Counties Manukau Health reports on its At Risk Individuals Model of Care which uses the Whānau Tahi platform.

In response to concerns that people with long term health conditions are not always well supported by proactive or co-ordinated services, Counties Manukau Health (CMH) introduced the At Risk Individuals (ARI) model of care.

The ARI model of care provides funding to primary care practices (via Primary Health Organisations) for extended consultations, home visits and other services designed to support patients to achieve their own health goals.

CMH commissioned the Health Services Research Centre at Victoria University of Wellington to evaluate ARI, with an emphasis on the extent to which the new model of care is changing the way primary care practices work.

Read more here: www.victoria.ac.nz

Collaboration for Impact

I recently attended the Collaboration for Impact conference held in Auckland which stated:

“According to international literature ‘Collaboration for Impact’ offers a new way of resolving complex social problems with a vision for creating lasting change.”


Putting Whānau in the Driving Seat

Whānau Tahi Connected Care is a keyICT enabler to the Counties Manukau Health, Ko Awatea Planned Proactive Care programme, a key work stream of the Manāaki Hauora programme “enabling whānau self-management”.

Manāaki Hauora incorporates a collection of workstreams focused on building capacity and capability in individuals with long term conditions to play an active role in their care (as a key member of their care team) where their aspirations are given top priority.


Collective Impact Alliances to support reduction of Obesity in children

Rates of childhood obesity dropping, but adults continue to tip the scale

Whilst obesity targets for children appear to have dropped by a significant 2% in the years 2015 - 2016 the data is unable to tell us the changes in behaviour and or activities of this cohort of children for us to focus on or to consolidate for further wellbeing gains.

Perhaps now is the time to release the power of the data available in the B4 Schools Checks data set held by the MoH as its Custodian, and to share this with other systems such as Whānau ora’s social plan which captures and measures tamariki aspirations for well-being in a whānau centred and supported approach.

This could include

‘Measuring the quality of school practices around food, physical education and active play which would tell us what goes on where children spend a large chunk of their day, ...........and this is just the beginning!

B4 School Checks are giving more new entrants the best start

Health Minister Jonathan Coleman says the Whanau Tahi IT platform is giving kids the best start to their school lives.

The B4 School Checks is one of the products available on the Whanau Tahi platform and helps identify potential health or development issues four year old children preparing for school may have.

Dr Coleman said more parents are sending their children to school for the first time this week in the knowledge a B4 School Check has picked up any issues at an early stage.


Planned and proactive care in Counties gets airing at world congress

Emergency department attendances and hospital bed days are well down for some of the sickest people in Counties Manukau, just as primary–secondary integration gathers momentum in the district.

A halving of ED and inpatient admission rates for “planned and proactive care” patientsin a year is giving some confidence to the DHB’s primary health and community servicesdirector, Benedict Hefford.


Advantages of shared care plan is huge

Dr Peter Gow, Clinical Director Counties Manukau Health Adult Rehabilitation & Health of Older People (ARHOP) believes the shared care plans highlight for health professionals’ crucial information about what is important to the patient.

"I think we are acknowledging that there has been a whole lot of work done already and we now want to get shared care planning into mainstream practice. The advantages of using them are just so huge.” He says.

“When ‘what is important’ is determined then that becomes the driver for improved health.”


A story of change: patient's plan brings room to silence

The Diabetes Team at Counties Manukau met as they regularly do to discuss and review cases. The next patient on the agenda for discussion had been through incredible challenges. Her e-shared care plan was projected on the screen.

As we scrolled through her e-shared care plan we came to the box where her goals and aspirations were carefully noted," says Gill Aspin, Clinical Nurse Specialist. "They were simple, humbling, and powerful. The room fell silent. It brought the patient into the room with us. The human being was what we discussed as we kept these goals in mind."


e-shared care plan rolls off the tongue

Everyone we talk to in General Practice knows about e-shared care plans," says Ta-Mera Rolland, Clinical Team Leader, of CM Health's VHIU (Very High-Intensity Users) Link Team.

"Patient centred shared care plans are now business as usual and real change is taking place." These plans enable primary, secondary and community-based teams, along with the patient to access and view their key health information, history, personal goals and aspirations.


Personalised Care Planning for People with Long-term Conditions Leads to Improved Health Status

The Cochrane Library has published a systematic review of research on the effects of personalised care planning for adults with long-term conditions, compared to usual care.

The authors' key finding is that:

Personalised care planning leads to improvements in certain indicators of physical and psychological health status and people's ability to self-manage their condition, when compared to usual care. The effects appear to be greater when the intervention is more comprehensive, intensive and well-integrated into routine care. Evidence on the relative cost effectiveness of this approach is limited and uncertain.

The Library's work is crucial as it is the gold-standard for independent summary reviews of existing research. In this case, the authors reviewed 19 studies involving 10,856 participants.


Advance Care Planning

I spoke at the Health Informatics New Zealand conference in early November about Advance Care Planning (or ACP). It was rewarding to think about and prepare for the talk and heartening to speak to a full house.


Prof. Chad Boult Talks About Connected Care

Prof. Chad Boult speaks about his experiences and views on connected care, during his visit to the Australasian Long Term Conditions conference in Auckland, New Zealand.