Better, sooner, more convenient health care in Midlands

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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
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MihimihiKo te amorangi ki muaKo te
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Better, sooner, more convenient health care in Midlands

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