Better, sooner, more convenient health care in Midlands

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