Better, sooner, more convenient health care in Midlands

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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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MihimihiKo te amorangi ki muaKo te
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Index cont.DiabetesHealth targetCur
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Better, sooner, more convenient health care in Midlands

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