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Integrated Care - why it matters

Posted by Diane Abad-Vergara on 10 December 2015 |

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“We were lost,” says Stu Bogun. “We’d been to a few clinics and my cholesterol and diabetes readings were sky high. They said I’d be dead by ANZAC day, yet no one had the time to help us. We hadn’t had positive experiences.”

Then Stu’s wife Fehi encouraged him to go to Greenstone Family Clinic as she heard they offered special diabetes / cholesterol treatment. He decided to give it a go and soon found that the special ingredient of 'time'.

“It was all so strange, we had no idea where the clinic was, but we booked an appointment and filled the form,” says Fehi Taufa. “It was the first time anyone has taken the time to explain everything. Then from that day they kept contacting us. They couldn’t be more helpful.”

Stu comes to an appointment at the clinic every two weeks. When he first received his cholesterol reading it was 32.5.

“I work doing runway repairs at the airport, I was at the point where I didn’t want to go to work. Sleeping all the time. I’d experience sugar highs then just feel really tired with no energy,” he says. “The nurse she was so brave. Brave enough to tell me straight that I need to start looking after myself, how to eat, what food to shop for, how to prepare it. Within two weeks my cholesterol was down to 17.”

Now Stu reports that he enjoys going to work. He is also happy because being in good health will assist him and Fehi in their application to formally adopt a child.

“They taught me how to encourage him and care for him with the right food and exercise’,” says Fehi. “I nearly lost my husband, if it wasn’t for these guys he wouldn’t have made Christmas. They just had the time to explain. Gave us books and this great plate which shows portion sizes is excellent.”

“I was down in the dumps. I had no oomph. This is the first time anyone has taken the time to explain things and work with us. They taught us how to eat better. My cholesterol has more than halved, I’m back to gardening and have just finished off building a deck!”

Stu epitomizes some of the positive stories that clinicians hear each day as a result of their support through the ‘at risk’ initiative, which is part of Counties Manukau Health’s drive to achieve better integrated care. There are now 16,000 people in the district experiencing the positive benefits of integrated care.

Counties Manukau’s population is growing, ageing, changing and the demand for our hospital services is rising at a rapid rate. We are seeing an increase in chronic conditions such as diabetes and heart disease. 

“As more hospital admissions occur due to preventable causes, we need to examine what could be improved in how we deliver our services, says Harry Rea, Professor of Medicine and Clinical Director of Integrated Care at CM Health. “Care of people with several long-term medical conditions becomes complicated, especially for those who face other complicating social and economic factors. Some of the dimensions of good healthcare include access, compassion, continuity, coordination, comprehensiveness and care that are delivered in the context of whaanau and community.”

For many of our patients, good care can no longer be delivered by a single part of the system in isolation.  Integrated care that coordinates primary, secondary, social and community support is essential for most patients. 

We have a big challenge on our hands to integrate our services and systems across the health spectrum and empower our healthcare users to keep themselves well and at home - reducing unnecessary trips to hospital. For most people, it is best that their General Practice, supported by a wider community and specialist team is considered the main point of ongoing care. 

“There is a growing realisation that only 50% of our patients act on medical advice they are given. This strengthens the argument for integrated, interdisciplinary care delivered in the community,” says Professor Rea. “Adherence is heavily determined by a person’s ‘social determinants of health’ and unless these are assessed and addressed, clinical care and advice is wasted. Changing behaviour to improve adherence requires whaanau and household support.”

“There’s a need to better manage long-term conditions, keeping people at home with family and in the community,” says Benedict Hefford, Director of Primary Health and Community Services. “Counties Manukau Health is changing to ensure that our patients get the best care possible and that our resources meet demand.”

 

With a continued focus on integrated care, a number of projects, campaigns and improvement initiatives are taking place across Counties Manukau. Each project has a specific goal, but all have the needs of the patient and family/whaanau at its core.
  • CM Health is working to improve processes by redesigning how our services are delivered, this includes realigning and extending the capacity and scope of CM Health community teams and integrating with providers of Home and Community Support Services
  • Primary Care’s role is expanding with an increasing focus on prevention and early intervention. 
  • Further development of integrated, interdisciplinary care based around enhanced general practice teams
  • Locality clinical partnerships have been formed with hospital and primary care clinicians working together to treat patients from within the community. This will continue to evolve. 
  • Localities are our vehicle for implementation and ensure a local voice is heard within the planning process
  • There’s a big focus on patients with chronic illness or long-term conditions – equipping patients and family/whaanau to manage their conditions better with support in community settings. 
  • Integrated Care initiatives also include shared care plans, a greater focus on the role of nurses in primary care, and utilizing telehealth and virtual clinics. 
  • We will use technology better to ensure those involved in a patient's care have access to the right clinical information at the point of care. This will enable community staff to work more closely with general practice and create a smoother patient journey.