Better, sooner, more convenient health care in Midlands

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