Innovative and courageous general practice? You be the judge!
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Transcript of Innovative and courageous general practice? You be the judge!
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Innovative and courageous general practice?
You be the judge!
Linda Dubbeldam, Clinical Director Sue Dykes, Clinical Nurse Specialist
Dr Delamy Keall GPsi, Dr Pauline Blackmore GPsi, Lisa Martin RNsi
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The Tararua District
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Tararua Health Group
Established 20094 sites general practice, community health services and a community hospital 100 staff60 clinical – 37.5 FTE14,570 enrolled patients Single networked PMS90kms of fibre-optic cabling
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Barraud Street Health Centre Pahiatua Medical Centre Te Rongopai Dannevirke Community Hospital
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Critical Success Factors
Inspired leadershipVirtual integration - Single networked PMSShared back room functionsOperational Management Team – doctors doctor, nurses nurse Clinical Excellence Group – Clinical Director Workforce development
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Health of Older People Service
• Non-acute interdisciplinary care for frail older people with moderate to high health needs
• Maori and Pacific 55yrs+• Other ethnicities 65yrs+• Comprehensive health assessments • Case management• Aspirational targets
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(some of) Our Team
Alex Graham - Community Pharmacist; Michelle Burgess - InterRAI Assessor/Practice Nurse Pahiatua Medical Centre; Pauline Blackmore - GPsi/GP Barraud Street Health Centre; Fiona Moscrop - CPHO Clinical Pharmacist; Delamy Keall - GPsi/GP Pahiatua Medical Centre; Linda Dubbeldam – Clinical Director; Lisa Martin - RNsi; Sue Dykes - CNS.
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The THG way
• Best use of available resources • Assessment• Care and support • Medical and medicine management • Shared consults, sharing learning • Short term focused intensive mobile• General practice based
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THG Practice Profile
• 17/01/10 – 16/01/11• Age, ethnicity, # long term meds, ARC
residency, # acute admissions, # reported falls, living status, # primary care presentations, care plus status
• Applied weighting to flag those most at risk of harm or injury
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Our Older PeopleAge Maori Pacific Other Total55-59 129 1 13060-64 74 4 7865-69 65 540 60570-74 46 472 51875-79 34 350 38480-84 13 1 275 28985-89 7 192 19990-94 4 79 8395-99 1 17 18100-104 3 3Total 373 6 1928 2307
16.2% 0.3% 83.5%
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Weighting Scores
1 2 3 4 5 6 7 8 9 10 110
100
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400
500
600
700
800
Total
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1 2 3 4 5 6 7 8 9 10 110%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Other
Pacific
Maori
Score
% o
f elig
ible
eth
niciti
es
Weighting by Ethnicity
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Primary Care Presentations
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 23 31 360
50
100
150
200
250
300
350
400
OtherPacificMaori
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Polypharmacy
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 24 28 ?0
50
100
150
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400
450
# of LTM
# of
pati
ents
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Living Alone?
9%
55%
37%
Yes
No
Don't know
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The THG Way
• Proactive approach to referrals• Clinical pharmacist review • Joint MUR CNS/community pharmacists• Community pharmacists full access to THG
MedTech• Multi-dis case management• Standardised SOs ARC• Falls assessment
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Sustaining Innovation
• Exploring the seamless sharing of information between THG and Tararua ARC facilities
• Involvement of physical activity educators → Physio-led falls prevention programme
• Applying some science to the weighting scores Summer student/Masters project
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Visionary? Innovative? Courageous?
You be the judge