Page 8 - Regional Services Plan 2016/19

Objective 2: Integrate across continuums of care
Midland region is committed to developing integrated services across continuums of care. This provides improved quality, safety and the patient’s experience of care. It also leads to more timely treatment and care, which in turn can result in better patient outcomes. Improved system integration can also support clinical and financial sustainability of services.
Figure 1 (below) describes a population health continuum of care. It describes (reading from left to right) various stages in decline in health and wellbeing, from being healthy and well to having end-stage (end-of-life) conditions. Keeping healthy and people proactively managing their health to prevent deterioration and a complication, is really vital. And it is important to note that everyone will not experience all stages equally. For example, the length of time spent living healthy and well may differ for individuals, as may the length of time with end-stage conditions.
The vision statement of the updated New Zealand Health Strategy puts it well that
‘All New Zealanders live well, stay well, and get well’ Figure 1: Population health continuum of care
Population Health Continuum of Care
There is no single accepted definition of integrated healthcare2. However, most definitions include references to seamlessness, co-ordination, patient centeredness, and whole of system working together.
Health and disability services are delivered by a complex network of organisations and people. Integrated healthcare is seen as essential to transforming the way that care is provided for people with long term chronic health conditions and to enable people with complex medical and social needs to live healthy, fulfilling, independent lives3. People living with multiple health and social care needs often experience highly fragmented services which are complex to navigate, leading to less than optimal experiences of care and outcomes.
Our response to the challenge requires a strong re-orientation away from the current emphasis on episodic and acute care towards prevention, self-care, better co-ordination, and care that addresses social determinants of health.
2 The King’s Fund: Lessons from experience - Making integrated care happen and scale and pace
3 A report to the Department of Health and the NHS Future Forum: Integrated care for patients and populations:
Improving outcomes by working together http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations- improving-outcomes-working-together
General population living healthy and well
At risk population Focus: Keeping healthy
Population developing early conditions Focus: Managing health
Population with long-term conditions
Focus: Preventing deterioration/complications
Population with end-stage conditions Focus: Support
8
REGIONAL INITIATIVES AND ACTIVITIES TO ACHIEVE OUR REGIONAL OBJECTIVES