Kia Ora Vision ,

Kia Ora Vision Programme to manage LTC population centered around the needs of the patient. Includes interdisciplinary care planning and service co-ordination, and supporting people to optimize self-management In Northland the current Care Plus programme allows four free funded visits per year for a person with Long Term Conditions to visit their GP or nurse. Criteria is different between the two PHOs but both have the criteria that the person must have two long term conditions The current programme resource is not always allocated to the patients who need it the most i.e patients who have a Long Term Condition and are at high risk due to physical, and/or psychosocial factors. Risk stratification is required There are no consistent quality and processes for standards of care, care planning or discharge planning for Care Plus patients. The programme lacks flexibility with the funding . There is currently poor integration between primary and secondary care for people with Long Term Conditions – a “whole of system “ approach is required for optimum care .

Care Plus review Care Plus reviewed by Leonie Gallagher in 2010 Review identified – Rigid criteria, not many discharged off programme, funding not flexible, care plan were not patient centred and not all patients had care plans, variable utilisation rates, resources not always targeted to those who needed it the most

Change to Kia Ora Vision Kia Ora Vision programme introduced in 2016 More flexibility for eligibility. Resources targeted to people who need it the most irrespective of age More flexibility for types of consults based on individualised need e.g. longer consults, nurse led clinics, email consults, MDT’s, group sessions (preferable at no patient cost but practice may apply charges at it’s own discretion) A patient centric Care Plan that builds an understanding of ‘what matters to me’ (the patient) that promotes health literacy and engagement in health goals Optimising peoples self-management abilities e.g. green prescription referral, Whakamana Hauora, Diabetes self-management programme An intraoperative platform that can improve interprofessional collaboration and provide consistency of care and transparency of care across multiple members of a care team (secondary and primary)

Eligibility AND/OR 3 or more LTCs. The patient is amenable to change / their outcome can be changed OR  One or more LTC and evidence of non-adherence or unstable diagnostics: HbA1C > 100 and previously prescribed insulin; or Uric acid >0.36 and previously prescribed allopurinol; or Total cholesterol >6.0 and previously prescribed lipid lowering; or Systolic BP >160 and previously prescribed 2 or more anti-hypertensives; or Diastolic BP>95 and previously prescribed 2 or more anti-hypertensives; or INR <1.2 on 2 or more consecutive tests; or BMI > 40; or PARR >30%; or COPD (measure to be determined); or FAMA. AND/OR  

And /OR Chronic Pain Equity consideration Risk taking behaviour – e.g AOD, self harm etc Medication risk e.g. polypharmacy(>5)High risk e.g methotrexate, Opioid, warfarin tx, medication change or initiation e.g. insulin Social risks e.g domestic violence, CYPs involvement, concerns regarding poverty employment, deprivation , no supports, social isolation, falls risk, ESOL Gestational diabetes Frail elderly Palliative care Non attendance GP or OPC>2 or high attendance Co morbidities>3 Chronic Pain Equity consideration

Steps to care planning Identify the patient Identify the Care team Initiate the care plan Set goals with the patient Monitor progress Review, update and/or close

Identify the patient Risk stratification - Risk reports, audit tools, clinical knowledge Who are the people in your practice with the most complex needs? Who are those patients who would benefit from having a comprehensive care plan and care co-ordination? Who will access the risk reports in NPHOS? Print out DrINFO lists? Who will review the reports and identify who needs to be on KOV? How often? How will this be communicated to the team?

Identify the patient Tools for risk stratification DHB data – frequent admissions/ attendance to ED (Risk Reports, NPHOS website) Provided data detailing your current KOV and non –KOV patients with the highest utilisation rates and those with known LTCs who are not being seen- this will improve targeting of care. Clinical judgement – those patients that health practitioners identify as benefiting from more intensive management. It would be expected everyone has at the minimum an annual review but it may be you choose to see some patients quarterly, twice a year or more frequently if they are needing more intensive care. Dr Info audit for patients with LTC’s (eligible), disease register (CVD, Diabetes, COPD), query for polypharmacy (NSAID’s) PMS Query Tool for self made audits

Identify the care team Named care plan co-ordinator Who will be the co-ordinator for the patient? Who are the other health and social services involved?

Initiate the care plan Invite patient for care planning appointment (Patients to be amenable to change and have indicated they wish to participate in programme) Enrol on Careplus F3 tab When/how will this be booked into templates? How will KOV appts be invoiced to track funding?

Set goals with the patient Goals are patient centred and set collaboratively Utilise Whanau Tahi to document personalised care plan “What matters to me” Tasks are set that are steps towards goals Tayloring packages to allow patients to be seen as often as deemed high need “what is it that you would like to do that you can’t do now?” SMART goals

Monitoring progress Monitoring by care plan co-ordinator Check in regularly with patient on progress How will any changes be communicated to the care team?

Review, update and / or close Review care plan with the patient and care team every 3-6 mths or as appropriate Multidisciplinary team meetings and review for patients that have multiple providers involved in their day-to-day health care Document progress, update care plan or close

Programme Measures 80% of eligible population is enrolled in the Kia Ora Vision programme (eligible formula approx. 5% popn, includes age, socio-economic status, ethnicity) Enrolled Kia Ora Vision clients who have a Whanau Tahi care plan – 50% increasing incrementally to 90% by June 2021 Equity – ethnicity split of patients enrolled in Kia Ora Vision should be reflective of the ethnicity split of your eligible Care Plus residual population. Quality of plans - Whanau Tahi plans are audited as per Personalised Care Plan audit tool