innovative and courageous general practice? you be the judge!
DESCRIPTION
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. The Tararua District . Tararua Health Group . Established 2009 - PowerPoint PPT PresentationTRANSCRIPT
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
The Tararua District
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
Barraud Street Health Centre Pahiatua Medical Centre Te Rongopai Dannevirke Community Hospital
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
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
(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.
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
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
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%
Weighting Scores
1 2 3 4 5 6 7 8 9 10 110
100
200
300
400
500
600
700
800
Total
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
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
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
200
250
300
350
400
450
# of LTM
# of
pati
ents
Living Alone?
9%
55%
37%
Yes
No
Don't know
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
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
Visionary? Innovative? Courageous?
You be the judge