innovative and courageous general practice? you be the judge! linda dubbeldam, clinical director sue...

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 Total

55-59 129 1 130

60-64 74 4 78

65-69 65 540 605

70-74 46 472 518

75-79 34 350 38480-84 13 1 275 289

85-89 7 192 199

90-94 4 79 83

95-99 1 17 18

100-104 3 3Total 373 6 1928 2307

16.2% 0.3% 83.5%

Weighting Scores

1 2 3 4 5 6 7 8 9 10 11

Total 58 569 750 485 219 128 58 27 9 3 1

50

150

250

350

450

550

650

750

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 36

Maori 45 32 60 54 36 40 27 15 12 12 9 5 5 3 2 5 1 1 2 2 4 NaN NaN 1 NaN

Pacific 1 1 2 NaN 1 1 NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN NaN

Other 101 139 258 288 299 222 163 111 99 48 53 42 28 29 13 8 8 5 2 5 4 1 1 NaN 1

25

75

125

175

225

275

325

375

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 ?

Total 408 173 203 233 206 207 186 157 106 87 89 60 52 29 27 13 10 7 5 2 3 1 1 1 1 40

25

75

125

175

225

275

325

375

425

# 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