Patients with more complex care needs deserve a well co-ordinated, proactive approach to their care. Our ‘Year of Care’ programme allows for comprehensive health planning with a patient ensuring that everyone providing care to them is working from that one plan. This is a proactive, interdisciplinary team approach in which the team schedules in a patient’s appointments, reviews, specialist care and social care over six to twelve months. The process also includes agreeing on a self-management plan with each patient and ensuring they know what to do when they become ill or concerned. Each patient has a named care coordinator to monitor delivery of the plan and the patient experience.
The Year of Care is a partnership with the patient, their care team and their whanau. The patient is encouraged, if able, to take a leading role in setting and meeting their own health goals. Managing patients in this way is widely recognised as producing better outcomes, and it reduces the likelihood of urgent, ad-hoc treatment causing problems for other patient scheduling.
All our Health Care Home practices hold an active register of patients who require this level of care. The care planning process is led by appropriately trained practice nurses and we are often asked how the nurses create time to undertake this work. It’s aligned to them releasing tasks and activities to the Medical Centre Assistant or practice administration.
The Year of Care was one of the reasons we knew we had to modernise our technology
No longer was it good enough to run a system that prevented high quality coordinated care even though the technology was available, we were determined our patients should have one record, one care plan and that they could choose who saw and updated it.
“Feedback from nurses implementing the Year of Care has highlighted the benefits of having a longer time with patients. They’ve been able to identify previously unknown and unmet needs that are important for the patient.”Ngaire Signal