Planned, Proactive Care Modified DCIP 2016 Date: Created by:

The Programs ARI & eShared Care Modified DCIP/DCIP Enhanced Primary Care CCM Depression Manaaki Hauora SMS Safety in Practice I & II Falls & Frail Elderly PHO programs Brief explanation of ARI program for those board members unfamiliar with it. Emphasize that there are many components to the ARI program but this presentation will discuss access to MDTs and the complex patients they & PHC have to deal with. Also importance of relationship between existing PHC home and the patient.

Proactive Planned Care Risk stratification e-tool under development, clinical criteria agreed in the meantime 5 Care delivery and coordination 1 2 4 GP Enrolled Population Risk stratification Care planning Day-to-day Non-exhaustive examples Whanau Support Community pharmacist Practice nurse 6 Case conference 3 Shared protocols & pathways Allied Health GP District nurse Community Mental Health Case conferences to be used from time to time for very complex patients who need MDT input to their care plan SME Coordinator SMO Care pathways and agreed clinical protocols are used to inform assessment, care planning, & coordination All ‘at risk’ patients should have a plan that is proportionate to their clinical and social needs, risks and ability to benefit: Logged on e-shared care

Patient Health Questionnaire-2 (PHQ-2): Over the past two weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things. 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Feeling down, depressed, or hopeless. 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Total point score: ______________ Score interpretation: PHQ-2 Probability of major depressive disorder Probability of any depressive disorder score (%) (%) 1  15.4 36.9 2   21.1 48.3 3   38.4 75.0 4   45.5 81.2 5   56.4 84.6 6   78.6 92.9

Proactive Planned Care Risk stratification e-tool under development, clinical criteria agreed in the meantime 5 Care delivery and coordination 1 2 4 GP Enrolled Population Risk stratification Care planning Day-to-day Non-exhaustive examples Whanau Support Community pharmacist Practice nurse 6 Case conference 3 Shared protocols & pathways Allied Health GP District nurse Community Mental Health Case conferences to be used from time to time for very complex patients who need MDT input to their care plan SME Coordinator SMO Care pathways and agreed clinical protocols are used to inform assessment, care planning, & coordination All ‘at risk’ patients should have a plan that is proportionate to their clinical and social needs, risks and ability to benefit: Logged on e-shared care

ACTIVATED PATIENT PROACTIVE PRACTICE TEAM STEPPED CARE SELF CARE SMS PROGRAMMES End of life DHB Maori & Pacific teams Front door Locality coordinator VHIU Complex cases with comorbidities 3-5% all cases LEVEL 3 Intense Professional Care (case management) Modified DCIP Frailty, falls Integrated mental health LTC PHO:SIA $$ Higher risk cases 15-20% LTC 1:1 PHC based health coaching Peer support LEVEL 2 Shared Care Professional Care ARI LEVEL 1 Supported Self Care Group models: Practice based eShared Care Primary Health Care Home CCM Depression, CHSI 70-80% LTC Self Care DCIP Virtual: text, internet, social media, apps …. COMMUNITY AT RISK (High tech) Localities PHO’s NGO’s “Activated Community” Community Partners e.g. alcohol strategy Community based models: - church - gyms - NGO’s - green Rx ACTIVATED PATIENT PROACTIVE PRACTICE TEAM

Self-management support promotion Process map SMS –the SMS: Care plan cycle   Self-management support promotion   Any door is the right door Multiple entry points to SMS including: Self-referral NGOs Clinicians Communities   5. Self-Management Support Care Plan cycle Care Plan 1. Patient identification   2. Assessment: Partners in Health or Readiness to Change   Assessment findings 3. Initiate CCMS Shared Care Plan 4. Enter SMS Care Plan cycle Primary Health Care Assessment Menu of SMS options Menu of SMS options for patient: Existing internal options within practice Range of SMS options (peer/professional, group, home based, electronic etc) Health Coach Existing community groups/services, NGOs   Combined Predictive Risk Tool   GP/PN identified/ Clinician intuition Care Plan Essential components but not mandatory for accessing SMS funded services   Any door is the right door Bulk of funding

Proactive Planned Care Risk stratification e-tool under development, clinical criteria agreed in the meantime 5 Care delivery and coordination 1 2 4 GP Enrolled Population Risk stratification Care planning Day-to-day Non-exhaustive examples Whanau Support Community pharmacist Practice nurse 6 Case conference 3 Shared protocols & pathways Allied Health GP District nurse Community Mental Health Case conferences to be used from time to time for very complex patients who need MDT input to their care plan SME Coordinator SMO Care pathways and agreed clinical protocols are used to inform assessment, care planning, & coordination All ‘at risk’ patients should have a plan that is proportionate to their clinical and social needs, risks and ability to benefit: Logged on e-shared care