Better, sooner, more convenient health care in Midlands

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