Community integration


What is community integration?

Community Integration (previously known as Community Health Services Integration or CHSI) delivers services closer to where patients live and work by placing more services in the community and developing locality based teams who are skilled in delivering a range of functions.

The changes to how we work are in response to increasing demand on health services from a growing and ageing population. Clinical teams have called for more co-ordinated and patient centred service delivery supported by better-linked systems. The focus is on improving the health and outcomes of people in our community and determining how to best support them to progress healthy and well through their life journey.

For most people, the main point of contact will be their general practice. We aim to no longer see episodes of care in various services (e.g. hospital admission) as a transfer of care. Instead, we aim to have a continuous journey through health services where extended care and support is provided at times of need.

Community Integration is part of the wider Integrated Care strategic initiative which includes working through localities, a focus on chronic conditions via Planned Proactive Care (PPC), Enhanced Primary Care and will be enabled by future establishment of Community Hubs. 

Why is change needed?

Counties Manukau Health has committed to investing in primary and community care to reduce demand across our system and provide a better patient experience. We currently provide high-quality community services, but staff have told us that they feel services could be organised, located and carried out differently, enabling a greater focus on the patient and whaanau journey and enabling our clinicians to spend more time with patients. Nearly 60% of acute hospital admissions are for less than 48 hours and we know that some of these could be managed in community settings with rapid response services. Many CM Health community services currently operate in isolation of one another, and this can create a lack of equity of access to services. This, combined with our current reliance on manual and paper-based systems can lead to delays for our patients, inefficiencies in our processes and a patient journey that is hard to track.ses and a patient journey that is hard to track.

What does CM Health aim to achieve?

  • Create a smoother and more visible patient journey.
  • Extend the capacity and scope of CM Health community teams to ensure a timely response to patient need including a proactive approach and a rapid response for urgent need.
  • Enable community staff to work more efficiently through the use of technology.
  • Integrate with providers of Home & Community Support Services to improve patient and whaanau outcomes.
  • Our teams will be mobile, multi-skilled, and equipped to work together to enable the first best response for our patients.

What will be the difference?

More integrated, effective and patient and whaanau centred services.
  • Non-complex wound care will be provided by general practice.
  • Locality based community teams will be aligned to and work closely with general practice clusters.
  • Rapid response and supported discharge services will be operational in all localities.
  • Centralised community service intake, screening and coordination will be provided through Community Central
  • Intensive short-term reablement (rehabilitation)
  • services will be provided to restore and maximise functional independence.

How will we do this?

Community Health Teams will be integrated with primary care clusters within localities, taking an interdisciplinary approach. As required, resources will be shared across localities to ensure expertise is aligned to patient need. Services will provide general access to community, specialist nursing and allied health services, integrate with contracted home & community support services and include the following functions:

Reablement
Enables individuals to be as well as they can be in their own home. This includes rebuilding confidence, supporting the development of daily living skills and promoting community access and integration. Reablement is a community led initiative supported by primary care teams. The service is intended to provide enhanced support for individuals with moderate to complex needs who have the potential to benefit from an intensive period of 2-6 weeks of functional home assistance and community-based rehabilitation. It is led by CM Health professionals in collaboration with contracted short-term home and community support service providers.  Click here for patient brochure.

Rapid response
A function to provide urgent services as required for an unplanned event. Enabling people to remain at home and potentially avoid unnecessary hospital admission.

Supported discharge
This function promotes safe early hospital discharge for appropriate patients, enabling recovery, restoration of function and opportunity to maximise independence in their own environment as soon as they are medically stable.

Rehabilitation
Rehabilitation provides therapies for people within their own home to restore function and independent living. It can include medical and nursing care, physical therapies, occupational therapy and psychological services.
Rehabilitation sets personal goals, manages a person’s individual condition and improves their ability to carry out everyday activities that have been affected by illness or injury. It emphasises self-management and takes account of the wider family and social realities.

Community central
Community Health teams will be enabled by Community Central which will provide centralised intake and triage for our community teams, supporting this through improved scheduling and rostering. It will provide our community teams with mobile technology to support their work and facilitate sharing of information.

Home and community support services
Will be part of an integrated community health response and will integrate with Reablement, Rapid Response or Supported Discharge services to maximise independence and quality of life. General practice will work collaboratively with home and community support services to jointly provide interventions to maintain a persons wellness and provide health promotion. There will be a joint intake and coordination service process via Community Central.


What will be different for patient, whaanau and staff?

Services will be more integrated, effective and patient centred. Patients and whaanau will be supported by a team who work together to best support them to achieve their goals.

  • General practices will be supported by an enhanced general practice team including community teams.
  • Our community health staff will work in a more efficient and effective way – utilising technology to support their work.
  • We will treat a hospital admission as a short part of a patient’s journey – and recognise that 99% of care is provided in the community and our approach should reflect this.
  • There will be a central point of access (contact and referral) to community services that supports a best first response for services, triaging, allocating resources and capacity planning capability.
  • All service requests result in a plan to meet the identified need – no declines but redirection of request/support for another service to provide the response directly.

When will the change take place?

We are currently working with CM Health teams to prepare for this change. 2017 will see the implementation of an integrated community services service delivery model.

For further information please email the Transformation Team and one of us will be in touch.

See also: