Better, sooner, more convenient health care in Midlands

3 The Integrated Family Health NetworkA regional focus on improving patient journeysTo those people in Midlands at risk of or living with DiabetesPromise 6:Promise 7:If you live with Diabetes you will have a Chronic Disease Self-Management Plan.The Midlands region will rebuild the Annual Reviews, Diabetes and Renal Care forbetter outcomes.To those people in Midlands who experience mental illnessPromise 8:Promise 9:If you live with mental illness you will have a Relapse Plan that is current andactively managed.If you live with mental illness you will have a single point access for all yourhealthcare needs.To the older population of MidlandsPromise 10:Promise 11:As an older person living in Midlands you will have a goal focused CareManagement Plan.As an older person living in Midlands you will have single point access for all yourhealthcare needs.To those people who have become disengaged from the health systemPromise 12:If you are lost we will help you find your way.Primary Health has, and always retains, the primary Duty of Care for their patients on that journey.Our role as a region is to provide those at the coal-face with the tools they need to ensure each andevery journey is optimised.To ensure that no one goes into an administrative black hole or a diagnostic cul-de-sac. That no onefails to fill a prescription or attend a specialist appointment. That no one goes undiagnosed due toan administrative blunder. That no one finds themselves in a sleep-out in the back-blocks of ruralNew Zealand with a dialysis machine and no support.To do this we need to focus on not only providing the very best direct primary health care, we alsoneed to take responsibility for the points of transfer throughout their life, and ensure that at no stageare they “dropped”.This will be achieved by implementing the following:Access to Medical RecordsWe need to place the patient, and by extension, his or her records at the centre of the system.Their primary health team are the guardians of a patient’s health – but it is they who have ultimateresponsibility. Similarly, we are the guardians of their health records – but it is they who own them.This ownership needs to be reflected in terms of access and transparency. It is this transparencyand access that will also improve the ability of health providers to collaborate on any individual’sheath care.Currently the Midlands Network cannot find an “off the shelf” solution that will support the newmodels of care being proposed. The proposed response to this is to stretch the capacity of theexisting systems using the first wave patient portals and look to shift as many systems within the firstwave Integrated Family Health Centre to a co-located hosted and managed environment.This approach will ensure that we have the basis for supporting the new models of care but alsothat we are well positioned to inhale and adopt new systems as they arrive on the scene vianational processes.33