Better, sooner, more convenient health care in Midlands

4 The Integrated Family Health CentreA local focus on taking control of the dayFlow Team servicing both mobile and in-situ teamWho they are:• Patient Advocate role• Medical PA for all General Practitioners• Patient Flow WorkersWhy they exist:Focused on patient satisfaction, patient engagement and maintaining a complete baseline recordof the patient’s health record. The Flow Team is a dedicated amount of resource that is focused onkeeping the day moving according to a team plan. They are the conduit or fulcrum between thein-situ and the community team. Their core mission is to keep the largest possible proportion of theirenrolled population engaged.Engaged High Needs Non- EngagedManage pre visit planningReview workflow and plan accordinglyCoordinate patient centred careAnswer patient phone-callsMake follow up contactUpdate patient records post and previsitManage call backsManage regular check up apptmentsManage patient health milestonesMeet & greet - provide pre visitscreeningLiaise with referral centreOversee IT and admin systemsAllocate walk in capacityCoordinate team work in progressManage patient expectationsOrganising General Practitioneravailability for case conferencingEnsuring General Practitioner availabilityfor case conferencesEnsuring General Practitioner availabilityfor triage situations from communityteamsLocate non-engaged patientsManage interface between communityand in-situ careStakeholder management andengagementHold key community relationshipsKeeping community team up to dateFlag alerts needing particular attentionor sensitivityFlag inter-agency visiting on complexcasesHelp access to fund solutions to barriersfor engagement (childcare, travel etc)What they do:A Health Care Team working in the community but based at theIntegrated Family Health CentreWho they are:• Mobile Nurse team (Healthright Nurse, District Nurse, Public Health Nurse)• Health Coach• Kaiawhina/ Patient LiaisonWhy they exist:Patients often prefer, for a variety of reasons, to receive their care in the community. A team thatcomes to a patient’s home or another more neutral setting in the community can often overcomebarriers to access that can be seen as overwhelming in an in-situ setting. This team provides timeframed,coordinated General Practitioner lead care and ensures a more wrap around service for thepatient and their family.A team may be based in an area specific to the Integrated Family Health Centre population thatrequires significant support (Older Persons), a geographic location or community, a cultural or hapubased group or a specific ethnic community.43