Wairarapa Community PHO EOI - New Zealand Doctor

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3.9.3.4 Key Performance Indicators SECTION 3.9.3 - PHARMACY Health System Develop Organisation relationships and Design between local pharmacists and primary care teams. Promote Legislation changes to allow expanded pharmacist roles. Promote new Pharmacy funding model based on patient populations Workforce accreditation e.g. MUR, Clinical qualifications Explore the concept of linking pharmacists to a shared enrolled population Decision Support Clinical Information Systems Support for self management Combined CPD sessions Standard protocols/guideli nes for treatment of minor conditions and triage of patients into care pathways/plans IT link between local pharmacies and general practices Pharmacy walk in clinics/triage in pilot localities Pharmacist prescribing – minor conditions, repeat prescribing, smoking cessation Implement an shared enrolled population model Implement walk in clinics and additional services across the region Ongoing development and Integrated IT decision support on all provider systems so pharmacists can access a shared clinical record IT links integrating all health providers within the IFHC including Secondary services Patient access to health info and clinical record (ManageMyHealth) IT links between all health providers and NGO, community and social services 64
3.9.4 Older Persons Services Our Goal: Action One lead health practitioner will ensure continuity of care and will be supported by the MDT The health needs of Older Persons will be met by a patient centric system across the multi-disciplinary teams and providers involved in their care Action We will implement common clinical leadership, agreed care pathways and clinical guidelines, and associated education opportunities to ensure our workforce is fit for purpose Action We will enable an integrated approach to comprehensive assessment and a shared electronic health record Background Assisting older people to remain active and engaged in their community is a key focus in the Older Persons Strategy 22 , the Wairarapa District Annual Plan and the Wairarapa Clinical Services Plan. To achieve this older people require care and support that is integrated and coordinated between various health care providers in hospital, primary care and the community and social agencies. In primary care new strategies are needed to recognise increasing demand as the population ages and the increasing acuity of those for whom they have primary responsibility, whether they are in home or residential care settings. The Care Co-ordination and Care Management functions in particular are not well integrated with primary and community providers and there are significant barriers to rapid responses when the needs of patients change quickly. Acute Demand in primary care, correlates directly with age, as outlined in Section 3.4. Older patients, by far, represent the largest number of patients admitted to hospital with ‘acute’ medical illness, much of which is actually an acute deterioration in the setting of long-term illness. For these reasons, the acute illness deserves particular consideration. Currently geriatric medicine is practiced in a number of different inpatient, outpatient and community settings reflecting the comprehensive nature of the speciality. In primary care comprehensive assessment is a fundamental pillar of excellent General Practice. 23 The essence of geriatric medicine as a specialty is to assess and treat the medical and rehabilitative needs of older people. The medical need comprises the whole range of acute, acute-on-chronic and chronic illness. This is done through a process known as comprehensive geriatric assessment. 2425 As patients move through various stages of life and their 22 Health of Older People Strategy, Ministry of Health, April 2002 23 The Royal New Zealand College of General Practitioners / Aiming for Excellence 2009 24 Comprehensive Geriatric Assessment: a meta analysis of controlled trials. The Lancet, Vol 342, 1993. 65
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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
Page 13 and 14: 3.0 The Proposed Initiative / Packa
Page 15 and 16: The Wairarapa Integrated Family Hea
Page 17 and 18: health services, as well as selecte
Page 19 and 20: Immunisation Outreach (1 FTE curren
Page 21 and 22: Local delivery of as much service a
Page 23 and 24: Whānau Ora approaches are infused
Page 25 and 26: Practice Decision Support modules (
Page 27 and 28: 3.3.4 Key Performance Indicators SE
Page 29 and 30: patients transported to ED and redu
Page 31 and 32: 3.5 Patients with Long Term Conditi
Page 33 and 34: visible to all providers working wi
Page 35 and 36: 3.6 Whānau Ora "Whānau Ora is the
Page 37 and 38: Māori Mental Health positions, Wh
Page 39 and 40: Te Rūnanga Hauora o Wairarapa AOD
Page 41 and 42: WCPHO/CH will continue to support a
Page 43 and 44: A shared approach to service improv
Page 45 and 46: WEEK CLINICAL PATHWAY COLLABORATIVE
Page 47 and 48: Practice performance monitoring pro
Page 49 and 50: Figure 1: The Business Unit Model I
Page 51 and 52: Alongside the business and operatio
Page 53 and 54: o o Direct primary care referrals f
Page 55 and 56: 3.8.4 Key Performance Indicators SE
Page 57 and 58: 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: 3.9.3.2 Decision Support and Clinic
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 and 110: when dealing with Long Term Conditi
Page 111 and 112: The Practice Liaison team forms an
Page 113 and 114: meet the needs of the workforce. Th
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achieving a systematic approach to
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Secondary funding is not able to be
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Rural Funding and Kimberley 71,000
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Funding sources for capital items w
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The organisation’s financial syst
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7.0 References 1. National Health C
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Appendix 2 - Letters of support for
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Appendix 4 - Terms of Reference of
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number of national forums and organ
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Alison Appleton Manager, Human Reso
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Appendix 6 -Compass Health Staff li
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Hancock Tui Mobile Nurse Hart Nicky
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Gartrell Stephanie Operations Manag
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Wairarapa Community PHO EOI - New Zealand Doctor

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