Whangaroa Health Services Review Preferred Model of Care

7. Service integrationAn important NHSP action for improving patient experience is to develop coordinated multidisciplinarymodels of care across primary and community providers (inclusive of Whanau Ora Collectives 7 ), and withspecialist services, with a focus on integrated, culturally competent care particularly for long-term conditions.As identified in the Funding and Service Profile, a number of different organisations provide health and socialservices in Whangaroa with varying levels of coordination (relying largely on personal relationships ratherthan organisational mandate and action). Community nursing services in particular have a wide range ofproviders including: NDHB (district nursing; school based public health nursing; community mental health nursing) WHST (mobile nursing; diabetes nursing) TROW (marae-based outreach nursing; rheumatic fever school-based nursing) Plunket (well-child nursing).The wide range of providers risks confusion for patients, duplicated use of scarce resources, and suboptimaloutcomes. It also means that local organisations lack economies of scale and scope.There has been some recent progress made towards better aligning services through co-location of most ofthe nursing workforce on the WHST campus. There is now an opportunity to take this further throughmanaged coordination, and moving towards integration. This can occur within and between organisationsand professional groups. The primary care response discussed above – including the shift to planned andpreventive care based on risk stratification and tailored models of care, and the review of triage andresponse - will enable identification of opportunities for integration of primary and community care. Inaddition, the services for older people section below identifies the opportunity for better linkage with homebasedsupport services.Goals in improving service integration include: Develop patient-centred and coordinated care Develop evidence-based pathways Avoid duplication of services Ensure no gaps in services Develop a locally-based multidisciplinary team with critical mass.Key actions include: Undertaking a comprehensive stocktake of existing services, their overlap, and any gaps Patient journey mapping Evidence-based pathway implementation for prioritised common conditions Introducing a shared care record for all health professionals, and as appropriate, community supportworkers Aligning local quality indicators with NHSP outcome measures.7TROW and WHST (together with Hokianga Health) are members of Te Pu O Te Wheke Whanau Ora Collective. The Collective has recently beenadvised of new TPK funding for four Whanau Ora navigators.20