Pen Blackmore, Clinical Manager reflects on the first year of developing the Health Care Home extended care model.


Last year, working with Lakes District Health Board we agreed a new approach to provide extended care services supporting the Health Care Home core concept of wrap around interdisciplinary care for patients that need more care that can be provided in their general practice.

What excited me was the four practices in our locality, Taupo Health Centre, Taupo Medical Centre, Lake Surgery and Pihanga Health in Turangi had all signed up to implement the Health Care Home model to provide new proactive and more supportive patient centred models of care. Developing shared care plans with a focus on the patient’s own goals.

This work was also linked to the work we have been doing with Lakes DHB supporting District Nurses to be be much better connected with us and the practices.

Being realistic I also realised this was transformational change for us all and all parties would need to appreciate the interdependence and partnership that would be required to achieve this.

Our team includes a:

  • Nurse Practitioner intern
  • Dietitian
  • Exercise Consultant
  • Social Worker
  • Clinical Pharmacist
  • Child Health Nurse
  • Community Support Worker
  • Administrative Support

The Health Care Home proactive ‘year of care’ health planning process was a perfect forum to ensure coordinated care for our clients with interdisciplinary team planning meetings being the place we decided to start.

Alongside an already active interdisciplinary team meeting in Turangi, health planning and practice processes were reviewed with a Practice Nurse lead allocated to the care coordination role and the opportunity to recommence nurse led clinics. We now have joint care planning meetings including the local Maori Provider, Tuwharetoa Health’s Long Term Condition Nurse.

A broader and more relationship focussed approach that has come from these meetings has assisted to implement ongoing health planning in general practice and more time for in-depth peer review has supported more positive patient centred outcomes. Becoming more focused on true patient goals our care has adapted by offering alternative types of consultations and we are seeing more whanau based group consultations for Maori, often facilitated by our community support worker engaging clients not previously engaged with primary care.

As a team, we are encouraged with the increased level of collaboration and shared care we are seeing as practices start to develop their own changes to support the Health Care Home model. Our next project with the practice teams is delivering the core concept of a wider Health Care Home team wrapping care in a targeted approach. We know our patients with diabetes who are not served well by traditional models of care and therefore need other approaches to ensure they stay well.

Still many of the learnings Dr Hayley Scott discusses in her blog around rallying the troops and smarter leadership ring true for me and are what we will continue to collectively engage in and encourage.

It’s too early to provide credible data on the impact of health outcomes as we typically work with people with complex issues that don’t respond, or deserve, a quick fix. What we do know is that we are seeing more of the right people we can help, we have made it easier for practices to bring in more care for their patients and our caseload has increased and the feedback from patients is that we are making difference to how they care for themselves. An outcome in itself.

As Albert Einstein said “problems cannot be solved by the same level of thinking that created them”