Māori Health Plan – Chronic Disease Management in Primary Care The Care Plus program can be utilised to target our most comorbid population who could benefit from a patient centred, goal led approach to improvements in health care. It is known that Māori are overrepresented in this latter population and effective use of this funded PHO scheme is an opportunity to redress inequities in healthcare.
Eligibility This program is available to all patients who fulfil the enrolment criteria: Are expected to need ‘intensive clinical management (2hr+) in the next 6 months And at least one of: • Has had 6 First level Service Primary Care visits in the past 6 months • Has had 2 acute non surgical admission in past 12 months • Has a terminal illness • Has 2 or more chronic conditions • Is on active review for elective services Recent changes to the scheme allow a flexible allocation of resources tailored to patient need – 2- 8 patient reviews are funded. Practices are being encouraged to look at their risk stratification data to enable targeting of their resources with an equitable and needs led approach. The risk stratification tool is available through the Thalamus reporting system. Get in touch with your General Practice Liaison if you don’t yet have access to Thalamus. The PHO is able to provide regular data from the Risk Stratification tool to track an individual practices program usage using an equity lens. An additional multidisciplinary approach can identify a further cohort of patients with chronic disease through team led discussions for opportunistic patient identification. A flow on patient need may come from the annual diabetic review and possibly from the COPD program. One of the challenges is identification of eligible patients – continual socialisation of the program at clinical meetings will empower an equitable approach.
Opportunities for Care plus provision A multidisciplinary approach is encouraged with use of nurses, nurse practitioners, GPs and clinical pharmacists. An individualised care plan is written for patients – either utilising the built in templates on clinical systems or from Health Navigator: www.healthnavigator.org.nz/healthyliving/c/care-plans-and-action-plans/
Updated July 2021