Primary and community teams – expanding opportunities for future networks

摘要

For decades, General Practice teams, community nurses and allied health rehabilitation teams in Capital & Coast District Health Board (CCDHB) have delivered care in the community but have not meet the needs of the population as demonstrated by the growing acute demand. In 2016, through the CCDHB alliance the Health Care Home (HCH) model was jointly implemented with the local Primary Health Organisation across Wellington, New Zealand. In addition to practice developments, the integration of community nurses and allied health rehabilitation teams was a focus. The aim of the CCDHB HCH programme was to improve health care in the community through delivering new models of preventative, proactive and acute care in primary care. Alliance leads developed the local HCH approach that is supported with change teams and clear milestones. Intermediate outcomes of process and quality measures as well as longer term outcomes in acute demand are monitored through a collaborative governance group. The CCDHB programme will reach eighty percent of its population by June 2019. This will include about 240,000 people and include the majority of the Māori and Pacific population who are a focus as they experience health inequalities. CCDHB and the PHOs will have jointly invested approximately $13m between 2016 to 2019 to support the HCH initiative. Beyond 2019 resourcing will evolve to reflect the new maintenance phase as well as the role of HCHs as the core of CCDHBs future Community Health Networks. Analysis of the first tranche of HCH practices have shown improvements in emergency department presentations. These practices offer an additional 120 appointments a week, have returned over 281 working days back to the community through GP triage and have enabled more than 17,000 people to interact with their practice via the patient portal. Multidisciplinary care planning is being well received exampled by a GP stating that “Multidisciplinary team meetings with district nurses and allied health are worth their weight in gold”. Health leaders from other areas in New Zealand have liaised with the CCDHB HCH team to learn about the collaborative development process. The CCDHB development has alignment with some areas in New Zealand. It is unique in its joint investment through the alliance and focus on the integration of the hospital community nursing and allied health services with the practices. While implementation of the CCDHB HCH model is still underway, the initiative has already delivered an enhanced model of care to tens of thousands of people. An increased focus on Māori and Pacific populations are being added to the programme as it matures. Interim measures of process and quality indicate positive progress. While still early days, longer term measures are showing positive results in acute demand. The HCH progress provides a strong platform for the establishment of Community Health Networks in CCDHB. It has demonstrated the ability for the sector to work together to deliver new models of care and will provide a mature primary care sector that will be the central organising point for the networks.