Inspiring new ideas and stronger partnerships for improving population health (Hawkes Bay DHB)

Asia Pacific Integrated Care- Brisbane Australia6-8 November 2017

Introduction (Context and Problem Statement)

The HBDHB Mental Health Service provides care to 3,000 clients at any one time. Mental Health Service (MHS), range from inpatient through to intensive care, community-based services and community-based case consultation.

While the MHS had moved to the use of an electronic record, the system did not provide the ability to create a living, updatable ‘Assessment’ and ‘Plan’ document leading to many issues:

  • Clients having to repeat their story multiple times
  • Clinicians spending considerable time recreating assessments which were not updatable
  • Multiple documents confusing providers and clients – introducing the potential for clinical risk
  • No capacity to audit or generate reports on provider compliance/ carry out analytics on client wellbeing/targets met.

Short description of practice change implemented

The Mental Health Service wanted to develop new plans that were ‘living documents’ to ensure one ‘Assessment’ and one ‘Plan’ per client available at the click of a button and to guarantee that all carers were working on the ‘same’ plan making it consumer centric.

Whānau Tahi Limited (WTL) was chosen as the provider of choice for MHS services to be delivered safely and successfully using its Connected Care platform.This allows us to hold a single care plan in a single place accessible by whānau and their authorised care providers.

Aim and theory of change

Team Based Care - Connecting Providers to put consumers first. This approach is recognised world-wide through organisations such as the International Foundation for Integrated Care.An integrated care model requires partnering with providers across the social and health care continuum focussed on a client’s specific needs and desires – aspirations for well-being belong to the client - our role is to weave services around whānau to help them achieve their goals.

Targeted population and stakeholders

Hawkes Bay Mental Health Service providers and consumers - inpatient through to intensive care, community-based services and community-based case consultation.

Sustainability and transferability

MHS engaged consumers/providers to define pathways for the ‘Plans’ to ensure that we met needs of consumers, multiple clinical disciplines and health care providers, along with various treatment settings (e.g. child and adolescent mental health, substance use treatment through to inpatient mental health). This served to gain early ‘buy-in’ as we had developed clinical champions before the plans were developed into electronic forms in collaboration with Whānau Tahi.


Significant benefits have emerged from the introduction of the Whānau Tahi solution:

  • Consumers have one collaborative (shared care) plan accessible at the click of a button by the multi-disciplinary team members who share care delivery across secondary, primary and community care provider organisations.
  • Reduced administration of records means more time for clinicians delivering frontline care
  • The full audit functionality means that we can measure our progress at the click of a button and have information available for analysis to improve:
    • health outcomes for our clients
    • efficiency, productivity, auditability and consumer satisfaction

Lessons learned

  • Have high expectations and encourage a feeling of excitement about innovation and change
  • Be clear about what you want and why and share your vision – using sponsors and champions including consumers
  • Engage a vendor as a partner willing to collaborate to do something different