Wairarapa Community PHO EOI - New Zealand Doctor

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Creating an Integrated Health System The Past Disconnected providers Fragmented services Provider focused Enablers Clear roles and responsibilities for each provider Well developed integrator functions District-wide patient pathways Primary care established as “medical home” Improved communications and e-connectivity Joint clinical forums and governance Regional clinical leadership and networking Regional decision making The Future Connected providers Integrated services Patient centred Wairarapa Clinical Services Plan September 2009 The Wairarapa Integrated Family Health Model of care is proposed to achieve the WDHB Clinical Services Action Plan “Triple Aim” of: Improving the health of the population Improving the patient experience and Reducing and controlling costs. The Wairarapa IFHM outlined in this EOI also moves forward on the implementation of the Central Region District Health Boards Regional Clinical Services Plan (2008). For Wairarapa the challenge is to establish a well integrated network of primary and secondary health care services across the district, in a way which utilises the collective synergy of health services in the district and wider region, but which delivers as much healthcare as close to the patients home as possible. This EOI proposal links with the locality focused PHO/DHB/Compass Health proposals from the Capital and Coast DHB and MidCentral DHB areas. Compass Health is the common Management Services Organisation for eight PHOs in all three DHB areas. A covering letter to the three detailed DHB area based proposals, will highlight how regional synergies and economy of scale for service delivery, clinical and management support across the majority of the lower North Island population, will be realised. The overall aim in establishing the Wairarapa Integrated Family Health Model of care is to ensure that there is a fundamental shift within health care, in which a greater level of services and care is moved from the hospital setting into a model that is supported by a comprehensive network of community-based facilities in which primary, community and some secondary services are collocated. The set of proposals in our EOI build on the healthcare achievements already realised in the Wairarapa including significant clinical ownership of the development process, significant investment by Practitioners in healthcare delivery, a high performing PHO (see appendix 3: Letter from WDHB Chair), a high performing DHB and a well developed relationship with the Māori community. 6
Background and Development Process This proposal has first and foremost been developed by considering the needs of patients and Whānau in their local environment, and engaging local clinicians and providers in wide ranging discussion and redesign of services. This included a significant body of work over the past 6 months in the Wairarapa working with our clinicians to create the Wairarapa Clinical Services Plan (attached at appendix 1). This EOI plans to advance the work of the Clinical Services Action Plan and also the Central DHBs Regional Clinical Services plan (2008) to the implementation stages. This proposal reflects shared strategic thinking, pragmatic service development and operational planning, integration of management services where indicated and the implementation of common and supported clinical governance. In some cases, where regional or national providers are involved or regional collaboration or critical mass is enabling or required, this proposal links to the locality focused PHO/DHB/Compass Health proposals from Mid-Central DHB and Capital and Coast DHB areas. Compass Health is the common Management Services Organisation for eight PHOs in all three DHB areas. Compass Health also holds direct contracts for a number of regional services. A covering letter to the three detailed DHB area based proposals, will highlight how regional synergies and economy of scale for service delivery, clinical and management support across the majority of the lower North Island population, will be realised. 7
Page 1 and 2: TRANSFORMING PRIMARY HEALTH CARE IN
Page 3 and 4: Contents 1.0 Lead Organisations det
Page 5: Executive Summary Better, Sooner an
Page 9 and 10: 1.3 Legal Structure Wairarapa Commu
Page 11 and 12: 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
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Enhanced collaboration across the c
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3.9.3 Pharmacy Our Goal: Action Com
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Medicines Management will be implem
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3.9.3.2 Decision Support and Clinic
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3.9.4 Older Persons Services Our Go
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The following organisations have be
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3.9.4.2 Decision Support / Clinical
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3.9.5 Urgent Care We are working th
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3.9.6 Primary Mental Health Service
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The Integrated Family Health Model
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3.10 Access Our Goal: Improve acces
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3.10.2 Decision Support / Clinical
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o assessment for FSAs in Primary Ca
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Meaningful effective linkages betwe
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SECTION 3.12 - VULNERABLE POPULATIO
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Expanded workforce through better u
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MSD has already developed the Commu
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CHWT currently has a Board of 5 Tru
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Associated partners of WCPHO: This
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excellent relationships with the tw
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good track record of issuing media
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Funding model for new integrated se
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4.7 Clinical Leadership Our Goal: M
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Mentoring and support for emerging
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4.8.2 E-Referrals Compass Health ha
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The unit could establish a regional
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when dealing with Long Term Conditi
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The Practice Liaison team forms an
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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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