Rachael Walker Clinical Nurse Specialist Renal Department Hawkes Bay District Health Board Stuart Barson HSA Global (Thursday, 3.35pm, Clinicians' Challenge)

1. Better Care for CKD Service
HSAGlobal &
Hawke’s Bay DHB

2. The Background
 Approx 17,000 people in HB have Chronic Kidney
Disease (CKD)
 Early detection and management is better and more
cost effective
 The majority of CKD patients can be managed in
primary care
 Secondary care needs to see the complex patients and
support primary care

3. The Challenge
 Knowledge of patients
 DHB audit shows it knows only 1/3 of patients
with mod/severe kidney disease
 Risk stratifying patients
 Managing resources
 Creating timely systems and processes
 Improving integration and collaboration

4. Goals - service
 Knowledge of patient population
 Risk stratification of patients
 Improved care co-ordination
 More efficient use of specialist services
 Clear pathways
 Efficient communication
 Better support for primary care
 Improved patient outcomes

5. Goals - solution
 Take a shared care approach – NHITB plan
 Re-use existing CCMS solution for feasibility
 Include the new stratification model
 Share key information and enable actions
 referral management
 active involvement in care planning
 patient interaction
 close the loop with pharmacy

6. Integrated CKD solution

9. The Outcome
 Integration
 More effective communication
 Exemplar for other DHB’s renal services
 More efficient utilisation of resources
 $ better spent
 Better service planning
 Improved patient outcomes