Kia Ora Vision

1. Kia Ora Vision ,

2. Kia Ora Vision • Programmeto 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

3. 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

4. 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)

5. Eligibility • 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

6. Chronic Pain Equity consideration

7. 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

8. 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?

9. 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

10. 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?

11. 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?

12. 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

13. 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?

14. 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

15. 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