Planned, proactive care
More than 60,000 people in Counties Manukau live with long term health conditions and we know that these people use a disproportionate amount of healthcare services, which are not always proactive or well-coordinated. CM Health offers these people more support to better manage their health conditions and keep well.
In July 2014 we introduced a new primary care led initiative aimed at better supporting people with long term conditions. This approach provides more planned, proactive care for patients who have long term conditions, such as diabetes or heart disease, and other risk factors which may be compounding their poor health such as inadequate housing or low health literacy.
General Practice teams identify patients who would benefit from the programme and once enrolled they will have:
- an electronic summary health record available to healthcare teams through their existing patient management systems so that key information is visible to everyone involved in that patient’s care.
- a designated care coordinator responsible for working in partnership with the person to understand “what matters to them" and support them to develop a goal based care plan.
- This Care Plan is available electronically online to the patient and members of their care team This enables the team to be able to update progress on actions to achieve the patients goals, and securely communicate with one another electronically.
- Patients are provided with an e-Shared Care key tag and wallet card which help to keep the Plans ‘top of mind’ for patients and clinicians across the system. By simply attaching the snap-off tag to their key ring, the patient will be able to prompt other clinicians involved in their care to view their care plan. These cards are distributed by General Practice Teams.
- Click here to view the patient brochure.
The funding programme for this model is called 'Planned Proactive Care (PPC)'.
If you have any questions, please email Integrated care team
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