1. CARE
ENHANCING PRIMARY
We’re working together to achieve health equity. Moving General Practice from being part of the system to the heart of the system.

2. CARE
ENHANCING PRIMARY
FUTURE Progressively implement a more sustainable model of General Practice across Counties Manukau. With increased system capacity, even better engagement with community & care closer to the patient.
NOW The way in which General Practice operates within Counties Manukau follows a traditional model - with minute GP consultation remaining as the backbone of General Practice. This is not sustainable.

3. CARE
ENHANCING PRIMARY
Releasing capacity in General Practice teams to enable more integrated and coordinated engagement with complex patients
Enabling practices to work in a more integrated way, to create capacity within their workflows to work more flexibly w/ complex patients.
Better for us. Better for our patients. Better for our communities.
Creating opportunities for patients to better engage with General Practice and to support self-management.
Enabling real-time clinical information implementation & integration of technology platforms, to facilitate timely triage, proactive care & improved coordination.
Reducing demand on hospital based services for unplanned and low acuity care

4. Transformational Change Programme Transformational Change Programme
CARE
ENHANCING PRIMARY
Transformational Change Programme
Transformational Change Programme
Business Model
Current Operating Model
Current Capabilities
Talent, Process, Technology, Data
Business Model
Target/Vision Operating Model
Required Capabilities
Talent, Process, Technology, Data

5. Transformational Change Programme
CARE
ENHANCING PRIMARY
Transformational Change Programme
Where we are currently
Phase 1:
Establish an Enhanced Primary Care model of care.
Phase 2:
Roll-out the Enhanced Primary Care model across a broader range of practices
Phase 3:
Implement the model and transform the experience for patients, community members and healthcare professionals

6. Potential Impact of Initial Phase
CARE
ENHANCING PRIMARY
Total Enrolled Population
197,048 $
Total inpatient spend ($m)
$148.68

7. CARE We all have a role to play to deliver Enhanced Primary Care.
Module 1: Increasing Capacity
CARE
ENHANCING PRIMARY
My practice has 30% more daily capacity by December 2016 “ ”
We all have a role to play to deliver Enhanced Primary Care.
Module 2: Increasing Efficiency “
My practice environment is optimised with no ‘choke points’ and minimal ‘hand offs’ by April 2017 ”
Module 3: Increasing Capability
Together we will involve people, whanau and families as an active part of their health team.
Together we will help make healthy options easy options for everyone.
Together we will provide excellent services that are well-supported to treat those who need us safely, with compassion and in a timely manner. “
My practice has practitioners all practicing at top of scope with use of HCAs and Health Coaches by July 2017 ”
Module 4: Increasing Effectiveness “
My practice has is effective at preventing unnecessary ED and hospital presentations by September 2017 ”

8. An alliance initiative
CARE
ENHANCING PRIMARY

9. Module 1: Increasing Capacity
Proposed Resource Requirements:
Clinical Lead
Change Manager
Improvement Advisor
IT and owners for technology requirements
L&D for patient portal training support
Timeframe to complete:
3 Months

10. My practice has 30% more daily capacity by December 2016
Increasing Capacity
Step One:
Map Acute Patient Journey for workflow optimisation
Step Two:
Telephone calls are away from reception
Step Three:
A telephony system with call counts is in place
Step Four:
Establish 2 hour morning telephone triage by GP
Step Five:
50% of enrolled patients are signed up to patient portal and can use this for prescription reordering and results collection “
My practice has 30% more daily capacity by December 2016 ”

11. Module 2: Increasing Efficiency
Proposed Resource Requirements:
Clinical Lead
Change Manager
Building design and layout Advisor
Improvement Advisor
IT for technology requirements
L&D for virtual consult training support
Timeframe to complete:
3 Months

12. Increasing Efficiency
Step One:
Consultation room is standardised and available for any consultation
Step Two:
Building layout is optimised for current state
Optimal future state designed
Active sign posting – reception desk is a navigator
Step Three:
Clinical pre-work management is in place
Step Four:
Administration activities are only carried out by administrators
Step Five:
Virtual consultation is used with 10% of my patients “
My practice environment is optimised with no ‘choke points’ and minimal ‘hand offs’ by April 2017 ”

13. Module 3: Increasing Capability
Proposed Resource Requirements:
Change Manager
Clinical Lead
L&D for Improvement facilitation training
Timeframe to complete:
4 Months

14. Increasing Capability
Step One:
Weekly MDT meeting established
Step Two:
Practice has a training improvement capabilities within the practice team
Step Three:
A nurse clinic is established
Step Four:
Scope of practice established for HCA /Health Coach
Step Five:
Cross disciplinary teams are in general practice including Pharmacist, Specialists “
My practice has practitioners all practicing at top of scope with use of HCAs and Health Coaches by July 2017 ”

15. Module 4: Increasing Effectiveness
Proposed Resource Requirements:
Change Manager
Clinical Lead
L&D for care plan and coordinator training
IT technical resource
Timeframe to complete:
4 Months

16. Increasing Effectiveness
Step One: Care plan is in place for all ARI patients and for 50% of other chronic care patients Step Two: Care co-ordinators are in place for all ARI and other chronic care patients Step Three: Practice extended hours are offered Step Four: Patients have a range of practice visits and costs to choose from Step Five: Home visiting is available to patients “
My practice is effective at preventing unnecessary ED and hospital presentations by September 2017 ”

17. Increasing Effectiveness
Step Six: Practice has access to a shared database to assist with population health and quality care management Step Seven: Home monitoring devices are available as part of planned proactive care and self management Step Eight: Partnership working for service delivery in place “
My practice is effective at preventing unnecessary ED and hospital presentations by September 2017 ”

18. Proposed Resource Model
Role
Functions
FTE
Total days per practice
Programme Manager
Programme co-ordination 1 26
PHO Lead Facilitator
PHO Lead
2.5 65
Finance Advisor
Financial model development
Change Manager
Change management expertise
HR Advisor
People and function mapping
0.5 13
Clinical Lead
Clinical oversight
Business Analyst
Business process analysis
Data Analyst
Data analysis and reporting
L&D resource support
L&D resource and training
Improvement advisor
Improvement activity planning
Communications Lead
Integrated communications
TOTAL CHANGE TEAM FTE 12
Per 10 Practices with days per practice based on 12 months