHauora Taranaki PHO was established in April 2003. The PHO has two equal shareholding bodies,Tui Ora Trust and Taranaki Primary Health Provider Inc. Members provide a wide range of servicesincluding first level health services to an enrolled population of 45,734 as at July 2009, which is 43%of the Taranaki population via its 17 practices. There is a vast population across the Taranaki regionthat also receives services from the 16 affiliated NGO providers of Tui Ora Ltd. Tui Ora Trust providesback office support to the PHO and its General Practice members. The demographic profile of theenrolled population as at June 2009 included a total Maori /Pacific Island population of 6,315 (12.8%)with a deprived population index of 15.2%.Lake Taupo PHOLake Taupo PHO was established in January 2003 as a non-profit limited liability company. It isowned jointly and equally by Pinnacle Incorporated and Tuwharetoa Health Services Limited. Thedistrict includes three distinct communities and their respective rural surrounds Mangakino, Taupoand Turangi, a total population of 34,700. The Board is supported by Local Management Groups(LMGs) in each of the three communities. The LMGs are the real eyes and ears of the PHO and withthe support of the PHO look for ways to improve access and health outcomes at a local level usingSIA and HP funding.LTPHO has a strong focus on chronic care through its HealthRight programme and has extendedthis original model to include tele-health, Better@Work and an internal clinical team includingNurse Practitioners, dietitian, social worker, primary mental health liaison nurse, smoking cessationand Living Well lifestyle coaches. It works with other “expert” providers to constantly improve theHealthRight programme including Healthcare New Zealand, Tuwharetoa Health, general practiceand Lifestyle Potential. All of these providers will be critical to delivering on the promises of this EOI.Peak Health TaranakiPeak Health Taranaki (PHT) was established in July 2003 and is one of three Primary HealthOrganisations (PHOs) in Taranaki. PHT has an enrolled population of 52,431 as at July 2009 whichis 49% of the Taranaki population via its relationship with Pinnacle Incorporated and its 16 generalpractice teams. The PHO population has a higher percentage of elderly and high needs comparedwith the New Zealand population. The general practice network covers both urban and ruralsettings, includes solo GPs to large group practices and is spread over North, Central and South23

The Integrated Family Health NetworkA regional focus on improving patient journeys3Taranaki. The PHT Board is supported by 3 Local Management Groups who provide a local interfacebetween the community and PHT. The areas represented are; North Taranaki, New Plymouth andCentral and Coastal Taranaki. The PHO has a mixture of Interim and Very Low Cost Access fundedgeneral practices. The demographic profile of the enrolled population as at June 2009 included atotal Maori /Pacific Island population of 6,068 (11.6%) with a deprived population index of 14.2%.Pinnacle IncorporatedPinInc is a not for profit incorporated society established in the late 1980s to provide support forquality improvement within General Practice Teams across the midland area. It has operated amidland wide quality plan for general practice teams which is currently in its 13th year. It was thefirst network of primary care teams to achieve accredited status (via RNZCGP Cornerstone) andis currently the only primary health care network operating a central events system via its HARMprogramme. PinInc has a current membership of 345 GPs, 381 Primary Care Nurses and 96 PracticeManagers. It is governed by member GPs, Nurses and Practice Managers.Vision: Through the development of strategic partnerships and the development of new models fordelivery ensure the future of a high quality general practice team environment ensuring high qualityhealth outcomes for our patients.Pinnacle Group LimitedPGL has been operating in the primary health care sector for 19 years. It is a not for profit limitedliability company. Since its formation, it has developed a wide range of innovative in-house tools andprocesses to support primary health care services in the midland region. It employs a mix of staffincluding a wide range of clinicians (GPs, Public Health Physicians and Nurses), project managers,accountants, IT specialists, population health analysts and practice administratorsPGL currently provides management services to a number of primary care providers andorganisations. It is independently governed by a board consisting of an independent professionalChair and Vice Chair along with representatives from primary health care providers with businessexperience.Vision: To create a world-leading primary health care environment that is sustainable, valuedand engaging.Taranaki Primary Health Provider Inc.Taranaki Primary Health Provider Inc (TPHP Inc) was established in 2003 as a limited liability companywith not for profit status to partner the Tui Ora Trust as equal, 50% shareholder partners in theformation of Taranaki PHO Ltd, a Primary Health Organisation to trade as Hauora Taranaki PHO.TPHP Inc evolved from a Taranaki based network of general practitioners that was owned andmanaged by First Health Ltd between August 1996 and March 2003. The 17 general practices ofHauora Taranaki PHO are affiliated to TPHP Inc that provides four directors to Hauora Taranaki PHOto represent the interests of the enrolled population and its providers. TPHP Inc is governed byan executive committee and elected by its provider members who are responsible for the society’sactivities.Te Hauora o Turanganui a KiwaTe Hauora o Turanganui a Kiwa (Turanga Health) was established in 1997 as a limited liabilitycompany. The entity represents the three Iwi of Turanganui a Kiwa (Gisborne); Rongowhakaata, TeAitanga a Mahaki and Ngai Tamanuhiri. Over its 12 year history the company has focused primarilyon working within the Turanganui a Kiwa Communities (Gisborne) and has looked to innovateprogramme delivery to address the diverse, and at times complex needs of its service population.As an example, Turanga Health runs a fortnightly Marae Based Kaumatua (Elderly) Programme thatintegrates health and social services to maintain Kaumatua wellness and through information andbetter practices keep them within their own home rather than using residential services or high levelsecondary care services.24

3 The Integrated Family Health NetworkA regional focus on improving patient journeysThe Company employs a mixture of personnel from Registered Nurses, Kaiawhina, Caregivers,Health Promoters, Health Educators and at times brings in Specialist skills to assist with particularneeds ie Podiatry. The Company over this time has also looked to establish strategic partnershipsand has entered into joint venture arrangements to establish the Turanganui Primary HealthOrganisation and also The Vanessa Lowndes Turanga Trust (an entity that provides life skills,vocational and supported employment services to those with special needs). The Company currentlyis looking to establish working protocols alongside General Practice.Tui OraTui Ora Trust was established in 1998 as the shareholder of Tui Ora Limited. The Trust comprisesfour representatives appointed by Kotahitanga, Tui Ora affiliated providers, and four representativesappointed by Te Whare Punanga Korero, the Iwi health forum comprising the eight Iwi of Taranaki.The Trust, as the owner of Tui Ora Limited, is responsible for the appointment of directors to theCompany and ensuring the objectives of Tui Ora Limited are upheld.Turanganui PHOTuranganui PHO (TPHO) is one of two Primary Health Organisations (PHOs) in the Tairawhiti district.TPHO has an enrolled population of 31,500 as at July 2009 which is 70% of the Tairawhiti population.TPHO is owned by Pinnacle Incorporated and Te Hauora o Turanganui a Kiwa (Turanga Health). ThePHO population has a higher percentage of Maori and high needs compared with the New Zealandpopulations. The six general practices and Turanga Health cover Gisborne City with Turanga Healthalso servicing the Maori rural population in the South West. The PHO has 100% very low cost accessfunded general practices.TPHOs primary purpose is helping individuals and families prevent illness and stay well - whai orangatonutanga ki nga whanau kia kore ai e te mate.This is achieved through four strategic goals:• Improving the health outcomes of the enrolled population of Turanganui PHO through improvingaccess, particularly for vulnerable populations.• Enhancing Stakeholder Relationships.• Continually Improving Organisational Development.• Future Primary Care Pathways.Tuwharetoa Health ServicesTuwharetoa Health Services Limited was established in 1995 as an iwi mandated (Ngati Tuwharetoa)health service provider within the Tuwharetoa rohe. Its sole shareholder is the Tuwharetoa MaoriTrust Board, a crown entity established in 1926, initially with a high priority focus on health servicesincluding employing GPs and nurses, but over time focused more broadly as guardians of iwiresources and on the wellbeing of the iwi in all facets of economic and social development.THSL currently delivers a broad range of community based services utilising a whanau ora approachto care including: service coordination for high needs, home based support, nursing services, mentalhealth and health promotion. THSL will be a critical partner to the success of this EOI both in termsof support for the Integrated Family Health Centre in Turangi and the delivery of mobile services.25

The Integrated Family Health NetworkA regional focus on improving patient journeys3Waikato Primary HealthWaikato Primary Health is a Primary Health Organisation that promotes the coordination of healthcare for people in Waikato communities, in cooperation with primary health care providers. Itsprimary purpose is to generate health gains for the 315,000 patients enrolled in the Pinnacle Waikatonetwork by:• Targeting services to areas of highest need.• Using available resources most effectively.• Improving access to primary health care services.• Integrating and coordinating primary care services.Outside of Hamilton, the Waikato region is characterised by a significant number of smaller townsthat largely serve rural communities. Local Management Groups (LMGs) have been established incluster groups corresponding to ‘communities of interest’. The areas represented are; Hamilton,Thames/Coromandel, Central Waikato, Matamata, North Waikato, South Waikato, King Countryand Taumarunui.“To have the healthiest population in New Zealand through leadership, innovation and partnershipswe will build and connect quality primary health care services which meet the health needs ofour people.”WPH is governed by member community/patient representatives, health professionals andindependent professionals.Clinical governance and leadership that has direct input into decisionmaking and implementation of improvementsKey to our approach, and to our submission, is a need to rebuild the contracting environmentmoving to a regional Midlands IFHN commissioning approach that supports regional, local (PHO)and practice-based commissioning.This model is shown below as a partnership between the Midlands Clinical Governance Group(MCGG), the Midlands Commissioning Board (MCB), The PHOs, the practices and Integrated FamilyHealth Centres and the people.This is a manifestation of a think regional, act local, philosophy which underpins our approachto everything.In essence we need to manage a shift away from the existing funding environment, which impedesdelivery of patient centred healthcare, to a one contract, one plan approach which enables theflexibility we need to design and deliver services where, when, and how, they are needed at alocal level.To do this the IFHN will establish two bodies responsible for guiding the commissioning and deliveryof services in the Midlands region; the Midlands Clinical Governance Group (MCGG) and theMidlands Commissioning Board.26

3The Integrated Family Health NetworkA regional focus on improving patient journeysIntegrated Family Health Network Commissioning ModelMCGGMCBWhatHowPHO PHO PHO PHO PHOWhereIFHCs and other PracticesPeopleThe establishment of the Midlands Commissioning BoardThe Midlands Commissioning Board (MCB) is made up of appointees (with specific agreedcompetencies) of the seven Midlands Integrated Family Health Network member organisations. Itsmembership will also include two independent members, one of whom will be the chair; and fromtime to time, specialists co-opted as required.This group provides a Midlands lead contract point for negotiating both regional and nationalfunding agreements, as well as enabling improved systems and capabilities for commissioningregional, local and practice level healthcare, without impacting the autonomy of the partnerorganisations.The MCB will ensure access to tools which will allow more effective regional and local commissioningof health services by the partner organisations and practices to improve the quality of outcomes forthe populations we serve, including:• leading the achievement of better health and well-being for the midlands community• reducing health inequalities by ensuring funding decisions are based on need• commissioning high quality services in partnership with clinicians and patients designed to meetthe needs and preferences of people regionally and locally• creating the right balance of co-operation and contestability to ensure that communities andtaxpayers benefit.In order to ensure that health provision, whilst reactive to individual needs, never loses sight of theregional population perspective, targets, and indeed promises, the MCB has a key role putting in27

The Integrated Family Health NetworkA regional focus on improving patient journeys3place incentives and support to ensure that locality based commissioners are empowered to provideinnovative high quality services to meet the needs of their population.This dual approach to service provision will ensure that the board will more effectively ensure thatthere are appropriate and proportionate arrangements in place for managing regional, local andpractice-based needs.The establishment of the Midlands Clinical Governance GroupClinical leadership, engagement, and involvement are fundamental to the development andcommissioning of effective and high quality primary health care services. The Midlands Networkrecognises the need for a strong clinical perspective in decision making concerning both regionaland local strategic planning and implementation of sustainable health care services acrossthe Network.The MCGG will have within its core membership: members of the Integrated Family HealthCareTeam (GPs, Primary Nurses, Pharmacists etc), Public Health Physicians, District Health Board GPLiaisons, Member of Maori Advisory Group, Laboratories representatives, Medical Advisor, NursingAdvisor, Quality Advisor, Population Health Advisor, District Health Board GM Funding and Planning,Secondary Medical Advisory, Community Services Manager.Other co-opted expertise as required could include: Physiotherapy, Podiatry, Dentistry, InformationManagers etc.The MCGG will work in partnership with central and local planners, Local PHO Boards, LocalManagement Groups (LMGs) and other key stakeholders, in identifying the needs and models ofservice, and to ensure the development of high quality, effective, safe and accessible services forthose enrolled in the Midlands Network.Key to the MCGG role will be the promotion, establishment and ongoing support forinterdisciplinary care. Interdisciplinary care is about organising services around patients in such a waythat it improves the care, communication and health outcomes for people. It calls on each disciplineto collaborate, to draw on one another’s expertise and to ensure that the very best care is providedfrom the expertise available amongst the professions for a particular person and their whanau.The role of MCGG will include the following four keys areas:1. Considering new and emerging policy developments affecting the health care sector (andparticularly the Midlands Network);This will include:• Discussing ideas for new initiatives in health care planning and provision;• Developing strategic position statements/discussion papers regarding new directions /developments in the health care sector;• Recommending strategies, policies and multi-level action to improve health andreduce inequalities;• Align advice as much as possible with key health care strategy documents.2. Guide strategic direction on new and existing health initiatives with the Midlands Network with aview to sustainability;This will include:• Evaluating strategies/projects under development within the partner organisations as well asexisting interventions, with particular emphasis on clinical and broader strategic relevance androbustness, process, quality and outcome measures;• Provide direction for improving existing health care initiatives across the Midlands Network;28

3 The Integrated Family Health NetworkA regional focus on improving patient journeys• Assessing new initiatives for clinical practicalities;• Identifying the impact of new/proposed initiatives on primary and secondary services;• Recommend and advise on quality and outcome measures for locally deliveredactivities/projects.3. Provide clinical guidance on the development and delivery of Midlands Network wide services;This will include;• Advice on the implementation of appropriate strategies to support clinical governance/qualityin provider services;• Approving/improving service specifications for primary care services;• Considering whether clinical and administrative processes are able to be practically applied;• To oversee Network wide services, identify any problems with services, and advice on possibleimprovements to services.4. Facilitate primary-secondary collaboration and/or integration.This will include:• Identifying service gaps in the delivery of primary care services or at the interface betweenprimary and secondary health services.Information management development that can enable new models ofcare, improve quality and efficiently deliver servicesPrimary sector health information systems are currently restricted by two key factors, firstly thelegacy systems of the monopoly provider and secondly, the significant underinvestment that is beingmade by the sector. The current small scale of the underlying business structure continues to undercapitalise due to real concerns around nil return on investment via the current market structure.Currently the Midlands Network has been unable to find an “off the shelf” solution that will supportthe new models of care being proposed. Our Network’s response to this is to stretch the capacity ofthe existing systems using the current Medtech Evolution Patient Portal and look in the second waveto shifting to a centrally hosted and managed environment.The introduction of a new information system that can bring all health services closer togetherregardless of setting will require strong central leadership and investment. The Midlands Networkwill participate in these discussions but will in the first instance look to pushing existing systems.Linked to this strategy will be a one tool per desktop policy where solutions will need to integratewith the existing solutions.For example, Manage My Health is an electronic patient health record tool from Medtech thatgives individuals the opportunity to manage their own healthcare. The tool gives the individualsaccess to their own medical records and results from their key family care provider, and to sharethis information with other providers which in turn allows them to better manage their dailyhealthcare needs.The tool is fully integrated with the current Medtech solution that 80% of practice teams currentlyuse as a practice management system and allows two way communications from the individual tothe provider through a safe portal. The Midlands Network will look in the first instance to use thisplatform to create a patient centric platform. Additional optional applications such as txt2remind willplay a key role in bridging the gap with the new technology natives of the network.BestPractice Clinical Decision Support has now been installed in all practices within the MidlandsNetwork and provides the network with a web based platform supporting complex patient29

The Integrated Family Health NetworkA regional focus on improving patient journeys3encounters with direct access to the latest international best practice information. The platformalso has the capacity to be expanded to support the full spectrum of primary and allied providersmeeting patient and community needs. In combination this approach will allow the network tomake the initial gains while at the same time giving the national process currently underway time tobear fruit.This approach will ensure that we have the basis for supporting the new models of care but also thatwe are well positioned to adopt new national systems as they arise.Capability to deliver services that are consistent withWhānau Ora approachesWhānau ora as stated in the Ministry of Health policy document He Korowai Oranga, defined as‘Maori families supported to achieve their maximum health and well-being’. It is important to notethat by the deeds and actions that have permeated this expression of interest, the Midlands Networkis reflecting whānau ora in action.The Midlands Network as evidenced by the recognition of the eleven regional partners is apartnership with Maori model. Through the treaty based PHOs involvement, the development of theexpression of interest has seen Maori have effective input into service planning, development anddesign from the early stages of thinking.There is a commitment through the establishment of the Midlands Commissioning Board andMidland wide Clinical Governance Group to partner with Maori in the planning, implementationand monitoring of better, sooner, more convenient primary care services. The Midlands Groupis confident through strong existing relationships of our capability and processes in the area ofpartnership governance.Our commitment to Duty of Care sharpens the decisions that are needed to improve the quality ofhealth services delivery for Maori patients and whānau. Through the establishment of the IntegratedFamily Health network we will ensure that programmes are established that utilise the range ofresources available across the sectors in cost effective consolidated services. For Maori this willbe reflected in our newly developed commissioning tool to facilitate needs analysis and serviceplanning, our regional promises, improved patient journey, work in health literacy and managedcommunication plan.The Midlands Group recognises that our workforce needs to reflect our population and commit tothe active development and growth of the current and future health workforce that strives to ensurethat Maori receive improved service provision.The approach taken by the Midlands Group ensures a regional commitment with local delivery.Therefore, at grassroots whānau, hapu, and Maori communities are supported to achieve theirown aims and aspirations for whānau ora. This is reflected in the view that the key is putting thepatient at the centre of everything we do. For whānau, hapu and Maori communities this will seemore information shared and more active dialogue to sharpen the whānau ora aspirations to ensurefunding is distributed according to need.The Midlands Group is confident that through partnership governance, structure, processes andactions we have the capability to deliver services that are consistent with whānau ora approaches.30

3 The Integrated Family Health NetworkA regional focus on improving patient journeysCapacity to provide improved workforce development opportunities,such as training facilities to support primary health care placements fora variety of disciplines (e.g. General Practice, Nursing, Allied Health)The Midlands Network has a range of workforce development opportunities working in pocketsacross the region. This currently includes:• Scholarships for undergraduate and post graduate study such as medicine, nursing, midwifery,podiatry, physiotherapy, occupational therapy, mental health, para-medicine, pharmacy,oral health etc.• Post graduate nursing scholarships for those already working in primary health care.• New graduate nurse pathway targeted to attract newly registered nurses to general practice. Itis structured as a one year internship programme where new graduate nurses work in urban andrural locations. The new graduates are supernumerary so are able to focus on learning.• Adding to this will be the additional capacity to ensure training programmes and placementopportunities are better supported across the Midlands Network and within Integrated FamilyHealth Centres.Two key enablers will be focused on, creating physical space set aside for teaching and learning andthe space within busy professionals days to support and provide the teaching role.Additional partnerships will be developed with education facilities to bring industry training into theprimary care health sector context to ensure all Integrated Family Health Centre protect and nurturetraining capacity.Processes to meaningfully engage consumers and the communityCommunity participation is a key component of the New Zealand Primary Health Care Strategy.The minimum requirements for Primary Health Organisations did not specify how the communityvoice should be heard at the governance level but did specify that PHOs must be responsive totheir communities and have genuine processes for including community, iwi and consumers in theirgoverning processes. Community participation in decision making happens at different levels indifferent ways.The Midlands Network will rely on the strong local connections with communities and other keystakeholders that have been developed and nurtured by the PHOs. Each has within their owncommunities developed a range of responses to local needs.In most cases PHOs are currently operating within the midrange of the ladder of participation. Acontinued commitment to developing higher degrees of participation is a fundamental given withinthe Midlands Network.District Health Board involvement and supportSupport and ongoing dialogue has been sought from the CEOs and GMs of Funding and Planningin each of the Midlands District Health Board areas covered within this EOI. Each District HealthBoard has indicated support for the Midlands Network proposal and for the enhanced anddeveloped role that primary care will play within the new environment. Some of the proposals withinthe EOI challenge the existing accountabilities for District Health Boards and the crown fundingagreements however there has been a range of discussions supporting the exploration of new waysof doing things collectively.Each District Health Board has also been asked to contribute a list of priorities and ideas for theEOI to address both local and regional needs from their perspective. This has contributed to theidentification of a range of ideas some which will be further developed via the business development31

The Integrated Family Health NetworkA regional focus on improving patient journeys3stage. Some tensions have arisen around some individual District Health Boards view that fundingshould be ring fenced around District Health Board boundaries. It is the one plan, “think regional-actlocal” discussion however that has contributed to the ongoing development of ideas.See Letters of Support from the CEOs of the four District Health Boards Lakes, Taranaki, TDH and WaikatoThe strength of our relationships with key stakeholders, clinicians,practitioners and the communityThe Midlands Network partners pride themselves on their local and regional relationships. Spreadthroughout the Network are multiple mechanisms for ensuring that dialogue and engagement is aliving process.Supporting the initial Expression of Interest are attached letters of support from key stakeholdersincluding:• Pinnacle Incorporated Board - representing 100 General Practice Teams.• Board of each partner PHO - representing the enrolled population.• Waikato Pharmacy Group - on behalf of pharmacy within the Midlands Network.We have also received enquiries from and started a range of discussions with a large number ofother parties that we would like to explore working with in regards to specific elements of businesscase development.Improving patient journeysThe Integrated Family Health Network utilises scale where itimproves outcomesThe network focuses on putting the primacy back into primary care. It focuses on the role of primarycare as being truly critical and belonging at the forefront of a patient’s healthcare.As part of this submission we are making 12 regional promises to the population we serve.12 Regional Promises to the Midlands PopulationTo Midlands children, young people and their familiesPromise 1:Promise 2:No Midlands child will be left behind.Midlands will have a well child focus (as opposed to a sick child one).To the Midlands populationPromise 3:If you are enrolled with a Midlands GP then you will be invited to complete a healthscreen once a year. Any issues flagged from that screen will be followed up with you(includes the option to decline the screen).To those people in Midlands living at risk of a cardiovascular eventPromise 4:Promise 5:Free Cardiovascular Risk Assessments for the eligible population(determines Diabetes).If you live at risk of a cardiovascular event you will have a Chronic DiseaseSelf-Management Plan.32

3 The Integrated Family Health NetworkA regional focus on improving patient journeysTo those people in Midlands at risk of or living with DiabetesPromise 6:Promise 7:If you live with Diabetes you will have a Chronic Disease Self-Management Plan.The Midlands region will rebuild the Annual Reviews, Diabetes and Renal Care forbetter outcomes.To those people in Midlands who experience mental illnessPromise 8:Promise 9:If you live with mental illness you will have a Relapse Plan that is current andactively managed.If you live with mental illness you will have a single point access for all yourhealthcare needs.To the older population of MidlandsPromise 10:Promise 11:As an older person living in Midlands you will have a goal focused CareManagement Plan.As an older person living in Midlands you will have single point access for all yourhealthcare needs.To those people who have become disengaged from the health systemPromise 12:If you are lost we will help you find your way.Primary Health has, and always retains, the primary Duty of Care for their patients on that journey.Our role as a region is to provide those at the coal-face with the tools they need to ensure each andevery journey is optimised.To ensure that no one goes into an administrative black hole or a diagnostic cul-de-sac. That no onefails to fill a prescription or attend a specialist appointment. That no one goes undiagnosed due toan administrative blunder. That no one finds themselves in a sleep-out in the back-blocks of ruralNew Zealand with a dialysis machine and no support.To do this we need to focus on not only providing the very best direct primary health care, we alsoneed to take responsibility for the points of transfer throughout their life, and ensure that at no stageare they “dropped”.This will be achieved by implementing the following:Access to Medical RecordsWe need to place the patient, and by extension, his or her records at the centre of the system.Their primary health team are the guardians of a patient’s health – but it is they who have ultimateresponsibility. Similarly, we are the guardians of their health records – but it is they who own them.This ownership needs to be reflected in terms of access and transparency. It is this transparencyand access that will also improve the ability of health providers to collaborate on any individual’sheath care.Currently the Midlands Network cannot find an “off the shelf” solution that will support the newmodels of care being proposed. The proposed response to this is to stretch the capacity of theexisting systems using the first wave patient portals and look to shift as many systems within the firstwave Integrated Family Health Centre to a co-located hosted and managed environment.This approach will ensure that we have the basis for supporting the new models of care but alsothat we are well positioned to inhale and adopt new systems as they arrive on the scene vianational processes.33

The Integrated Family Health NetworkA regional focus on improving patient journeys3This Expression of Interest uses the currently available MedTech Evolution as its core PatientManagement System. This new version of Medtech contains the following functionality:• Demographics.• Clinical Audit Trails.• Recalls and Screening.• Prescribing.• Accounts.• Appointments.• Multimedia Capability.• Health Management Tools.• Resource and Equipment Management and Venue Management.• Electronic Patient Connectivity.Community Managed Regional Referral Centre/Patient Access HubA continuing problem in the management of the interface between sending and receivingpractitioners has been the standard of referrals. Patient access to secondary services has oftenbeen hindered by referrals from sending practitioners that lack the detail or information requiredfor secondary care to make informed and timely decisions. Sending practitioners have becomeconfused over what constitutes an adequate referral.The result is that primary care has lost faith in its own system - referrals can be sent as many as 14times via myriad different methods in the belief that this will “get the referral through”. Primary Careneeds to acknowledge their role in the resulting disconnect and seek to address the issues that havearisen as a result.A community managed Regional Referral Centre will provide all primary and secondary care staff,patients, and community organisations within the Midlands region, with a service where they needmake only a single call in order to have a spectrum of queries answered. The aim of the RegionalReferral Centre is to coordinate and improve the patient journey while striving to keep Duty of Carethe guiding principle in all instances. A community managed Regional Referral Centre will providecoordination of Duty of Care for all patients requiring services across the Midlands Network.The Integrated Family Health Network will work with sending practitioners to ensure• Referral quality from sending practitioners is high resulting in better quality referrals for receiving practitioners.• Referral out to NGOs where services are available, more practicable and provide easier access.• Information and summary is provided to both sending and receiving practitioners.• Sending practitioners feel confident that all they need make is a single contact (with the right information provided) and thatDuty of Care for that patient will be handled by the Regional Referral Centre.The Integrated Family Health Network will work with receiving practitioners to ensure• Receiving practitioners have specified information they require in a referral.• Discharge information is provided to Primary Care (including pharmacy).• Urgent items in discharge information are flagged with Primary Care.• Medication changes, discontinuation is flagged to Primary Care.• Sending practitioners can have timely responses to referrals that meet the specified standard.• That once discharge occurs the receiving practitioner can be confident Duty of Care has been managed by theRegional Referral Centre.34

3 The Integrated Family Health NetworkA regional focus on improving patient journeysThe Integrated Family Health Network will work on behalf of patients to ensure:• No patient is left behind.• Duty of Care is managed on the patient’s behalf.• Information provided by the Regional Referral Centre to the patient and/or their family is in plain language and meets basichealth literacy standards.• The Regional Referral Centre will communicate all information to both sending and receiving practitioners on thepatients behalf.• Family and whanau are respected as a fundamental component of the patient’s well-being and kept informed of patient’sdischarge status where relevant.The Regional Referral Centre will provide time-framed responses to both sending and receivingpractitioners involved in the referral process. All contacts in and out of the referral centre will takeplace via a six “lines of care” with each line requiring extensive algorithms to be developed.It is acknowledged that while components of this service exist in many locations within each ofthe District Health Boards none of the services are patient focused or aim to provide an end toend Duty of Care model. Primary Care coordinating and owning the role of managing referralsmeans accountability on all sides of the process and increased standards of referrals fromsending practitioners.The Regional Referral Centre will have access to• Diagnostic booking schedules.• Transport and Accommodation budgets and bookings.• First Specialist Assessment appointments and procedures bookings.• Interface between primary and secondary care.• Community knowledge on where and when to refer.• Hospital Discharge schedule and information for coordination of follow up care withcommunity teams.• Community knowledge of regional boundaries of who provides services to whom.• Integrated Family Health Centre Health Teams.• Network Community and Mobile Teams.An e-referral system that interfaces with Medtech does currently exist in the Midlands area.Supported by BPac, Electronic Clinical Decision Support is an effective mechanism for transferringreferrals electronically and would form the basis of any network wide electronic based approachto referrals. The system uses pre-specified information according to referral type and intendeddestination and interfaces with patient notes, history and medication records appropriately.Leverageing off the BPac Electronic Clinical Decision Support and the subsequent e-referralsolution, the Midlands Network will move to all referrals being electronically transferred to receivingpractitioners within 12 months. The use of Electronic Clinical Decision Support specialty specificmodules will assist with improving the quality of referrals made by sending practitioners.While electronic referral will always form a core part of any approach to running an efficient andeffective Regional Referral Centre which operates in a timely manner, it is important to note thatelectronic processes are only one mechanism by which referrals can be made. The point of theRegional Referral Centre is to coordinate enquiries from a number of points of entry and to providea “no wrong door” set of responses where service and way finding are the key elements of a processwith the aim of Duty of Care.35

The Integrated Family Health NetworkA regional focus on improving patient journeys3The Regional Referral Centre will coordinate Duty of Care for the following five lines:• Clinical & Provider Pathways.• After Hours and Self-Management Service.• Discharge Process.• Diagnostics.• Travel & Accommodation.CLINICAL& PROVIDERPATHWAYSTRAVEL &ACCOMMODATIONREGIONALREFERRALCENTREAFTER HOURS& SelfmanagementSERVICEDIAGNOSTICSDISCHARGEPROCESSClinical & Provider Pathways LineThe emphasis here is twofold:a) improving the standard of referrals from the sending practitioner and;b) providing a timely service to sending practitioners regarding the nature, content, resultTime-framedand best destination for their referrals.• A commitment to arrange a consultation time for the patient with the appropriate practitionerinside a 30 minute time-frame.• Referrals are processed inside a set time-frame and either returned to the Integrated FamilyHealth Centre for more information or booked with secondary care and a response communicatedto all relevant parties (including pharmacy).• Fast service for referrals according to priority.36

3 The Integrated Family Health NetworkA regional focus on improving patient journeysInformed• Specialised advice regarding appropriate destination for referrals.• Advice to Integrated Family Health Care Teams other practitioners re: clinical pathways, private,public and NGO options for services.• Regional Referral Centre actively contributes suggestions to the referral conversation keepingsending practitioners informed of alternative, supplementary and/or complementary options foradditional and wrap around services.• Consistently mindful of the Duty of Care commitment by the Network to the patient.• Management and knowledge of cross-practice referrals to primary care specialists.• Confidential.• A confidential “no wrong door” line for enquiry by Social Services and Education for queriesrelating to correct approaches to health based issues that present in the community.Discharge Process LineFocus on a patient centred discharge process which transfers Duty of Care to a community team in atleast the short term (one follow up visit at least).The aim of this line is to address an issue that is poorly managed across the Midlands region. Theaim is to coordinate the discharge process along the core principle of Duty of Care resulting in:a) coordinated support for the patient and their family/whanau and;b) coordinated information for primary care regarding the patients care plan.Coordination• A nurse (from the Community Team) to visit the patient in hospital to assess and coordinateservices in the home once discharge has occurred.• A patient centred discharge process which transfers Duty of Care to a community team who willvisit the home within 48 hours to assess.• The provision of support for overcoming any barriers the patient and/or their caregivers have toachieving self-management.• A discharge process that focuses on comprehensive care planning and transfer of caremanagement and communication.• Nobody is sent home without Primary Care acknowledging their knowledge of the situation.Guaranteeing consistency across the Network• Regional Referral Centre adhering to established standards for Primary Care follow up andcommunication with family/whanau.• Discharge letter of prescription summarises discharge medications (what has been stopped,changed and started).• Public Health Nurses use this facility to ensure children’s records are transferred to theappropriate file.37

The Integrated Family Health NetworkA regional focus on improving patient journeys3Diagnostics LineTime-framedThe Regional Referral Centre commits to provide an appointment time inside XX minutes to thesending practitioner and the patient.AccessThe Regional Referral Centre has access to the following Diagnostic booking schedules:• Audiology.• Ultra-sound.• Endoscopy.• Colposcopy.• Radiology (Private and Public).• Vision & Hearing Testing.• Other Diagnostic Services.Travel and Accommodation LineConsistency of service• Timely assistance with transport arrangements.• Access to the right bed.• Reduced transport delays.Patient focused• Patients are transported to and from the right facility for the right service as quickly as possible.• Family/whanau know how, when and why this is occurring.• Booking systems for travel and accommodation that accounts for follow up care and whanau/family communication.After Hours & Self-Management LinesProviding the right information, in the right place, at the right time.• The Midlands Network will extend existing after hours solutions (including both hubs and sub-hubs) linked to Midland triage services.• An after hours service that when help is required, ensures patients know where to go, what toexpect and how to access follow up support.• The Midlands Network will ensure that the patient can access advice for acute services when theyneed them within 45 minutes.• Opportunities exist to partner with existing call centres such as St John’s to develop this MidlandsNetwork Service.• Health Information.• Chronic Disease Self-Management Support (overflow).• Tele-psychiatry.• Overflow - Telephone Triage for patient-initiated contact.38

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44. The Integrated Family Health CentreA local focus on taking control of the dayWhat is an Integrated Family Health Centre?An Integrated Family Health Centre involves a team of interdisciplinary professionals workingcollectively to manage the Duty of Care for their enrolled population. A set of non-negotiableminimum service standards defined by the Network determines whether or not a Primary Careservice can step up to the role of an Integrated Family Health Centre. Further customisation of theCentre in the form of commercial, clinical, virtual or allied services, is provided according to theneeds or demands of the enrolled population. As a result, each combination of services at a centrewill be unique and based on the population served.In an Integrated Family Health Centre every member of the Healthcare Team applies the Duty ofCare principle to every aspect of patient care for every enrolled patient.The Healthcare Team uses commissioning tools to predict work-flow as well as actively manage theirenrolled population. Management of that work-flow is achieved by analysing each Integrated FamilyHealth Centre’s population and active management of the enrolled population towards achievingindividual wellness goals.The result is overt patient and staff satisfaction through the refocusing of each staff member on theircore roles and skills.40

4The Integrated Family Health CentreA local focus on taking control of the dayThe Integrated Family Health Centre analyses its enrolled population extensively.Focusing on three areas of population• Engaged population.• High Risk populations.• Non-engaged populations.That have three levels of self-management• Self-managing (online/ tele support available).• Self-managing (support required).• Not self-managing (support required).Across two service delivery methods• Pick up: The patient receives their care from the in-situ Health Team located at the Centre. Thepatient travels to their health team to receive their service.• Delivery: The patient has chosen for personal reasons (access, geographic distance, culturalappropriateness, language barriers, physical mobility, whanau/family support) to receive their carein a community or household setting. The health team travels to the patient to deliver their care.Integrated Family Health CentreDeliveryReturn to engagedPickup• Mobile Nurse Team• Health Coach• Kaiawhina/Patient LiaisonNon-engagedPATIENT ADVOCATEMEDICAL PAFlow Team• GP• Nurse Team• Pharmacists• MidwiferyThe Healthcare Team is a wrap around health service for the individual. Time is spent introducing theteam to a person’s family and/or caregivers. According to patient expectations the GP will continueto be the lead clinical provider for the individual patient but unlike traditional arrangements, theentire team will carry the Duty of Care for the patient with everyone sharing information, resourcesand key tasks.The Healthcare Team itself is made up of three core elements:A core primary health team located in-situ at the Integrated FamilyHealth Centre:Who they are:• General Practitioner• Nurse Team (Enrolled Nurse, Registered Nurse, Tamariki Ora / Well Child Nurse, Disease StateManagement Nurses and Nurse Practitioners)41

The Integrated Family Health CentreA local focus on taking control of the day4• Community Pharmacists• Midwifery ServiceWhy they exist:This team becomes an individual’s health care team and takes on the responsibility of deliveringhealth care to their enrolled population. They provide coordinated, managed patient centred careto acute, chronic and well patients alike. Their focus is on the whole team providing the patients carewith each team member providing a key component of that circle of care.What they do:Self-managing (support available)Self-managing (support required)Not self-managing(support required)Well patient groupFocus on keeping the patient wellActive managementAchieve health milestones inside timeframesActively manage imms milestonesMonitor patient journey through thehealthright wheelReview information provided by thepatientReview changes in patient situation forpossible health risksRecommend wellness programmesHealth EducationRefer for secondary careTreat acute needsRecommend wellness programmesHealth Education and PromotionManage interventionsPatient centred management plansReview and plan with patient selfmanagementplansOversee Duty of Care model withcommunity management plansRefer for secondary careTreat acute needsRecommend wellness programmesHealth EducationManage interventionsPatient centred management plansReview and plan with patient selfmanagementplansOversee Duty of Care model withcommunity management plansDiscuss management optionscase conference for solutions withteamInter disciplinary team managementManagement Continuum42

4 The Integrated Family Health CentreA local focus on taking control of the dayFlow Team servicing both mobile and in-situ teamWho they are:• Patient Advocate role• Medical PA for all General Practitioners• Patient Flow WorkersWhy they exist:Focused on patient satisfaction, patient engagement and maintaining a complete baseline recordof the patient’s health record. The Flow Team is a dedicated amount of resource that is focused onkeeping the day moving according to a team plan. They are the conduit or fulcrum between thein-situ and the community team. Their core mission is to keep the largest possible proportion of theirenrolled population engaged.Engaged High Needs Non- EngagedManage pre visit planningReview workflow and plan accordinglyCoordinate patient centred careAnswer patient phone-callsMake follow up contactUpdate patient records post and previsitManage call backsManage regular check up apptmentsManage patient health milestonesMeet & greet - provide pre visitscreeningLiaise with referral centreOversee IT and admin systemsAllocate walk in capacityCoordinate team work in progressManage patient expectationsOrganising General Practitioneravailability for case conferencingEnsuring General Practitioner availabilityfor case conferencesEnsuring General Practitioner availabilityfor triage situations from communityteamsLocate non-engaged patientsManage interface between communityand in-situ careStakeholder management andengagementHold key community relationshipsKeeping community team up to dateFlag alerts needing particular attentionor sensitivityFlag inter-agency visiting on complexcasesHelp access to fund solutions to barriersfor engagement (childcare, travel etc)What they do:A Health Care Team working in the community but based at theIntegrated Family Health CentreWho they are:• Mobile Nurse team (Healthright Nurse, District Nurse, Public Health Nurse)• Health Coach• Kaiawhina/ Patient LiaisonWhy they exist:Patients often prefer, for a variety of reasons, to receive their care in the community. A team thatcomes to a patient’s home or another more neutral setting in the community can often overcomebarriers to access that can be seen as overwhelming in an in-situ setting. This team provides timeframed,coordinated General Practitioner lead care and ensures a more wrap around service for thepatient and their family.A team may be based in an area specific to the Integrated Family Health Centre population thatrequires significant support (Older Persons), a geographic location or community, a cultural or hapubased group or a specific ethnic community.43

The Integrated Family Health CentreA local focus on taking control of the day4What they do:Non-engagedDischarge from HospitalSupport required to work towardsself-managementLocateVisitWork with communityWork with family/whanauNo wrong doorLiaise with other community agenciesCoordinate complex case approachFocus on not overwhelming familyIncrease circle of indirect monitoring forU5s and over 65sEnsure patients are comfortable withdischarge instructionsVisit patient in hospital to plan at homecareSupport and advise familyCoordinate access/supportEnsure prescriptions are filledEstablish self-management plansEnsure patient understands instructionsto achieve self-managementReview self-management planProvide clinical assistance whererequiredCoordinate services where requiredLiaise with General Practitioner in orderto deliver appropriate careTime-framed regular care for chronicconditionsProvide education/support/guidance ingroup based situations specific to theneeds of the communityClip ons - customising with the optional extrasEach enrolled population brings with it it’s own specific elements and subtleties. Some communitiesmay have cultural or ethnic commonalities while others may share an age band spectrum orgeographical region.While every Integrated Family Health Centre will have its own base set of mandatory components, aseries of Centre Specific clip ons are available according to need, want, relationship or patient focus.The opportunity exists, where there is space and energy, for other non-clinical clip ons to be addedthat may serve to add further synergies or levels of convenience for an enrolled patient base. Suchelements should be considered as a part of the planning process wherever an Integrated FamilyHealth Centre is established and appropriate community decisions made at the time.Clinical / Allied Commercial Non-clinicalPhysiotherapyPodiatryDiabetic PodiatryOccupational TherapyNaturopath ServicesAccupunctureCounsellorsRongoaMirimiriDentistSpecialistsElective SurgeryMole MappingDietitiansNutritionistMassageCafeBeauty TherapyGymNatural HealthAlternative TherapiesHairdressersYoga/Pilates StudioRest HomeCACI ClinicsDaycareLarge scale employerWork & Income Case WorkersHeartland CentreChild, Youth & FamilyAge ConcernPromoting ParticipationStudyLink44

4 The Integrated Family Health CentreA local focus on taking control of the dayMinimum capability to be classed anIntegrated Family Health CentreWithin the Integrated Family Health Network there are geographical groupings of both virtual andphysically co-located providers who will form the basis for Integrated Family Health Centres. Usingadvanced commissioning tools, the Midlands Network will establish and build Integrated FamilyHealth Centres drawing together local services in packages required to meet the local health careneeds of a population.ProcessesIntegrated Family Health Centre Learning Plan in placeRIP Process (Rapid Implementation Process)Business ModelHarm Reduction RegisterPLPs and Integrated Family Health Centre LPsUse of the commissioning tool to analyse population and predict both work flow and plan work forceStaffingIn-situ Health Care Team (General Practitioner, Nurse Team, Pharmacists)Community Health Care Team (Mobile Nurse Team, Health Coach, Kaiawhina, Patient Liaison)Flow Team (Patient Advocate, Medical PA, Flow Team)Formalised relationship with LMC/Midwifery ServicesPharmacy as part of core health team (contractual relationship to purchase time)Online Capacity and FunctionalityOnline Patient ScreeningSecure emailMedtech EvolutionTXT to remind functionalityOnline webhealth touch screen for interactive pre and post screening and careEvery staff member has their own email address, internet access and Microsoft OfficeStandardised IT proficiency requirements for every Integrated Family Health Centre staff memberServiceWellness model of careUse of Double Diamond consultation method for all practitionersCommitment to Health Literacy standards and Health Literacy ScreeningCUT Method used by all staffPharmacy Clinics (managing a list of activities consistent with Integrated Family Health Centre accreditation)Integrated Family Health Centre AccreditedPopulation Focus - establishing some baselinesKey in moving towards a patient centred model of health care is an understanding of the consumer’sneeds, where they are located and how best to deliver the services to them. At the highest level,we can use the concepts of population health to provide a view of the overall health burden apopulation places upon a health system in any particular area.The health burden is simply the sum of all the users of the health system weighted by their relativedemand for services within it i.e. older people have a higher health burden than well people etc.45

The Integrated Family Health CentreA local focus on taking control of the day4It provides a useful overview of health system demand for high level resource allocation. Whenpopulation growth projections are applied it can be used to indicate future changes in demandpatterns, and provides graphical confirmation that without change the demand on the health systemwill become unsustainable.Midlands Network: Total Health Burden nowHigh Health BurdenMedium Health BurdenLow Health BurdenMidlands Network: Total Health Burden 20 years46

4The Integrated Family Health CentreA local focus on taking control of the dayAs a proof of concept the health burden model has been developed using demographic informationwithin mesh blocks, and disease prevalence ratios, checked against available disease coding data, toproject concentrations. The application of health burden becomes far more useful when applied tosmaller populations within areas covered by Integrated Family Health Centres, where the particularcharacteristics of the population and actual disease coding data can be used to refine the method tosub mesh block geographic coding.Incorporating other patient characteristics of engagement and their capability for healthmanagement against the health burden provides the ability to determine the nature of servicedelivery to the population within the Integrated Family Health Centre and other allied primary andsecondary health providers. The determination of the health service burden within a particular areaallows for far better planning of the health service resources required to support it.Integrated Family Health Centre Commissioning ToolGenderEthnicityIFHC EnrolledpopulationQuintileAge BandsPOPULATIONPrevalence RatesDiabetesCardio VascularMental HealthHealth BurdenYouth HealthWell / LifestyleDiabetesCardio VascularMental HealthOlder PeopleUserNeedsProfileEngagedNot EngagedSelf-ManagementSupport AvailableSelf-ManagementSupport RequiredNo Self-ManagementSupport RequiredNeeds ProfileService BurdenYouth HealthWell / LifestyleDiabetesCardio VascularMental HealthOlder PeoplePick UpDeliveryRequired HealthProvider Capacity(IHFC and AlliedProvider FTEs)Service StandardYouth HealthWell / LifestyleDiabetesCardio VascularMental HealthOlder PeoplePick UpDeliveryHealth ProviderBy Service TypeYouth HealthWell / LifestyleDiabetesCardio VascularMental HealthOlder PeopleConceptual model of the Commissioning Tool: Helping plan both staffing structure and workflowaccording to patient needs.47

The Integrated Family Health CentreA local focus on taking control of the day4Pharmacy as a valued part of the Health TeamIn an Integrated Family Health Centre, the Community Pharmacy and the Pharmacists will not onlybe included as part of the core Health Team but have access to the same MedTech system used bythe Centre. Pharmacists will be able to view patient records as part of the team. Communicationbetween the Flow Team, GPs and the Pharmacist will be seamless and the Pharmacist will be ableto double check any scripts with items of concerns with General Practitioners instantly. The DrugInteraction Alert System will be used regularly by General Practitioners and learnings reinforced byall parties.Community Pharmacies and Pharmacists will move to become part of the core Health Team. Theirprofessional knowledge will become a significant component of the working day and the circle ofpatient knowledge. The Integrated Family Health Centre will capitalise on a pharmacist’s ability toprovide follow up knowledge and support.As a member of the Health Team the Pharmacist will fill a key role in every patient’s coordinated caseconferenced Care Plan. In addition to this, Community Pharmacy will support the Integrated FamilyHealth Centre by providing the following services:• Comprehensive Warfarin Counselling;• Smoking Cessation Counselling;• Medicine Use Reviews;• Free Emergency Contraception for under 25 year olds;• Flu Vaccination Campaigns;• Waste Management Contract and DUMP (Disposal of Unwanted Medicines Programme);• Medication Counselling Service for patients initiated on medicines for mild tomoderate depression.Integrated Family Health Centres will work to ensure that scripts written by General Practitioners formedication are up to date. The aim is to reduce the number of scripts that are never picked up andincrease communication between all parties. Using a central record will mean that Health Teams willbe able to see instances where a prescription was never filled and enquire as to the reasons why.Follow up will form a central part of the new model of working for the Pharmacist. TXT forprescription pick up and follow up will become a central component of all Integrated Family HealthCentres. Anyone who doesn’t fill their script within 24 hours will receive a text follow up or reminderfrom the Pharmacist or Flow Team. Prescriptions will be able to be ordered and refilled online andpicked up or couriered directly by the pharmacist.Self-Management - support to self-manageIt is acknowledged (Doolan-Noble: 2009, Bycroft and Tracy: 2006, MOH: 2009) that patients have thegreatest influence on the outcome of their health, they decide when and what to eat, when they willexercise, when they will rest, when they will take their medication yet WHO states that ‘patients andtheir families are the most undervalued assets in the health care system’ (WHO: 2002).In order to capitalise on the influence of patients and their families in the management of long termconditions, health sector designers and funders state more emphasis needs to be placed on theconcepts of self-management, self care and self-management support.Telephone Support allowing Patients to self-manage their own health outcomesTele-health involves the use of tools and resources that connect patients and providers both at aninteraction level and a health information level. Examples include, at the simpler level, the use oftelephone, text message or email interactions to improve contact between the health service andthe patient to interactive monitoring of long term conditions which activates remote health careservices and adjustments of treatment plans.48

4 The Integrated Family Health CentreA local focus on taking control of the dayOnline/Mobile Phone functionality for the patient and the Health TeamBefore the visit After the Visit AnytimePre-populated question templatesVisit preparationOnline booking systemsOnline booking options (my doctor orany doctor, appointment duration etc)Request and cancel non-urgentappointmentsPatient selects amount of time they feelthe appointment will takeTXT appointment remindersTXT 2 Remind functionalityIntegrated Family Health Centre canview online lab resultsNotes from visit available online postvisitFollow up care plans available againstpatient fileTXT Message prescription follow upPatient appropriate follow up after everyvisit (TXT,email, phone, visit)Interactivesdrtom.com (sexual health website)Help 4 USecure email correspondenceConversations with General Practitioner(on phone)Communication around healthmilestonesDialogue around being wellEffective communication when a majorhealth event occursThe Patient Online Health ProfileEvery Integrated Family Health Centre patient will have their own online health profile. The coremeasurement for engagement will be patients who have had contact with the practice in the last12 months. Flow Teams will constantly work with all enrolled patients to have them complete theirbaseline health screen.What is it? How is it used? To do what?A patient controlled and centred onlineenvironment that has as its’ centralelement a baseline health screen.The screen forms a core part of selfmanagementfor the patient.Online base health screen updated bythe patient on an annual basisContains patient widgetsContains online question builderIs interactiveContains secure email connection withHealth TeamUpdated pre-visit and post-visitIs monitored and reviewed by staffIs used to measure engagementManagement of patient engagementaround pre-set health milestonesBirthday contactBy the patient in their own time at theirown convenienceAssist the patient in the active selfmanagementof their healthKeep the Health Team up to date with apatient’s current health needs.Anticipate any things that need followup pre visitFuture proof the Integrated FamilyHealth Centre against patientexpectations around managing theirhealth in an online environmentPatient will be able to see and choosethe duration of their appointmentTargeted communication with identified populations around core health and well-being issues.Online profiles can also be used as an effective method of communication with the population in theevent of a major health emergency (swine flu).Online baseline screens are not the solution for all but as patient expectation for onlinemanagement of personal information increases primary care must work to increase connectivitybetween patient and health team. Those who are not able to access an online environment will beassisted with completing their baseline health screening by the Flow Team.Patients are given patient instructions after a visit - for follow up care, lifestyle adjustment, actionplans, or advice, future screening dates etc. It is easy to understand and comprehend. The patientcan refer back to it via the self-management support service at any time.49

The Integrated Family Health CentreA local focus on taking control of the day4Integrated Family Health Centres:Where will they be located?Within the first 12 months there will be nine Integrated Family Health Centres establishedthroughout the Midlands Family Health Network. The proposed sites have been chosen based on arange of factors that include:• interest in and willingness to try new models;• where there is an urgent need to develop new facilities;• fragility of existing services;• high needs populations;• willingness to be flexible with the existing business model or to try alternatives.The sites below share a high level of readiness for change. It is assumed there are a number of othersites within the Midlands Network that will want to shift status as the model evolves.WhitiangaMercury Bay Medical CentreHamiltonNew Plymouth(2x IFHC)1. Carefirst2. Maru Wehi IntergratedWhanau Ora SiteTurangiPihanga HealthGisborne (2x IFHC)HaweraPateaWhile not everyone will be able to move to an Integrated Family Health Centre at once, theIntegrated Family Health Network will provide all practices and providers with access to a greaterflexibility of funding.The health burden maps that follow have been developed using demographic information withinmesh blocks, and disease prevalence ratios, checked against available disease coding data,to project concentrations. Incorporating other patient characteristics of engagement and theircapability for health management against the health burden provides the ability to determine thenature of service delivery to the population within the Integrated Family Health Centre and otherallied primary and secondary health providers. The determination of the health service burden withina particular area allows for far better planning of the health service resources required to support it.50

4 The Integrated Family Health CentreA local focus on taking control of the dayWithin 12 monthsHamilton (Hamilton City)Co-located over three sites in North Hamilton, General Practice staff are committed to a philosophyof caring for, and maintaining, a relationship with the patient. Service provision is broad – generalpractice, corporate health, ACC, drop-in, acute triageing, nurse clinics, corporate health checks andvisiting specialists. Each site has a pharmacy co-located and relationships with physiotherapists andconsultants within the Hamilton community.Innovation and exploring new ways of working with their practice population are at the forefrontof discussions with practice staff and all have expressed a willingness to engage in this journey.NorthCare currently has a steady stream of student nurses placed for five week periods as part oftheir training and have registered to become a teaching practice to support the development offuture General Practitioners.Hamilton Health Burden nowHigh Health BurdenMedium Health BurdenLow Health BurdenHamilton Health Burden 20 years51

The Integrated Family Health CentreA local focus on taking control of the day4Pihanga Health (Turangi Central)Pihanga Health 2007 Limited is a fully owned subsidiary of Lake Taupo PHO and now owns twomedical practices. For almost six years recruiting a GP to Pihanga had been an ongoing challengebut with the move into the Turangi Community Health Centre permanent resource has now beensecured. The nursing workforce is highly skilled and continues to provide the backbone of thegeneral practice services. In addition, increased management expertise has been critical to thedevelopment of the practice model.The Turangi Integrated Family Health Centre (Integrated Family Health Centre) will be based in theTurangi Community Health Centre, a $2m development opened a year ago. The centre supportedby grants or low interest loans from Genesis Energy, Bay Trust, Taupo District Council, the PHO and arange of other community groups; is ideally placed to be the base for integration of the key tenantsincluding physiotherapy, laboratory, General Practice, iwi health, Plunket, PHO and District HealthBoard visiting specialists.Turangi Burden nowHigh Health BurdenMedium Health BurdenLow Health BurdenTurangi Health Burden 20 years52

4 The Integrated Family Health CentreA local focus on taking control of the dayGisborne (Gisborne City)Turanganui PHO enrolled patients currently receive services from six General Practices spreadacross Gisborne City. There is one large General Practice based in Kaiti, the eastern largest andmost deprived suburb in Gisborne. It has been clear for some time to the owners of that progressivepractice that the way services are delivered needs to change but the current physical environment isproviding barriers to that change. They have been planning for two years to move to a purpose builtfacility and have worked with Turanganui iwi to achieve that aspiration.With the introduction of the IHFC and IHFN concepts, Turanganui PHO are able to support thatpractice, their 12,000 patients and that suburb to reach their goal. The remainder of the practicesare collectively in the centre and western suburbs and represent smaller group practices and sologeneral practitioners. They have been approached to also consider a western amalgamation thatwould see two Integrated Family Health Centre service the whole TPHO enrolled population withsatellite and mobile services available to those patients unable to access new facilities. The changein physical environments, plus the amalgamation of all general practices, allows Turanganui PHO toexplore different ownership and IT models that will better suit the concept of better, sooner, moreconvenient primary care.Gisborne Health Burden nowHigh Health BurdenMedium Health BurdenLow Health BurdenGisborne Health Burden 20 years53

The Integrated Family Health CentreA local focus on taking control of the day4Mercury Bay Medical Centre (Whitianga: Public Private Partnership)Mercury Bay Medical Centre provides services to the community of Whitianga and surroundingareas on the Coromandel Peninsula. The town is rurally isolated with a 90 minute drive to the nearestA&E and has a population of 3,500 within the town and a similar number in surrounding areas. Thepopulation includes a higher than average elderly population. In addition, the population swells toaround 30,000 during the summer season.The acute care and 24/7 after hours services that the medical centre provides are crucial for such anisolated community. The medical centre has sought to encapsulate an ethos in line with the conceptof an Integrated Family Health Centre. In addition to traditional GP services the medical centre isproviding a range of services including phlebotomy, physiotherapy, radiology and podiatry plus arange of nurse clinics. In addition a range of specialists visit the town on a regular basis includingOrthopedic, Ophthalmology, Podiatry and diabetes services.Community discussions have started around the opportunity to develop a new purpose builtcommunity primary care structure. Local developers have contributed plans and ideas to the localproviders and community to allow them to develop the concept and range of services required.Part of this planning includes how to develop further the provision of training facilities for medicalstudents within the Whitianga area.Whitianga Health Burden nowHigh Health BurdenMedium Health BurdenLow Health BurdenWhitianga Health Burden 20 years54

4 The Integrated Family Health CentreA local focus on taking control of the dayNew Plymouth (2xIFHC)Maru WehiLocated in New Plymouth, the centre was established in 2003 as part of an initiative to consolidatea broad range of kaupapa Maori and mainstream services on a single site. Services include a mix ofonsite and outreach services including a mobile bus service. The scope of services include GeneralPractice, traditional healing and rongoa, primary and whanau ora services, health promotionprogrammes, nursing, Tamariki Ora and Kaiawhina services, home based support services anddisability support services, community based specialist mental health services and employmentsupport services.Maru Wehi is well placed to lead an emerging model of care that aims to improve outcomes forwhanau. A whanau ora approach acknowledges that the needs of an individual are consideredin the context of the needs of their whanau and that the needs of each whanau are consideredin the context of the community that they live in or identify with. Meeting these needs requires amulti focused and coordinated response from service providers. A key principle of the model is anacknowledgment that achieving self determination is central to the wellbeing of all whanau. In thiscontext, services are multi-disciplinary team based, coordinated across sectors including health,social services and education agencies and, when required, are committed to the longer-term needsof the whanau. The model of care would be supported by a robust IT system that will link communityservices together with primary and secondary services.CarefirstCarefirst is the largest General Practice in Taranaki, located in New Plymouth. The doctors associatedto Carefirst are Dr Stephanus Schoeman, Dr Susan Oldfield, Dr Alison Gadsby, Dr Geoff Putt, DrGeoff Tvrdeich, Dr Dawn White, Dr Lucy Gibberd, Dr Vivienne Law, Dr Carey Nazzer, Dr AbagailPoole, Dr Amanda Brown, Dr Lester Kelly and Dr Tom Nicholson. Carefirst runs a walk in clinicseven days a week. Providers linked to this practice include a dietitian, cardiac clinic, men’s clinic,physiotherapy, radiology, plastic surgeon, minor surgery, pharmacy, aural micro-suction, cosmeticappearance clinic and visiting specialists.55

The Integrated Family Health CentreA local focus on taking control of the day4New Plymouth Health Burden nowHigh Health BurdenMedium Health BurdenLow Health BurdenNew Plymouth Health Burden 20 years56

4 The Integrated Family Health CentreA local focus on taking control of the daySouth Taranaki (Hawera)The proposals set out in the Midlands EOI will support a new and exciting model of clinical care andits delivery for South Taranaki. The Integrated Family Health Centre will be a primary, secondary andcommunity integration initiative between TDHB and primary care that will wrap the existing, oftenfragmented services around the community population.The largest GP practice in South Taranaki is the South Taranaki Medical Trust (Trading as SouthCare)that formed in 2003. It is operated out of a purpose built facility opened in October 2005. This facilitywas built on land purchased from the TDHB and is located next door to the Hawera Hospital. Thereare two other GP practices in Hawera and three practices in neighbouring rural towns, includingPatea that will also benefit from the proposed South Taranaki Integrated Family Health Centre.The wrap around services that will initially be integrated into the Integrated Family Health Centrewill be those currently provided by the TDHB that include the allied health services of diabetes,occupational & physiotherapy, podiatry and social work, ACC services including community nursing,physiotherapy, functional reactivation, Otago Falls And Training For Independence Programmes.South Taranaki Health Burden nowHigh Health BurdenMedium Health BurdenLow Health BurdenSouth Taranaki Health Burden 20 years57

The Integrated Family Health CentreA local focus on taking control of the day4Patea Medical TrustThe Patea Medical Trust is a General Practice situated in the south Taranaki town of Patea. It servicesthe area between Manutahi and Waitotara and encompasses the surrounding rural communities. TheTrust Board is elected from the community and is responsible for the overall running of the practice.The Patea Medical Trust shares the building with the Taranaki District Health Board (TDHB) relatedhealth service. The Practice is Cornerstone accredited, fully computerised (MedTech) and is wellequipped for general practice and GP with specialist interest equipment.The general practice has an enrolled population of 2775 (July 2009) has a rural subsidy scoringof 55 and is staffed by 1.5FTE of general practitioner, 2.4FTE Practice Nurse and 2.0FTE practicemanagement.The Patea Medical Trust already exhibits many of the characteristics of an IFHC that will bestrengthened under the proposed strategies of the Midlands EOI.58

4 The Integrated Family Health CentreA local focus on taking control of the dayWithin 2 yearsIntegrated Family Health CentrePopulationWaitara (Taranaki) 5705Stratford 9651Tokoroa 15379Huntly 16530ImplementationChange managementPhase One: Analysis and ModellingExtensive Needs Analysis to establish staffing model according to enrolled population.Core analysis of practice to assess practice’s readiness for change and establish change plan.Current situational analysis• case conferencing mechanisms• use of evidence based treatment guidelines• employment of tracking mechanisms (tests, referrals, results)• pre-visit planning• performance reporting• workflow planning• alternatives to face to face visits• monthly reporting on financial statements• practice strategic vision• patient feedback mechanismsPhase Two: Readiness for ChangeTrain in core baseline Integrated Family Health Centre standards (CUT method, Health Literacy,Double Diamond Method).Establish communication materials around sense of identity with Integrated Family Health Centreand with enrolled population.Prepare staff for the scale of the change. Significant imagination is required because the meaning ofpatient care is going to change.LEAN thinking models established.Capacity employed to deliver increased levels of service.59

The Integrated Family Health CentreA local focus on taking control of the day4Phase Three: Go LiveRIP process (Rapid Implementation Process).Predict and Manage Risks.Account for new scheduling and access arrangements which could serve to confuse and to inhibitpatient care initially. Multiple use of new technology and information can be overwhelming.Phase Four: Support to achieve Business As Usual operationOngoing support from team to guarantee consistent BAU service in accordance with IntegratedFamily Health Centre baselines.Capacity and expectation managementOur vision is a model where we are able to improve quality of care outcomes by empoweringand motivating teams of people who specialise in primary health care. The challenge withimplementation of an Integrated Family Health Centre is to manage the patient expectations in amanner which has them embrace this change:• Promoting everyone in the patient’s health care team as having good professional knowledge.• Promoting everyone in the healthcare team as having a purpose.• Promoting the idea with the patient of “no longer feeling like a number”.• Ensuring a consistent level of service for all patients.• Communicating with patients in a way that is seen as meaningful and genuine from apatient perspective.• Managing of patient expectations (e.g. they won’t see their General Practitioner every time butthey will see someone from their “health care team”).In addition to this, the Integrated Family Health Centre must make a crucial change to the way theyoperate. Becoming more patient centred means asking questions and showing the patient that theirIntegrated Family Health Centre listened. They need to know:• What does the patient want to see?• What does the patient think?• What do they need?• What do they want to change?Patients and communities will see their community health team as an integrated team of peoplewhere the hand is aware of what the foot is doing. Patient stories will contain examples of managedand consistent care - not disaster stories. Patients will become the evangelists. When patients andcommunity stakeholders want advice on a health contact or piece of information they will:• know how to contact the team;• think to contact the team;• respect the team’s advice as expert and professional;• trust the team to deliver on their promises.60

55. CommunityA focus on health literacyA focus on Health Literacy - self-management supportOur health care system places significant reading demands on patients. They must read andunderstand signs, registration forms, prescription bottles, home-glucose monitors, dischargeinstructions, health education materials, and appointment slips. For most health care providers,reading is so much a part of daily life that we think little about this and usually operate under theassumption that all patients can read adequately. Every office or clinic is filled with informationalbrochures for patients. The woman who is leaving the hospital with her newborn may be givenwritten instructions on how to clean the umbilical cord or check for a fever. Busy clinicians may giveprescriptions to patients with minimal explanation.A patient’s ability to be able to cope with this barrage of information is a concept known as healthliteracy, which is defined as the degree to which individuals have the capacity to obtain, process,and understand basic health information and health services needed to make appropriate healthdecisions. Effective health literacy begins in early childhood and continually builds on knowledgeand experience gained throughout the life span.The potential for negative health outcomes associated with low literacy, and particularly with lowhealth literacy, is not restricted to a small portion of the population. According to research in 2006,just under half (43%) of New Zealanders over the age of 16 do not possess the minimum healthliteracy skills required to read and understand medication and nutrition labels. In all of these cases,inadequate literacy skills can pose significant health and safety risks: improving the health literacyskills of New Zealander’s is therefore a critical issue.Research suggests that people with low health literacy:• Make more medication or treatment errors;• Are less able to follow treatments;• Lack the skills needed to negotiate the health care system;• Are at a higher risk for hospitalisation than people with adequate literacy skills.Delving further into the extent of health literacy, while a large percentage of adults are estimatedto have low health literacy, there are also a percentage of adults who have the skills and knowledgeto be literate but choose not to use them. Defined as ‘aliterate’ this group chooses not to read,prefer visual media (television or internet) to print media (newspapers or brochures). They approachlearning through trial and error and will avoid reading instructions (Eagle et. al.: 2005).Health literate patients will:Effectively manage their own healthShared decision-making is a key component of our Duty of Care, one of the components of theIntegrated Family Health Centre. Patient-centred care puts responsibility for important aspectsof self care and monitoring in patients’ hands. Shared decision-making requires that patients fullyunderstand their health problems and treatment options. This can be challenging for people whohave difficulties with reading, writing, numeracy, problem-solving and complicated oral information.Learning about health-related issues allows individuals to gain control over their own health byhelping them make educated decisions to improve their health outcomes. Attaining any controlover health outcomes requires the ability to find reliable and up-to-date health-related information,the ability to understand that information, and the ability to apply the information to specific life62

5 CommunityA focus on health literacysituations. Literacy skills are a critical component in this equation and too many New Zealander’s lackstrong health-literacy skills.Accurately fill out forms that relate to their health care needsMany patients have experienced serious medication errors resulting from their inability to readlabels. To cope with these problems, patients with low literacy rely heavily on oral explanations, visualclues, and demonstrations of tasks to learn new material. Most also use a friend or family member asa surrogate reader.Confidently ask questions of their health teamEncouraging patients to actively manage their own health at the point of contact with theirHealth Team.Use of the patient initiated questions model - “AskMe3”.Use of question templates and formal recording of answers with patients.Flow managers talk to each patient about AskMe3 and ensure that they feel comfortable asking andanswering the questions in the General Practitioner visit.Be confident in their understanding of instructions relating to their medicationPrescriptions the patient can understand.Group visits.Labels on things that you can understand.Follow up from the Integrated Family Health Centre that confirms understanding.Be confident in their ability to understand and follow post visit care plansThe introduction of new best practice models of care for management of long term conditions willplace unrealistic expectations on people with low health literacy levels. A review of randomisedcontrolled trial studies showed that 62% of patients with lower reading skills were unable or unwillingto engage in self-management (Heneghan et. al.: 2006).Most patients forget up to 80% of what their doctor tells them as soon as they leave the office, nearly50% of what they do remember is recalled incorrectly. To care for themselves and participate in theirhealth care, patients must be able to understand and act on information and instructions given tothem by their healthcare providers.Patients must be able to process what is required of them, and clarify if they do not understand.Difficulty in following instructions may result in the wrong medication/amounts taken, incorrecthealth concerns conveyed to family or potentially more health problems and therefore more visits tothe General Practitioner. Patients must be able to retain what is said to them, and be able to retrievethis information when required. This enables them to manage their own health care/medications etc.A Health Team informed of and actively addressing health literacy needsThe compensatory behaviour used by adults with low health literacy combined with the feelings ofembarrassment or shame, make it difficult for the health sector to detect this population group. Onestudy found that most physicians overestimated the level of literacy for individual patients with longterm conditions particularly for minority patients, leading the researchers to conclude that there wasa mismatch between how communication is carried out and understood between physician and thepatient in a clinic visit interaction (Kelly and Haidet: 2007).63

CommunityA focus on health literacy5Listening to UnderstandTo listen with understanding, listeners need to develop a critical awareness of who is speaking andwhy. As they become aware of different speakers’ purposes and points of view, they are able to maketheir own judgments about the relevance, reliability or bias of what they hear.Effective listening takes place during two way communication. The important element thatdistinguishes two-way communication from one-way communication is verbal feedback. Verbalfeedback occurs when the listener sends verbal responses to the speaker about their conversation. Inessence we are attempting to eliminate misunderstanding.The key to Listening To Understand is to use verbal feedback to eliminate misunderstandings. Verbalfeedback can be in the form of asking clarifying questions or paraphrasing.Speaking to CommunicateThe need to listen for details in specific situations, and to be able to communicate those details backto the practitioner is vital. The “CUT” method is an extremely effective technique in which you (asthe General Practitioner, nurse, pharmacist, Flow Team member etc) ask the patient to explain toyou the critical action items from the consultation. Health professionals can then provide immediatefeedback and educational efforts to correct details the patient did not comprehend.Creating an environment that ensures equitable access to the health systemThe goal is to help patients become informed and motivated. This cannot be achieved without awelcoming environment in which patients are comfortable asking questions. Shame is a prominentemotion that patients with limited literacy associate with medical encounters. Everything from theinitial contact with the Flow Team through to referrals should be made clear and simple.Patients with low literacy harbour a deep sense of shame, which is reinforced by healthcare staff whobecome frustrated or angry when someone cannot complete a form or read instructions. Seekingmedical care is intimidating for patients with low literacy because they cannot understand signs andregistration forms.A Network committed to improving their Health Literacy standardsA baseline set of health literacy standardsA Midlands Network Health and Literacy Committee made up of health providers, librarians,communications and marketing specialists, adult educators, and literacy practitioners will set andmanage a baseline set of health and literacy standards. The committee will use a broad scope forhealth literacy interventions, basing initiatives on both literacy and health literacy research.Workforce Development and trainingEfforts to improve health literacy will include appropriate educational and support strategiesdirected toward health professionals. Health care providers need to be supported to develop thecompetencies to provide self-management support and to have options for self-managementsupport available to match the needs of the patients. Best practice models of care for long termconditions need to be designed to reflect the needs of people with low health literacy levels.Development of a health literacy screen based on NZ data (using AsTTle)An online interactive screening tool to assess a patient’s health literacy level will be developed. Thepatient will use the screen on an interactive webhealth touch screen in an Integrated Family HealthCentre environment. The screen will use the AsTTle literacy and numeracy assessment tool and havethe option of “clip-on” modules that screen for individual comprehension levels and understandingby key disease state and level of care.Using theCUT MethodThe CUT Methodasks all membersof the Heath Team tofocus on the cycleof learning• Check the patient isgiven the informationin an appropriateformat• confirmUnderstanding ofthe information isparamount• Teach theinformation ina patientcentred manner64

5 CommunityA focus on health literacyScope of planned InitiativesPatient Healthcare Team NetworkPlain languagePost-visit plansReferral formsHealth screeningHealth infoDischarge informationPharmacy labelsImproving AccessOwn language patient advocatesQuestion buildersUse of images and video tocommunicate informationHighly visual action plansPost-visit advice available by phone oremailPatient journal - for complex, high needcases where patient can note theirown questions, concerns, needs forexplanationsListening to UnderstandHealth Literacy ScreeningAsk me 3Flow Managers to screen for healthliteracy levelsActive ListeningAddress quizzical looksSpeaking to CommunicatePopulation specific targets for healthliteracy (monitor and report progress)Use of CUT methodAvoid acronyms and other new wordsCareful use of idiomsUse of Visual Aids and Illustrationsprovide health context for medical andnumerical conceptsEnvironmentVisual symbols in health way-findingAssessment of health literacy andappropriate communicationCreate a welcome and supportiveenvironmentStandardsPolicies of use of plain languageAccreditation standards for IntegratedFamily Health CentreLiteracy CommitteeHealth Literacy a mandatory componentof Integrated Family Health CentreNetwork standards for all patientcommunications and interactionsAsTTle based assessment toolWorkforce DevelopmentDiscussion of health literacy issues withhealth studentsPlain language workshopsProfessional Continuing EducationInitiativesIntegrate health literacy into curriculumAlphabet Soup (family learningprogramme)Curriculum units that integrate with keyhealth literacy outcomes65

CommunityA focus on health literacy566

66. Our NetworkA focus on workforce knowledge, skills and attitudePutting primacy back into primaryAt the moment many people in the health sector equate primary care with rudimentary care.A parallel is often drawn with education, where primary school is to a tertiary institution what primarycare is to tertiary care. The parallel we need to foster is that of a primary advisor vs specialist advisor.A primary advisor typically has a more rounded knowledge of a subject and takes advantage of morespecialised advice when they determine it is required.This is consistent with the Duty of Care model we are implementing in the Midlands region, whereprimary health care is associated with primacy, that it is, by necessity, at the centre of our modelof care.Primary Healthcare has, and always retains, the primary Duty of Care for their patients.In this model the General Practitioner, as the pre-eminent generalist in the health system, is theprimary diagnostician in a patient’s life. This role is truly critical and belongs at the forefront of apatient’s healthcare.It is this role that we wish to highlight, encourage and give focus.The General Practitioner is the diagnostic heart of his or her primary care team.This work obviously dovetails the work to be done on devolution within primary health teams -untying issues of control and status from issues of patient well-being and capacity management.Our vision is a model where we are able to improve quality of care outcomes by empowering andmotivating teams of people who specialise in primary health care.To achieve this we will implement the following strategies:• The implementation of the Regional Referral Centre/Patient Access Hub and the implementationof an improved discharge process will allow the General Practitioner to retain the primary Duty ofCare overview throughout a patient’s journey within the health system.• Education regarding the legal Duty of Care issues and how they relate to the delegation andtransfer of patient care to encourage a more collaborative, team based approach to apatient’s care.• Improved access to patient’s records to allow all members of a patient’s health care team tocollaborate and to bring their particular skills to bear on a patient’s care.• Improved and streamlined access to diagnostics will allow General Practitioners to maintain directinvolvement in a patient’s care.• The use of pilot Integrated Family Health Centres as case studies to illustrate to all GeneralPractitioners the benefits of taking a team approach rather than an individual approach to apatient’s primary health care.• The introduction of Medical PAs for all General Practitioners in Integrated Family Health Centresto encourage more efficient handling of administrative and non-clinical activities.• Managing patient expectations, through a managed communication programme, of the role oftheir primary health care team rather than only a General Practitioner.• Demonstrating to patients, through improved and more timely communication surroundingreferrals, diagnostics, and discharge processes the role of their primary health care team as theirprimary health team.68

6 Our NetworkA focus on workforce knowledge, skills and attitude• Re-igniting the passion of our primary health teams through a managed communication processhighlighting the primacy of their role for all patients.Promotion of Primary Care as a desirable field to work inThe extensive contribution that primary health care nursing can make to reducing health inequalities,achieving population health gains and promoting and preventing disease is yet to be fully realised.In the ‘new’ primary health care environment, primary health care nursing has a unique opportunityto remodel and revitalise the contribution it makes to the health and well-being of New Zealanders.Primary health care nurses in the Pinnacle network will benefit educationally and professionallythrough having a structured career path to follow, regardless of whether they aspire to reach nursepractitioner level or choose to settle at any given point along the pathway.The aim of any framework for post-registration professional development should be to provide avariety of educational options and pathway strands, rather than a ladder approach that pressurisesnurses to reach a certain level of academic achievement. Short specialty programmes designedto develop clinical skills in the management of for example, diabetes, asthma, smoking cessation,the health and well-being of children, are made available throughout the network. Nurses arealso supported into formal primary health care post graduate nursing programmes leading to arecognised primary health care qualification and possible registration as a Nurse Practitioner. Wewill develop a strategy to support those nurses who aspire to become Nurse Practitioners to ensure,right scope, right population, right place and right service.The beginning point for growing the primary health care nursing workforce is our successfulgraduate internship programme which combines postgraduate study with a structured transitionto practice. The new graduates have an expanded 12 month orientation during which time theyare supernumerary and are exposed to a range of primary health care settings and experiences.The outcomes of this programme are a prepared workforce of nurses who are critical thinkers andlifelong learners able to respond to change with vision and resilience. These are the primary healthcare nurses of the future, these are the nurse leaders of the future.Changing Patient StoriesPatient stories will contain examples of managed and consistent care - not disaster stories. Patientswill become the evangelists and the energy behind the change in our community. Their stories ofexperiencing the Duty of Care model will be the infectious element that energises those who aretraditionally disengaged to re-engage with their practice and establish a dialogue with their healthteam again.Patients from the Midlands region will regret moving out of the area because the standard of theirprimary care experience will drop.When patients and community stakeholders want advice on a health contact or piece of informationthey will• think to contact their team;• know how to contact their team;• get a response in a timely fashion;• respect the team’s advice as expert and professional;• trust the team to deliver on their promises.69

Our NetworkA focus on workforce knowledge, skills and attitude6PHO seed-funding for local initiativesEach PHO will be encouraged to contribute 10% of any retained earnings generated in their regiondirectly into their community to support local community activities. This will encourage greaterengagement between the network and their communities, and build on the public’s perception ofprimary health as a local force for good.Medical PAs, Flow Teams and Patient AdvocatesTo enable Integrated Family Health Centre to work as they are designed to, new roles must beestablished in order to redirect work priorities to where they are best suited. The IntegratedFamily Health Centre has a bold new set of goals that are largely felt to be impossible by thefrontline workforce.Significant change will need to occur for the Integrated Family Health Centre to work as intended.The diagnostic role of the generalist is the most important. Position and longevity of contact aswell as local context and cultural understanding improve efficacy of diagnoses. The vision is for theGeneral Practitioner to be the highly skilled, highly motivated diagnostic generalist at the heart ofthe team. Everything around the General Practitioner supports the diagnostic machine that is ourGeneral Practitioner. New roles will be established inside the Health Team to enable this to occur.Medical PAsThis role works directly with the General Practitioner. They are the conduit between the Flow Teamand the General Practitioner, the patient and the General Practitioner and the patient and the FlowTeam. They work to anticipate visit needs with the patient, support the needs of the patient duringthe visit and provide connectivity to the General Practitioner post visit. This role uses the CUTmethod in all interactions with the patient regarding medical instructions or information. They arealso the administrative service that enables General Practitioner time to be freed up. They are servicefocused and patient centred in everything they do.Flow TeamsFlow Teams work to support the patient. Each Flow Team has a number of different componentsbut their central aim is to keep the highest possible number of patients with a complete and upto date baseline health screen, making them by definition - engaged. The Flow Team works as theconduit between the in-situ team and the community team. They ensure case conferencing occurs ina manner which ensures Duty of Care is top of mind at all times. The Flow Team coordinates pre andpost visit screens, follow ups, may assist with procedures, make planned care outreach calls, followup with post visit contact and prescription pick ups. They work with the Medical PA and pharmacy toensure any medication queries are cleared up as fast as possible. Liaison with the Regional ReferralCentre is an important part of their day ensuring transfer of care is maintained for all enrolledpatients being discharged from hospital.Patient AdvocatesThe Patient Advocate role is a resource dedicated specifically to keeping the number of disengagedpatients to a minimum. Often work with those who have disengaged from the system is confusedwith a team that provides health care in the community. Patients disengage for a number of reasons- sometimes the patient may not wish to receive health care but all too often it is simply life or theway the primary care chooses to interacts with their patients that gets in the way and forms the keybarrier to engagement. The Patient Advocate works in their community and inside the boundaries ofprivacy law to ensure the highest possible level of engagement. Engagement is defined as having afull baseline health screen that has been updated either online or manually on an annual basis.The role of Patient Advocate requires a specific skill set, that of knowing one’s community, andacknowledgement that this requires resources and time. It is not an administration task necessarily(although much of it can be done via the phone). It is about managing networks of people and70

6 Our NetworkA focus on workforce knowledge, skills and attitudekeeping lines of communication open. It will involve a good use of privacy law and good openworking relationships with other government agencies.Health CoachesHealth coaching, where a peer or professional takes an interactive role to support a patient to bean active participant in their self-management of a long term condition, was also identified as asolution. Peers or professionals were trained in behaviour change approaches like motivationalinterviewing and examples of effectiveness were shown in the area of smoking cessation, diabetesand cardiac rehabilitation. Success is improved, when coaches are supported, well trained and givensufficient time to undertake successful coaching sessions.Boutique Practice for Heart Sink PatientsProvision of time-framed enrolments with boutique practice environments to address issues facingheart sink patients. A fresh eyes wrap around approach to patients with continuing care issues thataims to provide the patient with a time-framed period to address core health and societal issues.Centralised and Coordinated Education TeamA central bank of educators which can provide coordinated, targeted support to the full spectrum offrontline staff involved in Primary Care. This structure will enable cross-organisational initiatives andlearning to be targeted not by clinical role or locale but in a targeted manner at groups of individualswho have a similar learning goal.By centrally coordinating education and learning around specific groups or an individual assessment,learning plans can be developed and assessed with the goal of providing a better quality of trainingand outcomes for patients across the region.Learning will be supported across the region by the use of a Personal Learning Plan (PLP) which isonline electronic and held as part of central record, accessible to all, at any time. This record willhold all professional development milestones achieved by each staff member as well as integratingstrongly with portfolio and registration requirements.Learning will be encouraged via a variety of mechanisms. Frontline staff will attend via a virtualclassroom environment rather than travel to a destination. Learners will take the approach to becomemore health literate therefore improving Duty of Care. Training will be coordinated, targeted andrelevant to an individuals personal assessment of themselves and their own learning.Personal Learning Plans (PLPs)Identification of the different groups involved in successfully implementing the plan.Involve goal setting mechanisms.Reflective Assessment Tool that is used by the practitioner to reflect on professional developmentduring the registration cycle.Critical friends and professional learning groups to enable the learning and reflectiveassessment process.Peer tutoring - expert based learning and teaching scenarios and ongoing support.Integrated Family Health Centre Learning Plans (Integrated Family Health Centre LPs)Specific to the learning needs of staff engaged with the centre and with the individual community.Includes topical, relevant and community specific topics and themes.Uses the expertise of other professions to cross pollinate around learning, resources andteaching methods.71

Our NetworkA focus on workforce knowledge, skills and attitude6Contributing to the knowledge landscape of New Zealand HealthThe Midlands Network will partner with a research institution to ensure that everything we do ismonitored and evaluated as we undergo this massive period of change. It is hope that such apartnership will support us in taking a new approach to horizon scanning for future possibilities andchange opportunities.IT systems and trainingA paradox exists at the heart of primary care. While the primary care service is almost entirelypaperless and nearly every individual practice runs its own Electronic Patient Management System,the frontline workforce is largely IT illiterate. For an industry whose patients are used to booking airtravel, balancing their finances and managing their day online or via a mobile phone, very rarely is apatient able to expect timely dialogue via email with their Health Team.Anecdotal evidence would suggest that this largely ageing workforce are content rather than skillsbased in their learning style and therefore have not transferred the skills they use in their day to dayuse of a Patient Management System into any wider application of IT.With the rapid changes from year to year in the application of technology in all workplaces, PrimaryCare must acknowledge and strategise in regards to how its workforce will increase not only their ITreadiness but continue to self-manage their own learning.The urgency of this situation can not be underestimated. Without a dramatic increase in the ITreadiness of the Primary Care workforce the patient base will continue to drift from the skilledprimary care workforce to the internet to inform their healthcare decisions and self-management.Primary Care must debate how it will address this issue.A workforce that is IT readyIntegrated Family Health NetworkIntegrated Family Health Centre StaffNetwork wide standard for use of basic IT systemsStandardised IT requirements for every Integrated FamilyHealth CentreStandard broadband requirements for all network membersVideo Conferencing available in the communityGeneric IT courses for all staffEmail addresses for every staff memberStandardised IT proficiency requirements for every IntegratedFamily Health Centre staff memberDevolution within General Practice – (legal and social status)Health policy has forever promoted the establishment of teams. However the reality is that manyhealth professionals view the medical, legal and public expectations as not supporting this. Furtherwork needs to be undertaken to support the development of a “safer” environment for change.72

77. Delivering on health targetsMaternity and Child healthHealth targetNational WDHB TDHB TDH LDHBImmunisationRates of 2 yr oldsTotal 85% 81% 79% 80% N/AMaori 85% 66% 79% N/A N/APacific Island 85% 74% N/A N/A N/ACurrent performanceCurrently we have a Well Child/Tamariki Ora programme that is disconnected from the immunisationprogramme. Mothers and their children receive their Well Child screening from a Well Childcontractor and their immunisations and health care from their General Practitioner.After the age of five years there are no more core health milestones until adulthood.All projects listed below currently operate in isolation from each other. Where a programme isoperating in all areas of the region, delivery methods and business models are specific to DistrictHealth Board, PHO or individual contractor. There is no evidence to suggest that the region lacks theskills to deliver a coordinated service but the service is far from coordinated or patient centred inits approach.• Going Home (Newborn transition).• Newborn Hearing Screening and Antenatal HIV Screening.• Immunisations.• Well Child Checks.• B4 School Very Important Project (including Vision & Hearing Screening).• Yr 9 HEADSS Assessment.• Public Health Nurse in Primary Schools.• Clinics in Secondary Schools.• One stop Youth Shops in high risk areas.Currently Primary Care in Midlands uses a sick child approach, seeing themselves as having two keyfunctions - treating a sick child and achieving immunisation milestones.74

7 Delivering on health targetsPerformance atQ3 2008/09National WDHB TDHB TDH LDHBImmunisationRates of 2 yr oldsTotal 78% 72% 78% 73% 65%Maori 73% 63% 69% 67% 57%Pacific Island 78% 66% N/A N/A N/ANeeds projectionsPerformance atQ3 2008/09National WDHB TDHB TDH LDHBImmunisationRates of 2 yr oldsTotal 78% 72% 78% 73% 65%Maori 73% 63% 69% 67% 57%Pacific Island 78% 66% N/A N/A N/ARegional PromisesTo Midlands children, young people and their familiesPromise 1:Promise 2:No Midlands child will be left behind.Midlands will have a well child focus (as opposed to a sick child one).75

Delivering on health targets7Current situation Midlands Network: Under 18 years25+ U18s per mesh block1-25 U18s per mesh blockWhat needs to changeRaising healthy and health conscious young people who are self-managing their ownhealth outcomesAll our staff will have access to the expertise of a staff member who has received high level ChildProtection Training.We will be aware that young people often require a diverse and creative set of responses when itcomes to overcoming barriers to health care.Communities working together to ensure better health outcomes for Midlands children andyoung peopleWe will have a workforce that is an active player in the Child Youth and Family “five eyes on underfives” programme.We acknowledge that a relevant and effective child and youth health programme can be one ofthe most cost effective investments a community can make to simultaneously improve educationand health.Our community has a responsibility to provide the resources and opportunities that children andyoung people need to build their lives.We will work with other organisations to ensure that every Midlands child has a coordinated wellchild focused approach to the Duty of Care model.We will be mindful of the fact that transfer of care is the primary area where child health falls down.Our network will work with each community to develop a system where the transfer of care is neverin question.76

7 Delivering on health targetsMaking services accessible to children, young people and their familiesFor maternity and child health, Duty of Care means a brave approach centred on the implementationof a no child left behind strategy. Midlands will ensure that the transfer of care is constant andmanaged for every Midlands child from birth to 17 years.We will be enthusiastic and excited about the potential of children and of young people.We will utilise the Well Child nurses to develop a coordinated well child approach for Primary Care.We will develop a workforce that is child and young person focused and aware.We will acknowledge that while our workforce are technological adopters/dinosaurs, our childrenare technological natives and in a patient centred world we must therefore interact in the medium oftheir choice and not ours.Old WayNew WayA healthy baby is born at the hospital. GeneralPractice is not informed nor are they aware oftheir Duty of Care in regard to immunisationsfor the child.As part of the going home project Primary Care is informed that baby has beenborn and enrolment with a General Practitioner is confirmed with Mum at birth.Both Mum and baby receive a “welcome to the world” communication from thepractice and contact regarding mental health resilience screening for Mum andimms/well child for baby.Mum fails to present with baby for their threemonth well child milestone check.The Well Child Nurse informs the Flow Team at the Integrated Family HealthCentre where mum is enrolled. A Patient Liaison visits the home to discover thatMum had misunderstood her role in the programme. A new appointment isfound and Mum is re-engaged with the well child programmes.George starts school. His Dad has not heardof the B4 School Programme and he is notenrolled with the dental service. Unknownto Dad, George’s behaviour issues and slowspeech development are related to the facthe cannot hear.As part of the Very Important Project George has been allocated at age four toa nurse to coordinate their B4 School Screen. George receives his B4 SchoolCheck which picks up his hearing issue. His visit to the Ear Nurse is coordinatedby the Regional Referral Centre and at the Nurse’s suggestion he is enrolled ata local ECE through Promoting Participation.A mother encounters challenges with hermental health after giving birth. The LMCdischarges her at six weeks without transfer ofnotes to the General Practitioner.The LMC is connected to the Integrated Family Health Centre and caseconferences with the General Practitioner around strategies to supportimproved resilience. The Flow Team coordinates wrap around care to ensureMum and baby receive quick, convenient and comprehensive treatment.A Year 9 student starts at their new secondaryschool. They have strange things happeningto their body which they are embarrassed todiscuss with their family doctorThe student is immediately aware that there is a school nurse available on site. Aspart of their PE class they complete a curriculum linked HEADSS assessment. Theyoung person discusses their concerns with the nurse and receives follow up care.A child is diagnosed with a chronic conditionwhich will require ongoing care - the GeneralPractitioner refers to the specialist and is notadvised of any care the child receives.The General Practitioner retains Duty of Care for the child. Dialogue isestablished between both the sending and receiving practitioner. The referralis coordinated by the Regional Referral Centre and is both timely and patientcentred in the information provided to the family.77

Delivering on health targets7How we will implement that change“Going Home”All children born in the Midlands area will become part of the Going Home initiative which seeks tocoordinate the discharge of mother and baby into a supportive environment.Establishing Duty of Care (5 eyes on Under 5s)Once allocated no child can be taken off the list unless they move to an address outside theMidlands area. Primary Care will take their role as a pair of eyes seriously. All Midlands staff will havea Child Protection Trained staff member they can go to for advice.Well Child MilestonesWell Child Nurses will be allocated to practices and will deliver their service to an enrolledpopulation as part of a General Practitioner lead Family Health Care Team. The service will alter tobecome wrap around rather than independent and dislocated.Public Health Nurse in every Early Childhood CentreEvery Midlands Early Childhood Centre will have a Public Health Nurse attached to it. They will beinformed child health experts that are excited and engaging sources of information on child health.Very Important ProjectAll Midlands four year olds will be part of the Very Important Project - a Project with a Whanau Orakaupapa which works with libraries and primary schools to have every four year old completefive milestones before they turn five (eyes and ears, teeth, B4 School, meet the teacher and jointhe library).Public Health Nurse in every Primary SchoolEvery Midlands Primary School will have a Public Health Nurse attached to it. They will be informedchild health experts that are excited and engaging sources of information on child health.Youth One Stop Shop co-located in high risk areasPopulation analysis will be undertaken to pinpoint key disengaged youth populations. Innovativeand challenging co-location opportunities will be identified and funded in order to bring health careto a disengaged youth sector.Year 4 Health CheckMidlands will establish a new curriculum linked health check for all Year 4s. It will connect with asimilar educational milestone and screen for any core developmental or health issues.School Clinic in every Secondary SchoolEvery high school will have a school nurse.Year 9 Health CheckMidlands will put in place HEADSS screening for all Year 9 students in the region. The programmewill be curriculum linked offering an opportunity for a consistent approach between educationand health.HPV VaccinationAs an information opportunity to encourage young women to begin to self-manage their own health.78

7 Delivering on health targetsHealth Testimonials - the High School Exit Health CheckMidlands young people will have the opportunity to undergo a baseline health screen as part of lifereadiness when they leave school. Upon the issuing of an Exit Certificate any Midlands young personwill qualify for a free health screen with either their school clinic or their General Practice. Dependingupon intended life direction this is an opportunity to assist the range of health choices that becomeavailable as a young person leaves school for the adult world. An opportunity for the Networkto reconnect with the young person at what has been a traditional “failure to care” point and tosupport the young person in re-assessing where they will receive their medical care.KPIsTwo year and four year Immunisations at 100%B4 School Check 100%Year 4 Check 100%Year 9 Check 100%HPV 100%Health Testimonial 100%*(100% assumption includes Declines)Relationships that will help make it happenCurrent regionalrelationshipsCommunity RelationshipsPractitioner SpecificrelationshipsChild Protection SocietyPaediatriciansMidwivesPlunketPublic Health NursesMinistry of EducationBirth CentresFamily Safety TeamsCar Seat EducationFamily StartYoung Parenting ProjectsMirimiriCarer Respite CarePromoting Participation WorkersSafe KidsFruit in SchoolsBreakfast ClubsYouth WorkersYouth Addiction ServicesPrimary Principals AssociationSecondary School Principals AssociationMaternal Mental HealthCommunity PaediatriciansRongo AteaEating Disorder ServicesRheumatic Fever RegisterOutreach & Mobile ImmunisationsSchool Dental ServiceAdolescent Dental HealthNewborn Hearing ScreeningAntenatal HIV ScreeningPost termination/miscarriage servicesChild Asthma ProgrammeResource Teacher of Learning andBehaviourSpeech and Language therapyRongoaSchool Counsellors79

Delivering on health targets780

Promise 1: No Midlands child will be left behind.Promise 2: Midlands will have a well child focus(as opposed to a sick child one).82

7 Delivering on health targetsSmoking and LifestyleHealth targetThere are currently no health targets that all DHBs collectively work towards.Current performanceSome practices offer the patient lifestyle advice as part of a usual consultation. Consultation isfocussed around a sick patient rather than a well patient model. The unintended consequence of thisapproach is a highly reactive model where patients seek answers around wellness and screening viagoogle and social networks; and interactions between patient and General Practitioner are basedaround moments when the patient does not feel well. Instructions are harder to hear and understandand plans around being well fall to the background while the immediate treatment of the reason forthe appointment comes to the fore.Patients receive recall letters that are sent with the best of intentions to the last known address of thepatient. Details are only updated when the patient presents at the medical centre. Recall letters arenot collated or aggregated in any way at all. A patient may receive three letters, in one day, for threedifferent reasons.Patient email addresses are very rarely, if ever, collected with the intention of using them to establishcommunication with the patient. The effect on the professional image of the General Practice isseverely tarnished by these elements of patient service.Needs projectionsTotal WDHB TDHB TDH LDHBCurrentPopulation274 534 180 153 54 688 322345 17348EstimatedOlder PeoplePopulation in 20years time428 863 280 591 84 724 37 021 26527Regional PromisesTo the Midlands populationPromise 3:If you are enrolled with a Midlands GP then you will be invited to complete ahealth screen once a year. Any issues flagged from that screen will be followedup with you (includes the option to decline the screen).83

Delivering on health targets7Current situation Midlands Network: Target Population50+ Target populationper mesh block1-50 Target populationper mesh blockWhat needs to changeA focus on preventative care and wellnessIt is unacceptable for any patient living with a chronic condition to remain a smoker.It is unacceptable for anyone with a BMI of 30 or more to not be actively working at reducingthat score.It is unacceptable to have a health sector workforce that does not walk the talk.There is great value in having staff who have made some of the behaviour changes we are asking ourpatients to make.A focus on coordinating the patient journeyWe will acknowledge that while our workforce are technological adopters/dinosaurs many of ourpatients are technological natives and in a patient centred world we must therefore interact in themedium of their choice and not ours.Service focused, patient centred approach to dealing with all patient enquiries.No wrong door.84

7 Delivering on health targetsOld WayNew WayHayden has to get a medical in order toqualify for his life insurance to be renewed.He has not been to the doctor in over fiveyears. At the medical Hayden discovers thathe must complete different parts of the checkat different locations and that none of theirschedules are shared. Hayden leaves feelingintensely frustrated with the process and tellshis workmates of his awful experience.As part of his birthday communication Hayden receives a basic health screen.The communication also includes a summary of screens he had last year and theones he will require over the coming twelve months. He completes the screenonline and uses the secure email to book an appointment for his medical.The Flow Team knows what the medical will require and make sure that Haydenreceives a coordinated check (bloods are taken at work and available at thecheck). The Medical PA emails Hayden to let him know that he will require anECG and that she has contacted the service to organise an appointment on hisbehalf. The medical is completed and highlights no areas for concern. Haydenis thoroughly impressed with the service and tells others about his experience.A blood test confirms Maree has highcholesterol. Maree googles her cholesterollevel and discovers that it is only marginalso she eats the piece of bacon and egg pieshe brought for lunch and throws away thepamphlets her General Practitioner gave her.Maree’s bloods were taken at work by the peripatetic phlebotomist. While sheis waiting for her check - a Flow Team member gives her a webhealth touchscreen with an interactive Heart Forecast. During the consult Maree’s GeneralPractitioner confirms that she has high cholesterol and works with her to createa self-management plan. Her General Practitioner’s Medical PA organises anappointment with Green Prx before she leaves and books another appointmentfor her in three months to review her progress. Maree’s appointment, contactdetails for Green Prx and self-management plan are available for her toview online.Vicki is 27 and flatting with two other youngwomen. Vicki has had three letters regardingher cervical smear but all have gone to herlast flat and she is unaware she has fallenoff the recall list. She thinks smears are ickyanyway, its winter and she will have to shaveher legs, the last time she had to go on herown and she felt like a real idiot.Vicki hasn’t cleared the letterbox in years and when her Integrated FamilyHealth Centre asked her if she wanted to receive her communication onlineshe jumped at the chance. Vicki received a reminder in her online birthdaycommunication that she would require a smear this year. She goes online andbooks an appointment that suits her. She also finds a link to a great website thatanswers some of her more gross questions without her having to ask them tosomeone’s face. The Flow Team rings to confirm her appointment and asks herif there is anyone she would like to bring with her. Vicki says she will bring one ofher flatmates and the Flow Team takes the opportunity to book an appointmentfor her flatmate’s smear while they are both there.Marama is a lifelong smoker who has had arecent health scare. She is currently inhospital and, as she can’t smoke in thereanyway, has taken the opportunity to getpassionate about quitting. She has hadnicotine patches while she has been inhospital. She asks one of the nurses abouthow to give up and the very friendly nursegives her lots of helpful pamphlets and asksher to talk to her Pharmacist about nicotinereplacement. Marama goes home and isunable to get to the pharmacy for the nextthree weeks. She recommences smoking andthe moment is lost.Marama is visited in hospital by a member of the Integrated Family Health Centrecommunity team. The Team member talks to Marama and discovers her desireto quit smoking. This is included on her discharge information and dischargeprescription. The Regional Referral Centre notes Marama’s intentions and flagsthese with the Integrated Family Health Centre for follow up. The IntegratedFamily Health Centre Community Team coordinate nicotine replacement therapyand smoking cessation support so that Marama’s good intentions do not becomea wasted effort.How we will implement that changeBasic (online or manual) health screening for every enrolled patientEvery patient to receive a basic health screen that is Integrated Family Health Centre initiated. Thescreen is updated annually and the definition of an unengaged patient will be determined by thenumber of patients that have not completed this screen in the last 12 months.85

Delivering on health targets7Active management of changes in patient’s personal situationsThrough excellent reporting systems the Flow Teams at each Integrated Family Health Centre areable to determine changes in patient online status. They work to liaise with patients around theactive management of appropriate and coordinated responses to address health issues.Interactive Lifestyle Screening on site and onlineFlow Team provides webhealth touch screens for patients that provide them with interactives andindependent learning around the patients key health areas.Lifestyle groups and coachingGroup sessions made available to patients to deal with core health issues.Coordinated communications and social marketing campaign to promote wellnessCommunity messages that are innovative and fresh in their approach to core wellness milestones.Screening for understanding around the issue of health literacyCore screening for every patient to assess health literacy. Clip on modules to assess understandingof core concepts for any issue requiring health knowledge to achieve self-management.Quit attempts for every smokerThe Flow Team tracks and manages a system which ensures every current smoker is supported tomake at least two Quit attempts in any one year period.PreventingBy linking together the Education and Health sectors, teachers can use the New Zealand curriculumto develop the knowledge, understandings, skills, and attitudes needed to maintain and enhancepersonal health.KPIsBasic Screening Test for the enrolled population (100%)Relationships that will help make it happenCurrent regionalrelationshipsCommunity RelationshipsPractitioner SpecificrelationshipsManiapoto Health Provider ConsortiumLifestyle Interventions ProvidersSport WaikatoHealthy Living CentresHealthy Homes ProgrammeNaturopathMirimiriCooking ClassesImproved Access to Fruit & VegSmoking CessationSmokefree Cessation in the WorkplaceGreen PrescriptionsQUIT PlansHapu Health Management ProgrammesDental ServicesCervical ScreeningBreast ScreeningProstate ChecksVirtual Skin Lesion ClinicsMole MappingSexual Health ScreeningMedicine Use ReviewsMinor Ailment Consults (Pharmacy)Cellulitis DVT ManagementOptometristDietitiansRongoa86

Promise 3: If you are enrolled with aMidlands GP then you willbe invited to completea health screen once ayear. Any issues flaggedfrom that screen will befollowed up with you(includes the option todecline the screen).88

7 Delivering on health targetsCardiovascularHealth targetPercentage of eligible adultpopulation who have hadtheir CVD risk assessment inthe last five yearsNational WDHB TDHB TDH LDHBTotal 70% 72% 64.80% 68.60% N/AMaori 60.50% 63% 49.20% N/A N/APacific Island 63.86% 58% 52% N/A N/ACurrent performanceSome demographic groups are not suitable for restorative elective procedures because ofperceived limited ability to prepare for, or recover from, the procedure or potential post procedurecomplications. Maori, Pacific and Indian sub-continent males are less likely to be active usersof preventative health care services. Health service deliverers have not successfully developedprogrammes to regularly and persistently encourage these demographics to participate eitherwith health providers or self-manage their health. Generally the lifestyle risk factors that need tobe reduced are significant, and require resources not readily available to populations withlimited resources.Service design for cardiovascular disease management services does not recognise that mostmen that are at risk are still in the employment phase of their life, making accessing servicesduring the health sector’s preferred hours impossible. Thought needs to be given to betterrelationships with employers that permit onsite health service provision, or better designed afterworking hours programmes.Improved handover of care for patients who have experienced their acute episode outside the areawhere they usually live needs to be vastly improved. Very rarely is information about their experience,treatment and post episode care transferred to their significant primary care provider.Percentage of eligible adultpopulation have had theirCVD risk assessment in thelast five years (Performance @Q3 2008/09)National WDHB TDHB TDH LDHBTotal 69.50% 67.50% 62.60% 68.60% 68.60%Maori 59.90% 56.90% 47% 63.80% 58.10%Pacific Island 64.50% 53.70% N/A N/A N/A89

Delivering on health targets7Needs projectionsTotal WDHB TDHB TDH LDHBEstimated CVD at risk population(Prevalence incl early symptoms)*24, 676 17, 572 3, 137 1919 2048CVD Event or risk >15% 59.90% 56.90% 47% 63.80% 58.10%(PHO Reporting)* 25072 17, 893 3, 376 2404 1399* Pinnacle Network enrolled population onlyRegional PromisesTo those people in Midlands living at risk a cardiovascular eventPromise 4: Free Cardiovascular Risk Assessments for the eligible population .Promise 5:If you live at risk of a Cardiovascular event you will have a Chronic DiseaseSelf-Management Plan.Current situation Midlands Network: Population living at risk of a cardiovascular event10+ Population per mesh block1-10 Population per mesh block90

7 Delivering on health targetsWhat needs to changeAddress screening access issues for populations who are not traditionally engaged withhealth servicesTransparent regional reporting on access rates, aggregated and targeted health needs assessments,and provider performance will be available publicly.Regional clinical governance and implementation design decision makers will formally adoptcardiovascular related best practice guidelines.Agreed and immediately identifiable pathways for improvement established.Development and availability of appropriate resources, programmes and appropriatly trainedpeople to work with patients with identified high risk of developing cardiovascular diseaseCardiovascular Risk Assessment tools and resources will become a standard part of primary andcommunity care.Review what needs to change in primary care including, but not limited to, workforce development(capacity and capability), resources and tools, opportunities for clinicians to easily access theguidelines through electronic decision tools, information technology, establishing or amending ofkey stakeholder relationships and funding models.A regional collaborative approach with recognised subject matter experts like the National HeartFoundation will be more formal and action orientated.91

Delivering on health targets7Old WayNew WayJack receives a letter asking him to contact his General Practicefor a cardiovascular risk assessment. He does not know whatthat means and throws the letter away.Hone receives a letter asking him to contact the GeneralPractice for a heart check. The letter is complicated andasks him to get a blood test at the laboratory. He does notunderstand all the parts of the letter and can’t get to thelaboratory as he works so he throws the letter away.The score from Jeremy’s heart check is 19. The Doctor quicklyruns through some advice, but is not sure what services areavailable that will suit what Jeremy has to do to reduce hisscore. The Doctor gives Jeremy a leaflet and tells him to ringthe number.The score from Kahurangi’s heart check is eight. The Doctortells him he is fine and keep doing what he is doing.Jason has had a cardiac event. He talks to his brother-in-lawGreg who also had a cardiac event two years ago. Greg tellshim about all the medications he is on. Jason is confused ashe is only on two medications and he does not know what theydo. Greg tells Jason to just ring up his doctor for a prescriptionwhich Greg does often without seeing any clinician for areview.George collapses at a tangi out of town. After several weeksin hospital he is discharged home. No one contacts George tooffer him any follow up care.At work, Jack has listened to workmates who talk about havinga heart check. He reads about heart checks in the paper andat masters rugby training the Kaiawhina from the Maori HealthProvider explains the process.Hone gets a choice in how he is contacted. If he choosesby letter/email, then a letter/email that meet health literacyguidelines is sent to Hone simply setting out what he needs todo. Hone can make his own heart check appointment at a timethat suits him and can get his blood test at work or the gymbefore his heart check appointment. The Flow Team contactHone to remind him about his appointment and answer anyquestions he has about the process.The score from Jeremy’s heart check is 19. The Doctor askssome questions about how Jeremy manages his life andchecks how best he likes to get information. The Doctorsuggests an approach to Jeremy about how to improve hisskill and knowledge about reducing his heart check score. Heagrees that further contact with the health team will need tohappen for Jeremy to develop his management plan. Jeremy’smanagement plan identifies all the steps and resources he canaccess to help him reduce his health check score throughself-management.As part of Kahurangi’s birthday communication, he is remindedof what he needs to continue doing to keep his score low andwhen he needs to next have a heart check.After Jason’s cardiac event, the pharmacist spends time withJason so he is clear on how many medications he should beon and what they are for. Jason is given simple information forhim to take away and further online access if he needs moreinformation. Contact is made with Jason if he does not collecthis medication, and he is recalled regularly to check that themedicine is still appropriate.The Regional Referral Centre coordinates the discharge andliaises with both the family and the practice to ensure allparties know what follow up care George requires.92

7 Delivering on health targetsHow we will implement that changeEquity of accessScreening populations who do not traditionally engage with health services.Referrals are organised in a systematic and consistent way that encourages equity of access forfurther specialised procedures.Programmes developed reflect a number of options for service delivery settings and hours in orderto ensure the availability of potential service users.Active Case ManagementMaintaining a pro-active relationship with all identified high-risk patients.Maintaining a pro-active relationship with all diagnosed patients.Programmes regularly and persistently encourage high-risk and diagnosed patients to self-managetheir health.Referrals are organised in a systematic and consistent way that encourages access for furtherinteraction with local service providers when the initial patient event is managed away from the localarea of residence.Road Map for Cardiovascular problemsA personalised directory to help cardiovascular patients navigate through their care and to assistwith the self-management of their condition.Take 10 to add 10An approach to healthier lifestyles that addresses the specific risk factors for chronic disease. A setof resources created for use in general practice, to encourage promotion of simple lifestyle changein consultations with patients. 10 minutes a day, 10 week programmes, 10 people in a group, live 10years longer.Be good to your heartA multi-media resource set aimed at patients with a low level of health literacy. The resource isdesigned to be visual, highly interactive and very user friendly. Focus is on the key health messagesaround cardiovascular, and how to achieve self-management.KPIs100% of the target population receives a cardiovascular risk assessment.All people whose screen results in “at risk” are on an actively managed plan.93

Delivering on health targets7Relationships that will help make it happenCurrent regionalrelationshipsCommunity RelationshipsPractitioner SpecificrelationshipsSport WaikatoManiapoto Health Provider ConsortiumHealthcare NZChronic Disease Self-ManagementCoursesCV Heart education ProgrammesLifestyle Management ProgrammesWhanau/Household ManagementLifetime LifestyleNZ Heart FoundationCardio Pulmonary Rehab programme.Cardiovascular Risk AssessmentsSpecialist Stroke ServiceCardiac RehabilitationStroke Pathways ReviewsHeart ForecastsIntegrated Heart Failure Programme94

Promise 4: Free Cardiovascular Risk Assessmentsfor the eligible population.Promise 5: If you live at risk of a Cardiovascularevent you will have a Chronic DiseaseSelf-Management Plan.95

7 Delivering on health targetsDiabetesHealth targetPercentage of people withDiabetes getting their freeannual checks targetsNational WDHB TDHB TDH LDHBTotal 56% 52% 69% 59% N/AMaori 53% 42% 59% N/A N/APacific Island 46% 52% 28% N/A N/ACurrent performanceFor most providers diabetes management is an integral part of general practice service delivery.The ongoing increase in the number of people diagnosed with diabetes is alarming and hasbeen described as the health challenge of the century. Most service delivery concentrates on themanagement of people diagnosed with Type I Diabetes with a free annual review undertaken. Thereis variability in uptake of this service across the region.It is expected that a retinal screening check is undertaken every two years and this is traditionallydelivered in a hospital. Again, there is variability in uptake of this service across the region. Somepeople with diabetes require podiatry treatment and this is also available for free, although accessto service is dependant on locale. There is no settled agreement on whether screening should beintroduced to manage people identified with symptoms that are precursors to diabetes.There has been an increase in the number of people with diabetes who require specialist servicesand there has been a movement to utilisation of dialysis with the percentage of patients selfmanagingat home haemodialysis increasing. The support services for managing the haemodialysisare delivered from Waikato Hospital which is difficult for people who live in provincial areas. Thereis concern that populations who are poor, or have limited education require more support locally tohelp with management; yet there are no current processes for this.Percentage of people withDiabetes getting theirfree annual checks targets(Performance @ Q3 2008/09)National WDHB TDHB TDH LDHBTotal 58% 53% 74% 59% 49%Maori 53% 43% 55% 60% 43%Pacific Island 54% 42% N/A N/A N/A97

Delivering on health targets7Needs projectionsTotal WDHB TDHB TDH LDHBDiabetes Estimated Population(Prevalence incl early symptoms)*31241 22326 3737 2481 2697Coded Diabetic Patients(PHO Reporting)*20230 14563 2685 1421 1557* Pinnacle Network enrolled population onlyRegional PromisesTo those people in Midlands at risk of or living with DiabetesPromise 6:Promise 7:If you live with Diabetes you will have a Chronic DiseaseSelf-Management Plan.The Midlands region will rebuild Diabetes, Renal Care and Annual Reviews forbetter outcomes.Current situation Midlands Network population living with Diabetes10+ Population per mesh block1-10 Population per mesh blockWhat needs to changeMaintaining wellness in populationsAll people will be offered cardiovascular risk assessments which will also capture informationabout diabetes.98

7 Delivering on health targetsIt is unacceptable for any diabetic to remain a smoker.It is unacceptable for any diabetic with a BMI of 30 or more to not be actively working at reducingthat score.It is unacceptable to have a health sector workforce that does not walk the talk.Working together to raise community knowledge about diabetes prevention and managementWe will have a workforce and community that are active players in the understanding of diabetesprevention and management.We acknowledge that a relevant and effective diabetes programme can be one of the most effectiveinvestments a community can make to improve health and reduce health costs.Success reducing the clinical management for all diabetics to within defined bestpractice rangesIt is unacceptable that people with diabetes have escalating clinical risk that could havebeen avoided.Managing people with diabetes better, ensuring that all get appropriate access to all servicesIt is unacceptable that people with diabetes are not referred to all publicly available services likeretinal screening and podiatry.We will work with other organisations to ensure that every diabetic has a coordinated approachthrough the Duty of Care model.We will be mindful of the fact that transfer of care from specialist to primary and/or community is themain area where diabetes management falls down. Our network will work with each community todevelop a system where the transfer of care is never in question.Old WayNew WayFour years ago Jonty was diagnosed with diabetes. Jonty wasgiven different brochures and referred to several communityservices but has not got in contact with anybody. While hehas received invitations from his General Practice to attendan annual review, he doesn’t see the point in going as hefeels fine.Jonty is diagnosed with diabetes. The Doctor suggests anapproach to Jonty which will improve his skills and knowledgeand they agree that the health team will work with Jonty todevelop his management plan. Jonty’s management planidentifies all the steps and resources he can access to help himself-manage. As part of Jonty’s birthday communication he isreminded of his need to attend his annual review and the FlowTeam contact Jonty to remind him about his appointment andanswer any questions he has about the process.Mike has been at Waikato Hospital where he has receivedextensive training on how to use a haemodialysis machine athome. While he feels confident at Waikato, he worries aboutwhat could go wrong when he returns to Gisborne. While hehas registered with the power company that he has necessarymedical equipment at home, he worries that he won’t haveprepaid credit on his cellphone to ring Waikato if he gets introuble. He also worries that the machine might get pinched asthere are a lot of break-ins in the area where he lives. He ringsGisborne Hospital to talk through this and is advised that heneeds to sort this out with Waikato Hospital.Although Mike is in Hospital in Waikato, the Integrated FamilyHealth Network arranged for him to be visited by a member ofone of the local Integrated Family Health Centre’s CommunityTeam. The Team member talks to Mike and works with one ofthe Waikato Hospital social workers and the Regional ReferralCentre to establish a discharge plan. The Regional ReferralCentre notes Mike’s concerns and flags these with his localIntegrated Family Health Centre for follow up. The IntegratedFamily Health Centre Community Team coordinate ongoingsupport with Mike and maintain a close relationship withWaikato Hospital to share his care.99

Delivering on health targets7How we will implement that changeDiabetes annual review for every enrolled diabetic patientEvery diabetic patient to receive an annual diabetes review that is Integrated Family Health Centreinitiated. The definition of a disengaged patient will be determined by the number of patients thathave not completed this screen in the last twelve months.Rebuilding and revitalising the Diabetic Annual Review ProgrammeIdentifying the barriers to the diabetic annual review and making the necessary changes.Education for self-managementEach patient will be assigned a specific Flow Team worker, who will be their support throughouttheir diabetes journey. Comprehensive training where patients learn how to manage their diabetesand the risks that come with it. Includes one on one and community education sessions run at theIntegrated Family Health Centre, Flow Teams managing a diabetic patient base.D-diaryAn online diabetes tool – targeting those patients who are computer savvy. This tool will help tomanage, educate and assess their specific case of diabetes. Blogs and online communities aremanaged by the Midlands Network while widgets and applications track history of blood sugarlevels, and resulting health outcomes.Counting carbs (CC4K) for kidsFor children who are diagnosed as having diabetes - Carbohydrate counting (CC4K) can allowchildren to eat a variety of foods, just like other kids, and to increase his or her sense of control andconfidence in managing diabetes. Education around CC4K will help to support both the child andthe extended family. CC4K could act as a preventative for siblings of the diabetic child.KPIsEveryone screened under the basic screening check.All people who screen as “at risk” are on an actively managed plan.Relationships that will help make it happenCurrent regionalrelationshipsCommunity RelationshipsPractitioner SpecificrelationshipsDiabetes AssociationManiapoto Health Provider ConsortiumHealth Care NZLocal Diabetes TeamsGeneral PodiatryLifetime LifestyleWhanau Ora WorkersWhanau/Household Diabetes MgmntLifestyle ProgrammesChronic Disease Self-ManagementCoursesDiabetes Youth New ZealandGet CheckedDialysis Stations & CoordinationVirtual Diabetes ClinicsMulti Disciplinary Diabetes TeamsSpecialist Diabetes ServiceSpecialist Renal ServiceOutreach Diabetes ClinicsTe Wai o RonaDiabetic PodiatryMobile Diabetes Clinics100

Promise 6: If you live with Diabetes youwill have a Chronic DiseaseSelf-Management Plan.Promise 7: The Midlands region will rebuildDiabetes, Renal Care and AnnualReviews for better outcomes.101

102

7 Delivering on health targetsMental healthHealth targetPercentage of long term clientswith up to date relapse plans(NMHSS criteria 16.4) anddescribe how this is assuredNational WDHB TDHB TDH LDHBTotal 93% 90% 90% 100% 90%Maori 53% 43% 55% 60% 43%Pacific Island 54% 42% N/A N/A N/ACurrent performanceCurrently specialist acute mental health services are delivered by providers where the focus of theclinicians is on the top 3% client group and their mental health needs. This care is provided usuallyat the exclusion of a patient’s other medical conditions and social needs. A growing frustration forprimary care and many NGO providers is their inability to gain access to community mental healthservices for second opinions or for clients they genuinely believe require specialist support.Approximately 50% of current investment is in community-based providers including rehabilitation,residential care, kaupapa maori providers and other related support services. Additionally, primarycare has embraced the new model of care for people with mild to moderate conditions. Evidencesuggests that early intervention in this area is likely to reduce the impact of co-morbidities andimprove service coordination.Social services play a major role in the support of people in the community.Needs projectionsThere are currently no health projections for mental illness in this geographical area.Regional PromisesTo those people in Midlands who experience mental illnessPromise 8:Promise 9:If you live with mental illness you will have a Relapse Plan that is current andactively managed.If you live with mental illness you will have single point access for all yourhealthcare needs.103

Delivering on health targets7Current situation Midlands Network: Population living with mental illness6+ Population permesh block1-6 Population permesh blockWhat needs to changeBuilding a resilient communityMental health is a fundamental element of the resilience, health assets, capabilities and positiveadaptation that enable people both to cope with adversity and to reach their full potential andhumanity. We need to aim to build a resilient community, by providing services and support to allmembers of the community.Educating our communitiesMental health is crucial to the future of New Zealand. It underpins the social and intellectual skillsthat will be needed to meet the new challenges of the 21st century. Education for the communityenhances early detection and intervention, and fosters an empathetic understanding andacceptance of those living with mental illnesses.Young People as targetsYoung People want fast track access to treatment and care; the opportunity to build a rapportwith one person to guide them through services; greater sensitivity from service professionals;alternatives to medication; and preventative strategies and access to resources prior to crisis point.Connecting servicesServices will work with Integrated Family Health Centres, schools, community agencies, families, andother providers to create a common understanding of the social and emotional skills that are eitherlacking or require focus for mental health patients.104

7 Delivering on health targetsThe Development of patient centered Mental Health ServicesConsultation between patients, community, providers and associated stakeholders can greatlyassist in the design of services that are innovative in terms of delivery and location. Kaupapa MaoriServices and Youth Drop-in Centres will be formed to reduce the stigma around accessing MentalHealth Services and improve uptake and early intervention for better health outcomes.Old WayNew WayHohepa is admitted to Henry Bennett following a courtappearance in Gisborne for assault. After a stay of four dayshe is discharged back to his community without a relapseplan or coordination with local services for follow-up.Hohepa is discharged with the support of the Regional ReferralCentre. They request a relapse plan from Henry Bennett prior tosending him home with responsibility for his care transferred tohis GP and primary mental health team at the Integrated FamilyHealth Centre.Nicky presents to a local GP with uncontrolled sadness.The Doctor suspects post-natal depression but would like aspecialist opinion from a psychiatrist at Community MentalHealth. A referral is initially sent but no response is receivedafter three days. This prompts a telephone call from the GPat which time he is informed that a lab work-up is requiredprior to the referral being accepted by the Triage Team.Worried for his patient the GP manages the case himself,seeing Nicky every two days until a whanau member can beorganised to provide carer support.Nicky presents to the local Integrated Family Health Centrewhich operates devolved mental health services. A teamincluding her GP, a psychiatric nurse and a psychiatrist utilisingtele-health technology from his office in Rotorua make adiagnosis in consultation with Nicky of post-natal depression. Hercare plan is developed including a review of her medications by apharmacist, a four session package of care with the Nurse and afollow-up visit with the GP in two weeks time.Danny is a chronic diabetic who recently lost his wife tocancer. He is recalled by his practice for a Diabetes GetChecked appointment. The Practice Nurse completes thecheck noting his HbA1c has climbed to 9.5, unusual forDanny who has been a good manager of his condition forsome years. No further issues were identified as part ofthe consultation.Danny is recalled for a Diabetes Get Checked appointmentduring which the practice nurse notices his restlessness andlack of concentration. This prompts her to conduct a Kessler 10Primary Mental Health Assessment and engage the IntegratedFamily Health Centres Mental Health Nurse Specialist to providea second opinion regarding the need for counselling. A diagnosisof mild depression is confirmed and an immediate referral ismade to the Regional Referral Centre for counselling to bearranged for Danny. An appointment is booked prior to himleaving the practice and he is seen by Taranaki Primary ProviderConnections the next day.How we will implement that changeIncrease workforce knowledge of mental health conditions and their management.Develop clear inclusion/exclusion criteria.Network Partnerships with NGOs and Government AgenciesBuild collaborative models of care that involve the “non-medical” issues that manage a patientshealth and well-being.• Formal shared care arrangements.• Increasing wellness through programmes to improve nutrition, increase exercise and toquit smoking.• Daily visiting service for people who otherwise would be in hospital or residential services.• Work and housing initiatives to support recovery.• Acute home based treatment – the aim is to prevent re-admission to hospital and to assistearly discharge.• A crisis community respite service (with skilled competent staff).105

Delivering on health targets7Care plansWe will implement care plans for all people with a mental illness who have several health careproviders working with them. A care plan explains the support provided by each of the mental healthcare providers and when treatment should be provided. The care plan might also include what todo in a crisis, or to prevent relapse. Primary care will show evidence of active management for thesecare plans.Be Kind to Your MindThe aim is to improve the mental health and wellbeing of targeted adults. This will be achieved byraising community awareness about what it means to be mentally healthy and promoting activitiesthat help maintain and protect the mental health of individuals and communities. Mental promotionactivities to decrease stigma and improve communities’ ability to access early intervention services.Happy KidsThe focus is on establishing and promoting resilience and emotional wellbeing in children andteenagers during their school years – specifically year six to year ten. The aim of the project is tomonitor the cognitive and social emotional wellbeing development of children as they experienceand cope with complex issues during this developmental stage. Happy kids complement theproposed HEADSS assessment of all year 9 students.KPIsAll mental health patients have in place an actively managed and reviewed relapse prevention plan.100% of Long Term users of the mental health services have their plans reviewed biannually.Number of acute community based treatments.Number of crisis community respite referrals.Reduction in unplanned readmission rates within one month of discharge.Reduction in average length of stay.Reduction in the number of acute mental health presentations to ED.Relationships that will help make it happenCurrent regionalrelationshipsCommunity RelationshipsPractitioner SpecificrelationshipsPrimary ConnectionsRichmond FellowshipTuranga HealthPathwaysOranga Ngatahi (physical focus forbetter mental health outcomes)Chemical Dependency CounsellorCommunity HousingWhanau Ora WorkersEarly Intervention ServicesSpecialised Primary Care Mental HealthServiceAdvocacy ServicesPacific Peoples ServiceHigh & Complex Needs Case MgmntSuicideEating DisorderDrug & AlcoholPsychiatristPsycholgistPatient Centred Mental Health PlansRelapse Prevention PlansLong Term Service Users Plan106

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Promise 8: If you live with mental illness you willhave a Relapse Plan that is currentand actively managed.Promise 9: If you live with mental illness you willhave single point access for all yourhealthcare needs.108

7 Delivering on health targetsOlder PeopleHealth targetThere are currently no health targets that all DHBs collectively work towards.Current performanceOlder people access healthcare predominantly through Primary Care Services if living in their ownhome and by primary care visitors for both routine and acute care if in rest homes.Primary care visits for older people are often pre-booked up to three months in advance. Olderpeople often have a mindset that they don’t access General Practitioner services before this routineappointment, regardless of worsening health symptoms. They arrive with a shopping list of ailmentsand expect to address them all in the one appointment. There is another group who enjoy their visitsto the General Practice to such an extent they become ‘frequent flyers’.There are a wide range of support services in most communities, but they are often disconnectedfrom primary care and older people and their families are unsure how to access them. GeneralPractitioners often don’t know what services are available and locating and coordinating them istime consuming.Rest Homes suffer from a lack of qualified clinical staff. Large numbers of the workforce are nonregulated,low paid and have varying skill levels. They rely on an already stretched primary careworkforce for both routine and acute care which is only available 9am – 5pm Monday to Friday.For older people who become unwell outside normal business hours the only option available torest home staff is to ring the ambulance and transfer to secondary services. Ambulance services areadditionally stretched with medical alarm call outs for older people living alone for which there is noalternative triage service.Needs projectionsTotal WDHB TDHB TDH LDHBCurrent Older People Population65+65157 41004 14995 5145 4053Estimated Older People Populationin 20 years time 65+81240 52448 16668 7091 5033Current Older People EnrolledPopulation 65+ (Pinnacle only)56522 40643 7634 3872 4372Regional PromisesTo the older population of MidlandsPromise 10:Promise 11:As an older person living in Midlands you will have a goal focused CareManagement Plan.As an older person living in Midlands you will have single point access for allyour healthcare needs.109

Delivering on health targets7Current situation Midlands Network Older Persons25+ Population permesh block1-25 Population permesh blockWhat needs to changeSingle point access to health care services for older peopleWe need to make sure that people have access to earlier clinical review and intervention in resthomes avoiding multiple transfers to ED and hospital.Development of a Nurse Specialist role to provide routine checks in rest home settings.Triage system available 24/7 for rest home non-regulated workforce to access advice foracute assessment.Engage older peopleWe have identified our elderly ‘at risk’ population and they are engaged with their self-managementcare plan.We will have strong relationships with the community and social services that will support the elderlyin their home.We will make sure that our older people are not afraid to ask for help and know how to do it 24/7.Getting the ‘transfer of care’ between primary and secondary for older people rightWe will work with secondary services to recognise the value of a planned discharge process that linksback to primary services which in turn will enhance the quality of care for the person.We will make sure that the ‘transfer of care’ process increases the patient and clinician’s confidencethat the person won’t be lost between services.We will make sure that clinical records follow the person’s journey – right time, right place,right information.110

7 Delivering on health targetsOld WayNew WayMabel resides in a rest home where there is onlyRegistered Nurse and General Practitioner careuntil 5.00pm, Monday to Friday. Mabel becomesunwell after 5.00pm with disorientation and a hightemperature. The only action available for staff is tocall an ambulance to take Mabel to ED as only nonregulatedworkforce are on duty.Rest Home staff have access to a clinical triage line by phone. Triagerecommends next steps for rest home staff i.e whether to treat Mabelon site or transfer her to after hours care.General Practitioner Mark visits the rest home routinelyonce a month and is presented with multiple complexissues saved up for every patient. Because of timeconstraints he can only allow brief consultation to dealwith the top priorities from each list. The rest of the listisn’t addressed.A nurse specialist / practitioner from the Integrated Family HealthCentre with scope of practice in elder care carries out regular routineassessments. They will have direct access to referral processes andappropriate clinical expertise for complex situations.Auntie Mavis relies on nephew ‘big Tony’ to get to herappointment at the medical centre. She has a needfor urgent access, however ‘big Tony’ is in Wellington.Auntie Mavis remains at home and her symptomsworsen without clinical intervention resulting inhospital admission.The practice has identified Auntie Mavis as a possible at risk patient.Auntie Mavis is aware of the Flow Team at her medical centre viaher management plan and makes early contact. The Mobile Nurse isdispatched to triage Auntie Mavis. A treatment plan developed whichprevents hospital admission.Mr Brown is discharged from hospital after aMyocardial Infarction event with Chronic Heart Failure.He is put in a taxi to return to his cold house with nofamily in the same town. He is confused as to anyfollow up arrangements and only has medication forthree days which is not in the usual blister pack.The Regional Referral Centre is informed that Mr Brown will bedischarged from hospital and from here on in his transfer of care ismanaged by the Centre. The Centre organises a mobile nurse to visitMr Brown in hospital and she discovers Mr Brown’s only daughter livesin Invercargill. The Nurse works with the Social Worker and Mr Brown’sdaughter to identify a family friend, based in New Plymouth, who ishappy to provide support to Mr Brown until he is back on his feet. Boththe Integrated Family Health Centre and the Pharmacy are aware of MrBrown’s discharge and change in medication.Gladys’ family are concerned about her living aloneand have purchased a medical alarm for peace of mindknowing that she can access help in an emergencysituation. Gladys has lost her medication and isconcerned enough to use her alarm which goesstraight through to Ambulance Services.Gladys still uses her alarm, but it is monitored by the triage line whoare able to reassure her about her medication concerns, suggestalternatives and send notification for the Flow Team from theIntegrated Family Health Centre to contact her first thing inthe morning.How we will implement that changeEyes on over 65sThe Network will ensure all older people know how to access healthcare services. All over 65s havean annual full assessment with Aged Care Plans put in place as required.Single point of access 24/7As part of the care plans, at risk over 65s will have:• a medical alarm as part of their management plan and know how to use it;• An information card that gives details of how to access the Regional Referral Centre for advice andservices. Information will be personalised;• 24/7 access to the Regional Referral Centre.111

Delivering on health targets7Aged Care Plan (ACP)Individually planned and coordinated packages of care tailored to help older members of ourcommunity remain in their own homes. They are to provide for the complex care needs of olderpeople. ACPs are flexible and designed to help with individual care needsRecipients of an ACP are entitled to: quality services that meet their assessed needs; where possible,their preferred level of social independence; having their dignity and privacy respected at all times;access information about the care options available and the facts they need to make informedchoices; access to details of the care being provided; and take part in developing a package ofservices that best meets their needs.Medication Management ServiceAll over 65s who are eligible have a review of their medicine-taking behaviour. There will be regularinteraction between the patient and their pharmacist in an effort to optimise outcomes from theirprescribed medicines by identifying access, adherence, and day-to-day medicine managementissues, and working together to find solutions to these issues.Over the tea cupsPrivate Public Partnership focused on keeping older people self-managing in their own homes orsupported care. This service provides regular social interaction for older people whose family andWhanau are unable to have regular face to face visits. The service provides the older person withregular social contact and supported access with day to day requirements. The family receiveselectronic time framed updates on their loved one’s situation.KPIsAll enrolled older people have a needs assessment completed.All enrolled older people have an actively managed quality of life plan.Reduced number of patients presenting inappropriately at ED from rest homes.Reduced hospital admissions.Reduced ambulance callouts.Relationships that will help make it happenCurrent regionalrelationshipsCommunity RelationshipsPractitioner SpecificrelationshipsGoal focused self-management plansPrimary Care case Mgmnt PlansMultidisciplinary Medicine Use ReviewsOlder Peoples Service Extension50s ForwardUpright & ActiveAgeWISEElder Protection ServiceOlder Migrants & Refugees ServicesHome-based Support ServicesRestorative Home Based CareFalls Prevention ProgrammeElderly Exercise ProgrammeLife Transitions ServiceCommunity Health CoachKaumatua ServicesTraining Programme for older peopleand caregiversIntermediate Care ServicesOlder Peoples Service ExtensionRest Home - Pharmacy ServicesSpecialist Services for Older PeopleIntegrated Specialist Services for OlderPeople112

Promise 10: As an older person living in Midlandsyou will have a goal focused CareManagement Plan.Promise 11: As an older person living in Midlandsyou will have single point access forall your healthcare needs.113

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88. Funding requirements“If clinicians are to be held to account for the quality outcomes of the care that they deliver, thenthey can reasonably expect that they will have the powers to affect those outcomes. This meansthey must be empowered to set the direction for the services they deliver, to make decisions onresources, and to make decisions on people.” - Professor of Surgery, the Lord Darzi, ParliamentaryUnder Secretary of State, Department of Health UK. NHS Next Stage Review Final Report, 2008.To support the establishment of a regional view and commissioning approach some brave stepsneed to be taken with existing agreements. The Midlands Network will require a one contract, oneplan starting point. To facilitate this the following arrangements will need to be in place byJuly 1 st , 2010.• Consolidation of the national PHO agreement for the five PHOs in one Midlands RegionalAgreement. This contract would exist between the Midland Commissioning Board and a LeadDistrict Health Board.• Existing essence of services within A-I to be retained – however greater flexibility agreed around“the rules” for a range of service lines eg: CarePlus, SIA , HP etc.• Removal of FFS lines and replaced with capitation arrangements linked to performance againstregional promises.• Schedule J local variations to be retained by agreement and passed directly through to existinglocal services.• New schedule ‘M’ to capture a range of new arrangements including:a. Pharmaceuticals and Laboratories arrangements;b. Devolution of service funding to enable MCB to “purchase” services to support theachievement of the regional promises. (the actual service lines transferred will be linked tothe individual business case development);c. Regional quality plan;d. Integrated Family Health Centre service specifications and related funding (this will be linkedto the greater flexibility in sections A-I and J);e. “Capital Credit line” 0 to low % interest for capital developments linked with agreedIntegrated Family Health Centre establishment (up to $3.47m);f. Establishment funding for the MCB and MCGG.For the MCB and the network to be effective all conversations around service planning and fundingwill need to be lifted to the regional level as the starting point. Within this process will be themechanisms for developing and retaining local solutions at a local level.Proof of concept and effective due diligence around fresh ways of doing things and devolution willbe key prior to the rebuilding of any services. In many cases while the budget is being moved to theMCB the current providers will remain provider arm based, but with a stronger link to primary andthe patients in the community. To manage concerns and risks associated with this, a no change ofprovider period of two years will be locked in.Flexible funding streams will be applied to see the development of true interdisciplinary teams inboth co-located and virtual settings.• The current base level of funding will be maintained across all first level setting.• As geographical localities indicate a willingness and desire to develop Integrated Family HealthCentre capacity a range of assessment tools will be applied to identify key indicators such as ASRdemographics, disease burden, existing service configuration costs, workforce elasticity etc.• Stocktaking of surrounding services will also occur to draw in other interested parties but alsoidentify referral pathways.116

8 Funding requirements (total picture)• Extensive mapping and flow processing.• RIP (Rapid Implementation Process) – shutdown + all staff, partners and patient involvement.• Facilitated RIP.• Contracting, system and staffing amendments.Devolved Service Cost ($)Discharge Process $2,545,000Needs assessment Service Coordination (only dealing with acute demand relatedissues as opposed to disability)$365,000Diagnostics (may cut by disease state) $13,200,000Nurse Educators $2,008,000Post Natal Care $420,000Well Child/Tamariki Ora $6,440,000Community Nursing $27,750,000Vision & Hearing Technicians $700,000b4 school $916,000Immunisation Services (Outreach and Mobile) $2,503,000Family Violence $353,000Breast Screening (coordination/budget for publicly funded) $270,000Smoking Cessation $499,000Community CVD Management $430,000Nurse Specialists (including Healthright Mobile Nurses) $100,000Occupational Therapy (some but not all) $1,495,000Physiotherapy (some but not all) $2,180,000Social Workers $506,000Diabetes Services (some but not all) $350,000Sexual Health $2,543,000Podiatry $280,000Speech Therapy $315 000This list is not exhaustive and the final detailed list will be driven by the supporting business case117

Funding requirements (total picture)8Primary health does not exist in isolation.The challenge for primary health is to shift to a wellness model of care. This shift will bear fruitdirectly in terms of better, sooner, more convenient access to primary heath services; it will also havea major impact on the prevalence of chronic conditions and the resulting acute demand.It is this reduction on demand in the secondary system that makes the implementation of structuressimilar to the Midlands IFHC model commonplace in countries where economic triggers supportshifts in funding from secondary to primary, if they reduce the overall cost of healthcare.A good example of this is the Group Health Medical Home model. Because the Group Healthsystem funds services through the line, they are able to allocate additional funds to the delivery ofprimary health in the knowledge that a healthier community will lead to reduced demand, and cost,in the secondary environment resulting in a net gain to Group Health.Our response to the challenge of contributing to a reduction in acute demand is similarly not for theoverall system to spend more. However, we do need to be able to shift resources and funding toPrimary Health when and where it will unlock an overall system-wide cost saving.It should also be recognised that changes in the performance of Primary Care may lead to shifts inthe funding requirements within the District Health Boards’ portfolio of services and providers.Where these shifts result in a saving to the secondary system we propose the creation of a rebatestructure to allow Primary health to continue to reinvest in activities that will create an overall savingfor the health system.It is therefore proposed that the devolution of funding is made within a partnering arrangementwith the individual District Health Boards where the total funding within any particular District HealthBoard area is economically neutral, and the efficiencies within the service delivery can be appliedwhere they best deliver better, sooner, more convenient health care.The collaboration between Primary and the District Health Boards will provide;• A holistic view of funding and planning across the health system.• A shared common vision for the provision of health services.• The most efficient use of funding.• The avoidance of duplication of health service activity.• A simpler contracting environment for allied health providers.• Improved health system performance.118

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99. Performance measuresQualityThe network already implements a quality plan environment across all practices spanning elementsof accreditation, service performance improvement and implementation of quality systems.Moving forward, the implementation of quality within the Midlands Network will incorporate thedevelopment of Integrated Family Health Centre accreditation against service quality standards, andthe development of ongoing quality improvement through comparison of performance betweencentres and sharing of best practice.Periodic Service ReviewThe Midlands Region will implement a Periodic Service Review System. The Periodic Service Reviewidentifies a standard of excellence for the provision of patient centred healthcare• Is based on a series of service standards.• Sets targets and charts progress towards those targets.• Ensures monitoring is regular and consistent.• Provides feedback that is instantly comprehensible and in a highly visual format.• Encourages the sharing of best practice with other team members.• Gives positive reinforcement of standards as a result of the ‘best score ever’ measure.The system will be designed to track the quality and consistency of the service Integrated FamilyHealth Centre Health Teams provide to their enrolled patients. Whether an individual is a FlowTeam member, a Medical PA, a Registered Nurse, a Patient Liaison, a Patient Advocate or a GeneralPractitioner, Primary Care is about working as a team in a bid to provide patient centered healthcareunder the Duty of Care Model.The Periodic Service Review System uses this same principle of team work. In order to increase aIntegrated Family Health Centre’s performance in delivering patient centred care it will be importantfor teams to work together to focus on the areas where a Health Team needs to improve. Sharingbest practice with others who may not have the same experience or training will be an importantpart of this process.The Periodic Service Review is made up of 13 lead elements.The elements have either a high impact on the reputation of the Network “or” when focused on, willhave the broadest effect on improving practice. The elements:• Are based on a model of patient centred Duty of Care and of a dedicated and integrated HealthTeam with a single minded focus: an enrolled population who is fully engaged with the selfmanagementof their own healthcare.• Have been defined by legislation, policy or practice guidelines.• Span the full spectrum of the Primary Care service.• Monitor the performance of the entire Integrated Family Health Centre Health Team as a whole.• Where we have multiple reporting requirements with differing targets we will ensure that ournetworks service has a higher standard than any of the reporting elements.120

9 Performance measuresIntegrated Family Health Centres will receive their performance results on a monthly basis. Resultsare calculated and provided to the Integrated Family Health Centre Heath Team in the first weekof each month. The report will give team performance in each of the 13 areas as well as giving oneoverall team percentage.The impact on day-to-day work of this style of reporting is minimal. The Periodic Service Reviewsystem focuses on work the Integrated Family Health Centre Health Team already does, or arerequired to do, as a result of legislation, policy or best practice. The most important thing is that thereporting system requires the team to use MedTech consistently.121

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1 Integrated Family Health Network9 Integrated Family Health CentresRadically better outcomes