Page 49 - Regional Services Plan 2016/19

2.6 Health of older people (Health of Older People Action Group)
Chair: Dr Phil Wood, Geriatrician Project Manager: TBA Lead Chief Executive: TBC
Vision: To conduct regional activity on behalf of the Midland DHBs that improves services for older people in order to facilitate ‘ageing in place’. This means that older people will be assisted and encouraged to remain in their own homes, by having access to services that are coordinated and responsive to their varied and changing needs, and services that promote and maintain independence.
Key Objectives:
 Keeping older people well and independent
 Reducing hospital admissions and rates of long-term residential care
 Providing timely and coordinated services for people with complex needs living in the community
 Reducing inequalities in health outcomes for Māori
 Reduce inequalities and improve quality using evidence-based best practice models of care
 Recommend regional solutions to meet service care needs in the primary, community, secondary and tertiary sectors and implement
solutions which allow the region to better understand its resources and older population.
 Promote organised systems of care
 Collaboration on regional dementia care
 Support continuing work on technological developments which support services
Measures*:
Measures to show success annually:
 Dementia care is better understood regionally and patient information is available to inform regional discussions where appropriate
 InterRAI data is available to review regionally
 Each Midland DHB is utilising advance care planning or monitoring regional activity
 Reports will be generated identifying frail elderly and they are better understood as a population group
 A reducing trend in falls and fractures regionally
Measures to show success over the next three years:
 Regional consistency is able to be monitored and care has improved
 Additional regional standard pathways of care have been developed
 interRAI is able to be used in decision making and clinicians/management agree that desired information is more freely available and data
quality has improved
 Data relating to patients being treated by regional services is better understood as are regional pathways that are available
* by ethnicity, locality and deprivation where possible
Line of Sight
 DHB Annual Plans: Please see section 2B.1.5.4 (pg 68-70) Bay of Plenty, 2B.1.3.4 (pg 117-120) Lakes, 2.3 (pg 101-105) Tairāwhiti, 2B.2.17 (pg 94-98) Taranaki and section 2.5.4 (pg 68-70) Waikato.
Initiative
Milestone/Date
Responsibility
1. Continue to improve regional pathways and care around cognitive impairment (dementia and delirium):
• Provide DHBs with ongoing support and overview so that DHBs identify and strengthen components of dementia care pathways within the parameters of the New Zealand Framework for Dementia Care.
• Support regional DHBs with analytics around patients diagnosed with dementia and/or delirium to better inform clinical discussions
o Establish baselines with an aim of 10% improvement P/A on agreed metrics
o Numbers of patients presenting to hospital regionally with dementia and/or
delirium are able to be identified and discussed with clinicians
o Clinicians are using information provided regionally to continue to inform and develop education pathways
• Complete an analysis of the current state of educational programmes and support groups to support family/ whānau carers in operation in the region
o Monitor regional education provided by the region’s DHBs to Aged Residential Care (ARC), GP and other services
• Regional activity that supports DHBs to build a regional response to reduce variability of education and support programmes available to support family/whānau carers and people living with dementia and/or delirium.
Q1 2016/17 + ongoing
Q2 2016/17
Q1 2016/17
Q4 2016/17
Q3 2016/17
Q4 2016/17 + ongoing Quarterly
Q2 2016/17 + ongoing
Project Manager HOP
Dementia and Delirium sub groups HSL Analytics
1: Improve Māori health outcomes
2: Integrate across continuums of care
3: Improve quality across all regional services
4: Build the workforce
5: Improve clinical information systems
6: Efficiently allocate public health system resources
REGIONAL SERVICES PLAN 2016-2019
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