Wairarapa Community PHO EOI - New Zealand Doctor

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condition changes, a seamless movement between different assessment approaches and care plans, needs to be established. A shared electronic health record will assist, and common utilisation of InterRai tools, including in Primary Care, will be implemented There is a body of evidence which shows that the outcomes for older people with multiple pathologies and functional problems are better if they have their treatment overseen by a multidisciplinary team led by a consultant specialist in geriatric medicine. Similarly in primary care, the care of older people is also dependent on a multi-disciplinary team who are employed by multiple providers, need to work together to get the best outcome. This team could be led by the GP, or a specialist Nurse and increasingly there is a call for the primary care MDT to have easy access to the specialist MDT advice and interventions. It is clear that a new whole of spectrum approach with integrated management and clinical leadership structures, clinical pathways and integrated communication systems and processes would bring about significant change in outcomes. The key factors leading to the need to improve how we deliver our care to the older population are: Demographic changes driving increasing demand Rise in complexity of the needs of older patients The need for effective use of staff along the care continuum and workforce pressures – creating interesting and stimulating career opportunities within this area of practice to train, retain and develop all the disciplines involved is important. The workforce is currently very stretched with some gaps in availability. For instance there is real pressure being reported in General Practices, where the number and complexity and consultations continue to rise. Residential care facilities are having increasing difficulty in meeting their contractual requirements for medical and nursing cover. Hospitals have vacancies in Geriatrician FTE The need for integration and enhancement of multi-disciplinary practices in care settings within and outside of the hospitals Equitable access for people across the Wairarapa. 3.9.4.1 Health System Organisation and Design Population and workforce demographics create a burning platform. This initiative will seek to use a systemic change approach to implementing an evidence based service delivery framework, as far as is possible within available resources. To implement such a systemic quality improvement process requires the commitment of the parties to do so and that has been confirmed. 25 The Merck Manual of Geriatrics - An interdisciplinary approach to caring for the elderly. August 2000 66
The following organisations have begun discussions to implement this initiative: The General Practice Teams across the Wairarapa Carter Court Lyndale Rest Home Aversham House Healthcare NZ Presbyterian Support Services Ultimate Care Masonic Villages Ambulance services Compass Health and PHOs Wairarapa DHB These organisations represent most of the major primary, community and hospital based aged care services in the Wairarapa. In the first instance, the initiative is focused at operational level, seeking to effect change within existing strategies. To ensure the vast array of services work together, the internal quality processes and systems integration first need addressing. Secondly, there may be some policy, funding and contractual level changes required. This framework is based on an initial assessment of the major challenges and possible solutions, by a group of local providers. This assessment is aligned closely with a review of outcomes of a number of new models of care for older persons service delivery. 26 26 IOM (Institute of Medicine). 2008. Retooling for an aging America: Building the health care workforce. Washington, DC: The National Academies Press. 67
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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
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 and 64: 3.9.3.2 Decision Support and Clinic
Page 65: 3.9.4 Older Persons Services Our Go
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
Page 115 and 116: 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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