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HealthRightHealthRight is the chronic care management (CCM) framework developed in primary health care for use in the Midland communities. It is driven from the belief that long term conditions are best managed in the primary health care and community settings.
Activities focus on prevention and detection as well as treatment of long term medical conditions. Implementation of the CCM framework is taking place in three waves to ensure that each section is well established. Wave one and two are under way and Wave three will occur in 2011. Wave One
Wave One established five navigation sites which were started in July 2007. One of the sites was closed in March 2008.
Navigation Site 2
Integrated Care Team
This navigation site is a community-based initiative in Tokoroa where two non-clinical coordinators based within local Maori and Pacific Island providers introduced self-management principles to people with complex diabetes needs. Self-management education is concerned with problem-solving skills to help the patient proactively deal with challenges related to their long term condition, and supplements traditional patient health education. This initiative complements and expands the existing Diabetes Nurse Specialist roles with two nurses now working in primary care.
Navigation Site 3
Primary/Secondary Cardiac Rehabilitation
This navigation site based in Taumaranui is aimed at implementing a coordinated Primary/Secondary cardiac rehabilitation programme. A non-clinical coordinator role has been introduced to coordinate multiple interventions for those with complex long term health conditions. The programme includes workshop-style sessions incorporating physical activity, dietetic and self-management interventions.
Navigation Site 4
Whanau Household King Country
This navigation site based in Te Kuiti is a household-based approach providing dietary and lifestyle coaching for people with diabetes. A coordinator position has been developed within a local Maori provider, to provide guidance and support to accessing multidisciplinary team services, physical activity and self- management education within the community.
Navigation Site 5
Just For The Health Of It
This navigation site builds on a new Green Prescription format being trialled by Sport Waikato. It involves a collaborative approach between Sport Waikato and Dieticians at Anglesea and introduces a workshop-style format incorporating physical activity, dietetic and self-management interventions. Self-management education is concerned with problem-solving skills to help the patient proactively deal with challenges related to their long term condition and supplements traditional patient health education.
For the HealthRight document click here. For the CCM business case click here. HealthRight Co-ordinators Going The Extra Mile
Thinking outside the square has been key for some Waikato health workers to ensure people with long-term conditions can access health and social services.
George Wiringi, co-ordinator of the Taumarunui based site provided by Hinengakau Maatua Whangai Iwi Social Services, said trying to motivate people to be proactive toward looking after their own health was a challenge but he decided to dig his toes in. To view the full press release please Click Here, to view the Ruapehu Press article please Click Here Margaret Reed, co-ordinator of the Te Kuiti and Otorohanga based sites provided by Ngâti Maniapoto Marae Pact Trust, said being able to react to individual need is both effective and rewarding for health workers and community members, but is not without its challenges. To view the full press release please Click Here to view the Waitomo News Article please Click Here Wave 2
There are four aspects to Wave Two.
• Implementation of screening for cardiovascular risk of all adult patients enrolled in practices associated with Waikato Primary Health.
• In ten general practices in the Hamilton regions packages of multidisciplinary care will be made available for people with chronic conditions. These packages include podiatry, counselling, medicine use review, exercise and dietary advice, smoking cessation, healthy cooking classes and interpreter services. • A team of eight HealthRight Mobile Nurses is being established to work with people with chronic conditions in the Hamilton Te Awamutu and Leamington areas. The nurses will undertake a case management role with people with cardiovascular disease and diabetes who have difficulty accessing their general practice. Helping people to become better managers of their own health will also be a key focus. They will facilitate the packages of multidisciplinary care for these people • Some people will take the renowned Stanford University “Living a Healthy Life” programme which supports self management for people with chronic conditions. |