Better, sooner, more convenient health care in Midlands

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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
The Integrated Family Health NetworkA regional focus on improving patient journeys3This Expression of Interest uses the currently available MedTech Evolution as its core PatientManagement System. This new version of Medtech contains the following functionality:• Demographics.• Clinical Audit Trails.• Recalls and Screening.• Prescribing.• Accounts.• Appointments.• Multimedia Capability.• Health Management Tools.• Resource and Equipment Management and Venue Management.• Electronic Patient Connectivity.Community Managed Regional Referral Centre/Patient Access HubA continuing problem in the management of the interface between sending and receivingpractitioners has been the standard of referrals. Patient access to secondary services has oftenbeen hindered by referrals from sending practitioners that lack the detail or information requiredfor secondary care to make informed and timely decisions. Sending practitioners have becomeconfused over what constitutes an adequate referral.The result is that primary care has lost faith in its own system - referrals can be sent as many as 14times via myriad different methods in the belief that this will “get the referral through”. Primary Careneeds to acknowledge their role in the resulting disconnect and seek to address the issues that havearisen as a result.A community managed Regional Referral Centre will provide all primary and secondary care staff,patients, and community organisations within the Midlands region, with a service where they needmake only a single call in order to have a spectrum of queries answered. The aim of the RegionalReferral Centre is to coordinate and improve the patient journey while striving to keep Duty of Carethe guiding principle in all instances. A community managed Regional Referral Centre will providecoordination of Duty of Care for all patients requiring services across the Midlands Network.The Integrated Family Health Network will work with sending practitioners to ensure• Referral quality from sending practitioners is high resulting in better quality referrals for receiving practitioners.• Referral out to NGOs where services are available, more practicable and provide easier access.• Information and summary is provided to both sending and receiving practitioners.• Sending practitioners feel confident that all they need make is a single contact (with the right information provided) and thatDuty of Care for that patient will be handled by the Regional Referral Centre.The Integrated Family Health Network will work with receiving practitioners to ensure• Receiving practitioners have specified information they require in a referral.• Discharge information is provided to Primary Care (including pharmacy).• Urgent items in discharge information are flagged with Primary Care.• Medication changes, discontinuation is flagged to Primary Care.• Sending practitioners can have timely responses to referrals that meet the specified standard.• That once discharge occurs the receiving practitioner can be confident Duty of Care has been managed by theRegional Referral Centre.34
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Better, sooner, more convenient health care in Midlands

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