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