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