Better, sooner, more convenient health care in Midlands

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7 Delivering on health targetsOld WayNew WayHayden has to get a medical in order toqualify for his life insurance to be renewed.He has not been to the doctor in over fiveyears. At the medical Hayden discovers thathe must complete different parts of the checkat different locations and that none of theirschedules are shared. Hayden leaves feelingintensely frustrated with the process and tellshis workmates of his awful experience.As part of his birthday communication Hayden receives a basic health screen.The communication also includes a summary of screens he had last year and theones he will require over the coming twelve months. He completes the screenonline and uses the secure email to book an appointment for his medical.The Flow Team knows what the medical will require and make sure that Haydenreceives a coordinated check (bloods are taken at work and available at thecheck). The Medical PA emails Hayden to let him know that he will require anECG and that she has contacted the service to organise an appointment on hisbehalf. The medical is completed and highlights no areas for concern. Haydenis thoroughly impressed with the service and tells others about his experience.A blood test confirms Maree has highcholesterol. Maree googles her cholesterollevel and discovers that it is only marginalso she eats the piece of bacon and egg pieshe brought for lunch and throws away thepamphlets her General Practitioner gave her.Maree’s bloods were taken at work by the peripatetic phlebotomist. While sheis waiting for her check - a Flow Team member gives her a webhealth touchscreen with an interactive Heart Forecast. During the consult Maree’s GeneralPractitioner confirms that she has high cholesterol and works with her to createa self-management plan. Her General Practitioner’s Medical PA organises anappointment with Green Prx before she leaves and books another appointmentfor her in three months to review her progress. Maree’s appointment, contactdetails for Green Prx and self-management plan are available for her toview online.Vicki is 27 and flatting with two other youngwomen. Vicki has had three letters regardingher cervical smear but all have gone to herlast flat and she is unaware she has fallenoff the recall list. She thinks smears are ickyanyway, its winter and she will have to shaveher legs, the last time she had to go on herown and she felt like a real idiot.Vicki hasn’t cleared the letterbox in years and when her Integrated FamilyHealth Centre asked her if she wanted to receive her communication onlineshe jumped at the chance. Vicki received a reminder in her online birthdaycommunication that she would require a smear this year. She goes online andbooks an appointment that suits her. She also finds a link to a great website thatanswers some of her more gross questions without her having to ask them tosomeone’s face. The Flow Team rings to confirm her appointment and asks herif there is anyone she would like to bring with her. Vicki says she will bring one ofher flatmates and the Flow Team takes the opportunity to book an appointmentfor her flatmate’s smear while they are both there.Marama is a lifelong smoker who has had arecent health scare. She is currently inhospital and, as she can’t smoke in thereanyway, has taken the opportunity to getpassionate about quitting. She has hadnicotine patches while she has been inhospital. She asks one of the nurses abouthow to give up and the very friendly nursegives her lots of helpful pamphlets and asksher to talk to her Pharmacist about nicotinereplacement. Marama goes home and isunable to get to the pharmacy for the nextthree weeks. She recommences smoking andthe moment is lost.Marama is visited in hospital by a member of the Integrated Family Health Centrecommunity team. The Team member talks to Marama and discovers her desireto quit smoking. This is included on her discharge information and dischargeprescription. The Regional Referral Centre notes Marama’s intentions and flagsthese with the Integrated Family Health Centre for follow up. The IntegratedFamily Health Centre Community Team coordinate nicotine replacement therapyand smoking cessation support so that Marama’s good intentions do not becomea wasted effort.How we will implement that changeBasic (online or manual) health screening for every enrolled patientEvery patient to receive a basic health screen that is Integrated Family Health Centre initiated. Thescreen is updated annually and the definition of an unengaged patient will be determined by thenumber of patients that have not completed this screen in the last 12 months.85
Delivering on health targets7Active management of changes in patient’s personal situationsThrough excellent reporting systems the Flow Teams at each Integrated Family Health Centre areable to determine changes in patient online status. They work to liaise with patients around theactive management of appropriate and coordinated responses to address health issues.Interactive Lifestyle Screening on site and onlineFlow Team provides webhealth touch screens for patients that provide them with interactives andindependent learning around the patients key health areas.Lifestyle groups and coachingGroup sessions made available to patients to deal with core health issues.Coordinated communications and social marketing campaign to promote wellnessCommunity messages that are innovative and fresh in their approach to core wellness milestones.Screening for understanding around the issue of health literacyCore screening for every patient to assess health literacy. Clip on modules to assess understandingof core concepts for any issue requiring health knowledge to achieve self-management.Quit attempts for every smokerThe Flow Team tracks and manages a system which ensures every current smoker is supported tomake at least two Quit attempts in any one year period.PreventingBy linking together the Education and Health sectors, teachers can use the New Zealand curriculumto develop the knowledge, understandings, skills, and attitudes needed to maintain and enhancepersonal health.KPIsBasic Screening Test for the enrolled population (100%)Relationships that will help make it happenCurrent regionalrelationshipsCommunity RelationshipsPractitioner SpecificrelationshipsManiapoto Health Provider ConsortiumLifestyle Interventions ProvidersSport WaikatoHealthy Living CentresHealthy Homes ProgrammeNaturopathMirimiriCooking ClassesImproved Access to Fruit & VegSmoking CessationSmokefree Cessation in the WorkplaceGreen PrescriptionsQUIT PlansHapu Health Management ProgrammesDental ServicesCervical ScreeningBreast ScreeningProstate ChecksVirtual Skin Lesion ClinicsMole MappingSexual Health ScreeningMedicine Use ReviewsMinor Ailment Consults (Pharmacy)Cellulitis DVT ManagementOptometristDietitiansRongoa86
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MihimihiKo te amorangi ki muaKo te
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Index cont.DiabetesHealth targetCur
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Devolution becomes aby-product of w
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22. IntroductionA model for better,
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IntroductionA model for better, soo
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The Integrated Family Health Networ
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Page 96: Promise 4: Free Cardiovascular Risk
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Page 109 and 110: Promise 8: If you live with mental
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Better, sooner, more convenient health care in Midlands

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