Community Services Integration into General Practice “Health Care Homes”

Abstract

For decades, healthcare providers have worked from separate organisations, with disconnected care and processes. General practice teams, District Nurses and Community Rehabilitation teams have worked with the same patients, but not so much with each other. In 2016, an Alliance initiative and District Health Board/Primary Health Organisation jointly funded project, introduced a “Health Care Home” model to General Practice teams in Wellington, New Zealand. Supporting integration of community services into general practice was included as part of a suite of mandated practice developments. Teams from both community nursing and allied health services were challenged to develop a new integrated model with general practice, based on desired outcomes and planned interventions. With change management support, these teams were assisted to implement their changes. Developments included practices having a named and known District Nurse and Allied Health person; re-introductions to each other’s capabilities and resources; improved contact processes; shared lists of patients; sharing skills; monthly Multi Disciplinary Team (MDT) meetings; joint proactive care management for risk modelled, complex people; use of shared care records; development of a joint care planning tool; and use of mobile technology. Outcomes of this project included improved relationships exampled by quotes from a GP, “MDTs are worth their weight in gold”, and from a community nurse “I have learnt so much about how general practice teams function, and they understand me more too”. Other health professionals and patients have joined the MDT meetings with remote attendance planned for in the future. Through this project, teams have understood the need to work differently. Developed local networks and alliances have helped improve efficiencies and proactive patient care. The future challenge is to sustain and enable further improvement and expansion of this successful model across the whole DHB.