Better, sooner, more convenient health care in Midlands

3 The Integrated Family Health NetworkA regional focus on improving patient journeysThe Integrated Family Health Network will work on behalf of patients to ensure:• No patient is left behind.• Duty of Care is managed on the patient’s behalf.• Information provided by the Regional Referral Centre to the patient and/or their family is in plain language and meets basichealth literacy standards.• The Regional Referral Centre will communicate all information to both sending and receiving practitioners on thepatients behalf.• Family and whanau are respected as a fundamental component of the patient’s well-being and kept informed of patient’sdischarge status where relevant.The Regional Referral Centre will provide time-framed responses to both sending and receivingpractitioners involved in the referral process. All contacts in and out of the referral centre will takeplace via a six “lines of care” with each line requiring extensive algorithms to be developed.It is acknowledged that while components of this service exist in many locations within each ofthe District Health Boards none of the services are patient focused or aim to provide an end toend Duty of Care model. Primary Care coordinating and owning the role of managing referralsmeans accountability on all sides of the process and increased standards of referrals fromsending practitioners.The Regional Referral Centre will have access to• Diagnostic booking schedules.• Transport and Accommodation budgets and bookings.• First Specialist Assessment appointments and procedures bookings.• Interface between primary and secondary care.• Community knowledge on where and when to refer.• Hospital Discharge schedule and information for coordination of follow up care withcommunity teams.• Community knowledge of regional boundaries of who provides services to whom.• Integrated Family Health Centre Health Teams.• Network Community and Mobile Teams.An e-referral system that interfaces with Medtech does currently exist in the Midlands area.Supported by BPac, Electronic Clinical Decision Support is an effective mechanism for transferringreferrals electronically and would form the basis of any network wide electronic based approachto referrals. The system uses pre-specified information according to referral type and intendeddestination and interfaces with patient notes, history and medication records appropriately.Leverageing off the BPac Electronic Clinical Decision Support and the subsequent e-referralsolution, the Midlands Network will move to all referrals being electronically transferred to receivingpractitioners within 12 months. The use of Electronic Clinical Decision Support specialty specificmodules will assist with improving the quality of referrals made by sending practitioners.While electronic referral will always form a core part of any approach to running an efficient andeffective Regional Referral Centre which operates in a timely manner, it is important to note thatelectronic processes are only one mechanism by which referrals can be made. The point of theRegional Referral Centre is to coordinate enquiries from a number of points of entry and to providea “no wrong door” set of responses where service and way finding are the key elements of a processwith the aim of Duty of Care.35