16. Work with local communities and enrolled populations Organising services around the defined population Reaching those patients who are not accessing healthcare Offering some โintenseโ care for whanau who require management of a new condition or existing conditions with one or more family member
17. Identify and remove health inequalities โDisparities in health status between different population groups are found worldwideโ (Robson B. 2006) Identifying a target group who are not having healthcare needs met by the service Being creative about the delivery of care with the intention of removing some barriers
18. Develop the Primary Health Care workforce Development of Mobile Primary whanau nurse Upskilling of all Practice nurses Integration of healthcare services within our organisation to deliver home based healthcare
30. Mobile Primary Whanau Nurse Building relationships with whanau โThe Brokerโ Liasewith allied health professionals Bring in experts where needed eg. Asthma nurse Holistic healthcare โ treating the entire family and looking at the environmental factors that impact on health
31. Kaiawhina Build relationships with families Support for Mobile Primary WhanauNurse Assist in making appointments with families
32. Family Start Employed within the organisation with the role of working with families to promote: Health Education Social services Referrals may be made by this team They may have established relationships with the identified families
35. Clinical Nurse Leader / facilitator Facilitation of Gpโs training and discussion of Mobile Primary Nurse role Fortnightly training sessions for teaching standing orders Policy written around the use of standing orders
36. Facilitation of Mobile Primary Whanau Nurse Core competencies Identified training needs for Mobile Primary whanau nurse Ensure adequate training delivered Facilitate meeting between specialist nurses and Mobile primary whanu nurse
37. Evaluation Limitations within a high needs population to always see the gains Measurements within the targeted group will be monitored and documented eg: Increases in immunisations Number of B4 school checks Number of education sessions
38. References Minestry of Health - Primary Health Care Strategy 2001 Primary Health Care in capital and coast district health board June 2009 Robson B, Harris R. Hauora: Maori standards of health 1V. A study of the years 2000 โ 2005. Kai Tiaki nursing magazine by Ann Manchester in April 2008 Volume 14
The purpose of this project is to improve, restore and maintain the health of the high needs population through the implementation of a home based nursing service. The high needs whanau would be identified according to health needs and health inequalities and with their consent the Mobile Primary whanau nurse would visittheir home. The goal being to: work with the enrolled population, assist in the removal of healthcare inequalities, and develop the Primary Health care workforce to deliver this service. This project has been developed within a Maori Health provider with an enrolled population of approximately 2900, at least 90% Maori, Pacific Island or high needs population.
Work with local communities and enrolled populationIt is important for a Primary healthcare service to deliver healthcare that meets the needs of the population group. The Primary Healthcare strategy discusses the need to organize services around the defined populations rather than just responding to those who seek care. Itโs about knowing the population group, working with this group and building relationships with the whanau with the aim of engaging them to participate in their Healthcare.As discussed in the Primary Healthcare Strategy the benefits of seeing a regular practitioner leads to - better preventative care, recognition of problems, better compliance and fewer hospital admissions. By enrolling in a PHO continuity of care is better achieved and if possible most appointments with the same GP. The recent report by Capital and Coast DHB June 2009 mentioned also that having an regular source of care can reduce the likelihood of Ed admissions and achieve better outcomes for low income populations. The key direction of working with local communities and enrolled population is crucial for this project with the aim of delivering the healthcare to those patients who may require some โintenseโ assistance for a period of time. It is about reaching those patients who are not accessing healthcare or delaying treatment until the problems becomes difficult to manage. Therefore by identifying and working with some of these families we intend to improve their health , education and provide heath care before the problem deteriorates.
Identify and remove health inequalitiesHealth inequalities are related to socio-economic differences, lifestyle, gender, poor housing, and lower education. The aim of Primary Healthcare strategy 2 is to identify the groups of people in the enrolled population of the Practice who have significant health inequalities and are missing out on services. As discussed in the Primary health strategy, identifying the groups of people who are not having their needs met by the existing service. Meeting these needs often requires different methods of delivery of care. For this reason I have chosen key direction 3 to deliver the healthcare to the community and attempt to remove some of the inequalities. Article in Kai Tiaki nursing magazine by Ann Manchester in April 2008 Volume 14 no 4 discussed the role o Mobile primary nurse Gill George who was able to reach those families who had not responded to recall letters, who had difficulties to accessing healthcare and did not always understand the health concern. The work done in the communities as she discussed required a highly skilled nurse who has a passion for working with high needs communities. In her article she talks about the number of immunizations given as well as identifying other health concerns while visiting families that she was able to address.
Develop the Primary Health Care workforceWithin NZ the Primary Healthcare workforce has been put together as Practices have joined PHOโs . As a result not all practitioners are matched to the population need. Primary health care nurses often leave secondary care and join Primary Health Care therefore needing training in core competencies for Primary health care nursing.This involves the development of well trained Primary Health Care nurses to deliver the type of services to the enrolled population. There are a core set of skills required by a Practice Nurse along with specialized skills to run clinics and perform specific procedures. The Primary Health care organization in this presentation has Mobile Primary nurses who receive referrals not only from the medical centre and therefore there case load can vary and is not always the enrolled population of the practice. The purpose of this projects aims to extend the service offered by the medical centre to the homes of the enrolled population. The Practice nurse would take on the role of Mobile primary whanau nurse through education and integration between the Clinical Director, GPโs, Practice nurses, family start and social worker. Development of this workforce is necessary in training methods and a new way to deliver healthcare to the high needs population in their homes. Up skilling of the identified Mobile Primary Whanau nurse will take place as well as general training for all staff such as implementation of standing orders which can be used both within the Medical centre and the community.
The Clinical director and Gpโs in consultation with the Clincial nurse leader and Practice nurses will be responsible for setting the criteria of referral to the Mobile Primary whanau nurse. Referrals can be made by the GP or the Practice nurse ensuring that the case load of the Mobile primary nurse is within the case management load of 15-20 clients. The referral process will be made through Mobile Primary Whanau referral located in the out box in med tech. This process aims to meet key direction 1 and 3.Clinical Director has the responsibility of writing evidence based standing orders to enable the Mobile Primary whanau nurse to deliver her extended role into the homes of the high needs target group. These standing orders include: treatment of uncomplicated UTI, impetigo and school sores, sore throat. It is then the responsibility of the Clinical Director to give the initial training to all staff to facilitate discussions and explanations of the orders. Once an order has been implemented the Clinical Director and the patientโs own GP is tasked to read the nurses notes in med tech. This also gives the ability to track the use of the orders and comply with the agreement of the standing orders. This process aims to meet key direction 3 .
The aim of this project is to increase access to identified families who would like to participate in our home based delivery service. The benefits of the Mobile Primary whanau nurse is that she may have engaged with the family in the medical centre and gained their consent to offer the extended service to their homes. Building relationships with families is an important part of this process. The criteria can be fairly broad and once in the home the Mobile Primary whanau nurse may identify more family members to treat.
The role of the Mobile Primary whanau nurse is to be theโ broker.โ A large part of her role will be establishing relationships and engaging with families. She will assist in identifying and working with families who meet the high needs criteria outlined. This nurse needs to have core competencies of : immunization, asthma training, basic wound care, resuscitation, B4 school check, training in delivery of standing orders for impetigo and minor skin infections, treatment of uncomplicated UTI and Sore throat. Obviously if these skills have not been achieved the appropriate training will need to take place.In my discussions with Dr Russell Wills โ Pediatrician โ he discussed the benefits of generalists and specialist and the need for the generalist nurse to have the relationship with the family and bring in the experts rather than just send the experts to the whanau.โ The Mobile Primary whanau nurse has general skills and will be the โbrokerโ to call on specialized help such as eczema nurse, asthma nurse who she can take along to work with the families.Within our organisation we have allied health professionals which may be called on from time to time such as social worker , family start and a liasonofficer.The Mobile Primary whanau nurse will involve caring for the whanau and the environment they are living in. For example if there is no heating in the house, refer if applicable to the healthy homes project to apply for home insulation. When looking at treating a family with scabies for example, ensure they have a washing machine and hot water to wash the sheets in. Some families may not use sheets and therefore it may be a case of washing the blankets on the bed. Sometimes it is a matter of the nurse looking at the environmental factors that impact on health.
It would be ideal to have Kiawhina to support and enhance the role of the Mobile Primary Whanau nurse. This person would need to be trained in first aid and ideally be interested in studying to ward a kaiawhinarole. The development of this person would include first aid training along with learning the basis of the education given by the nurse in the community.
The Family start team is employed in the same organization as the Medical Centre. They work with familyโs who have a child less than one year of age, with the goals of health, education and social services. Working with family start is an important link in the implementation of this project as they may have established relationships with the families. Family start could also refer enrolled patients to the Mobile Primary Whanau Nurse. The work implemented by family start includes: working with enrolled populations, removing health inequalities, offering comprehensive services and co-ordination of care by linking people with winz and other social services. Workforce development of the family start employee would occur as the nurse is trains families in healthcare such as: asthma education, use and cleaning of spacer for asthma and application of creams for eczema.
As Clinical Nurse Leader I will be booking fortnightly education sessions for the Clinical director to present the standing orders to the Gpโs, Practice nurses and Mobile Primary whanau nurse. These sessions will be on a Tuesday morning from 9am โ 10am. These orders can be used both within the Medical Centre by the Practice nurses and by the Mobile Primary Whanau nurse. This increases access to healthcare within the Medical centre when a GP is already booked. These standing orders are then put together in a booklet with a policy around usage in the front of the book along with the names of all nurses trained to use the standing orders.
As a Clinical Leader I have put together a list of core competencies required for this role and identified further training required. The Mobile Primary whanau nurse will be an extension of the existing Medical centre. Although one nurse has been identified to take on this role it may be shared depending on the already existing relationships built between current Practice nurses and patients. This role aims to meet key direction 1 by responding to the needs of the community. As a Clinical Nurse leader I will become familiar with the DHB services available to support this project such as the asthma nurse, eczema nurse and invite them to meet my nursing team.By implementing this different delivery of care we aim to remove the health inequalities. It is about being creative with the delivery of service.To develop this nurse to fulfill the role she will attend Asthma training and complete training in delivery of standing orders written by Clinical Director.
Evaluation of a project within a high needs population can be difficult. As inroads may be made in some areas there are still a number of patients who fail to attend appointments, respond to recalls which can impact on the overall key performance indicators. It can be difficult to measure the improvement of a childs skin as this does not always match the number of appointments that may have been made. Evaluation of this project will involve looking at the improvements in for example immunisation rates in the group of people within the home based delivery of care by the Mobile primary nurse. A qualitative assessement of questions to the family
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