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Innovative and courageous general practice? You be the judge!

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

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Innovative and courageous general practice? You be the judge!

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  1. 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

  2. The Tararua District

  3. Tararua Health Group Established 2009 4 sites general practice, community health services and a community hospital 100 staff 60 clinical – 37.5 FTE 14,570 enrolled patients Single networked PMS 90kms of fibre-optic cabling

  4. Barraud Street Health Centre Pahiatua Medical Centre Te Rongopai Dannevirke Community Hospital

  5. Critical Success Factors Inspired leadership Virtual integration - Single networked PMS Shared back room functions Operational Management Team – doctors doctor, nurses nurse Clinical Excellence Group – Clinical Director Workforce development

  6. 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

  7. (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.

  8. 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

  9. 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

  10. Our Older People

  11. Weighting Scores

  12. Weighting by Ethnicity

  13. Primary Care Presentations

  14. Polypharmacy

  15. Living Alone?

  16. 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

  17. 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

  18. Visionary? Innovative? Courageous? You be the judge

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