Whangaroa Health Services Review Preferred Model of Care

Figure 6 - Stylised risk stratification profile and associated intervention model. Note that the percentages of thepopulation ineach groupare not necessarily representative ofthe Whangaroa population, and are for illustrativepurposes onlyAn important component of shifting the balance to planned and preventive care is to develop acomprehensive understanding of the different levels of health need ofthe Whangaroa community, and inparticular, their health-risk profile. The use of risk profiling of the population enrolledwith primary care is animportant building blockfor plannedcare, allowing the design and application of care models to meet thevarying levels of health need. Figure 6 provides a stylised depiction of population risk stratification and thetypes of intervention that may effectively addresss the needs of different risk profile groups.Based on risk profiling of the Whangaroa community, care models for the different population segmentsscould be developed to match their level and type of need, and workforce capacity. A focus would be ondeveloping consistent, multidisciplinary approaches to needs assessment, careplanning and serviceedelivery. Care planswould be personalised to individual patients based on their health status,whanau/family support networks, and preferences, and thereby contribute to improved health outcomes andpatient experience of a responsive system.The care models wouldincrease inresource intensity as the level of risk increases. For people and theirwhanau with higher andmore complex needs, the care model could be intensified tocase management, andbroadened to include, for example, clinical pharmacy services, community mental health services, and socialservices.The objective would be to help people achieve the best health and quality of life possible by preventing riskfactors developing into long-term conditions, and stabilising current chronic conditions to prevent diseaseeprogression. Importantly, adoption of risk stratification supports a patient-centric approach to model of caredesign and resource allocation, and in turn supports better integrated service delivery.16