Wairarapa Community PHO EOI - New Zealand Doctor

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The department supports 90 community health workers based in PHOs, providing them with fully electronic district wide patient health records in patient homes and community clinics. It builds award winning software tools that integrate with Patient Management Systems to facilitate quality frameworks around Long Term Condition Management services such as CarePlus, provides full e-referral capabilities from GPTs to PHOs, and assists in complex and detailed health data collection and transport for reporting and analysis purposes. The organisation’s IM department create feedback loops to GPTs by producing regular reports and analysis in areas such as Cardiovascular Disease coverage, Diabetes Annual Review coverage, Immunisation coverage and PHO Performance Management target achievement. Such reports are produced at appropriate levels from aggregated practice or provider level reports, through to gap analysis reports at a patient level. 110
The Practice Liaison team forms an integral part of the interface between the technical aspects of information management and the practical application in GPTs. Its members provide specialist knowledge, advice and training to primary care providers, from business process to PMS use. 4.9 Workforce development Workforce development is a key tool in developing new services and expanding existing services. As well as new role development there is considerable scope for role expansion. The serious national shortage of health workers, including doctors and nurses, means that we need to rethink how to get the best from the people we have working in health. WCPHO/CH has a strong commitment to workforce development. This is evident by: career pathways for all staff a commitment to training and professional development opportunities for staff a commitment to providing best practice supervision for staff Guided Care Nurses: In the Integrated Family Health Model, Guided Care Clinicians will have key roles within general practice teams. These clinicians will be qualified professionals with additional training and experience in coordinating care. Guided Care Clinicians can fulfil roles in extended primary care teams as well as working across the “primary/secondary healthcare interface” and the “Primary Care/Social Services interface” - thus enhancing access to care and support and leading to service improvement. Nurse lead clinics: Well managed and efficient nurse triage clinics already provide improved health outcomes in the Wairarapa. For some time now it has been envisaged that Nurses will be developed to take a greater lead role in the running of such clinics. Through the Clinics Nurses provide assistance in primary acute care integration, better coordination of care, increased workforce capacity, the provision of practical and professional support to GPs, and the enhancement in the range of services available to people attending general practice services. We will extend on this concept. Multidisiplinary Teams (MDT) To ensure there is effective management of patients a multi-disciplinary team based approach will be used within the general practice team. This will include the GP, Practice Nurse, and Clinical Nurse Specialist or Nurse Practitioner, with other health professionals such as allied health professionals, mental health practitioner, podiatrist, optometrist, dentist etc brought in as part of team care arrangements. 45 Training will be provided as to how to utilise the MDT concept effectively. 45 Nurse led Clinics, Whitehorse Division of General Practice, 2007 111
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TRANSFORMING PRIMARY HEALTH CARE IN
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Contents 1.0 Lead Organisations det
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Executive Summary Better, Sooner an
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Background and Development Process
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1.3 Legal Structure Wairarapa Commu
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2004 Q3 2004 Q4 2005 Q1 2005 Q2 200
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3.0 The Proposed Initiative / Packa
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The Wairarapa Integrated Family Hea
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health services, as well as selecte
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Immunisation Outreach (1 FTE curren
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Local delivery of as much service a
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Whānau Ora approaches are infused
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Practice Decision Support modules (
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3.3.4 Key Performance Indicators SE
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patients transported to ED and redu
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3.5 Patients with Long Term Conditi
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visible to all providers working wi
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3.6 Whānau Ora "Whānau Ora is the
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Māori Mental Health positions, Wh
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Te Rūnanga Hauora o Wairarapa AOD
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WCPHO/CH will continue to support a
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A shared approach to service improv
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WEEK CLINICAL PATHWAY COLLABORATIVE
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Practice performance monitoring pro
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Figure 1: The Business Unit Model I
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Alongside the business and operatio
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o o Direct primary care referrals f
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3.8.4 Key Performance Indicators SE
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Enhanced collaboration across the c
Page 59 and 60: 3.9.3 Pharmacy Our Goal: Action Com
Page 61 and 62: Medicines Management will be implem
Page 63 and 64: 3.9.3.2 Decision Support and Clinic
Page 65 and 66: 3.9.4 Older Persons Services Our Go
Page 67 and 68: The following organisations have be
Page 69 and 70: 3.9.4.2 Decision Support / Clinical
Page 71 and 72: 3.9.5 Urgent Care We are working th
Page 73 and 74: 3.9.6 Primary Mental Health Service
Page 75 and 76: The Integrated Family Health Model
Page 77 and 78: 3.10 Access Our Goal: Improve acces
Page 79 and 80: 3.10.2 Decision Support / Clinical
Page 81 and 82: o assessment for FSAs in Primary Ca
Page 83 and 84: Meaningful effective linkages betwe
Page 85 and 86: SECTION 3.12 - VULNERABLE POPULATIO
Page 87 and 88: Expanded workforce through better u
Page 89 and 90: MSD has already developed the Commu
Page 91 and 92: CHWT currently has a Board of 5 Tru
Page 93 and 94: Associated partners of WCPHO: This
Page 95 and 96: excellent relationships with the tw
Page 97 and 98: good track record of issuing media
Page 99 and 100: Funding model for new integrated se
Page 101 and 102: 4.7 Clinical Leadership Our Goal: M
Page 103 and 104: Mentoring and support for emerging
Page 105 and 106: 4.8.2 E-Referrals Compass Health ha
Page 107 and 108: The unit could establish a regional
Page 109: when dealing with Long Term Conditi
Page 113 and 114: meet the needs of the workforce. Th
Page 115 and 116: achieving a systematic approach to
Page 117 and 118: Secondary funding is not able to be
Page 119 and 120: Rural Funding and Kimberley 71,000
Page 121 and 122: Funding sources for capital items w
Page 123 and 124: The organisation’s financial syst
Page 125 and 126: 7.0 References 1. National Health C
Page 127 and 128: Appendix 2 - Letters of support for
Page 129 and 130: Appendix 4 - Terms of Reference of
Page 131 and 132: number of national forums and organ
Page 133 and 134: Alison Appleton Manager, Human Reso
Page 135 and 136: Appendix 6 -Compass Health Staff li
Page 137 and 138: Hancock Tui Mobile Nurse Hart Nicky
Page 139 and 140: Gartrell Stephanie Operations Manag
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Wairarapa Community PHO EOI - New Zealand Doctor

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