Too narrow and too prescriptive is Helen Kjestrup’s verdict on Care Plus. So the clinical services manager for Masterton Medical Centre grabbed the chance offered by bulk-funding to say goodbye to the more onerous restrictions of Care Plus.
In its place has come the nurse-led guided model of care (GMC) for people with long-term conditions, which can be pitched at the level of need right up to dedicated case management for people with high and complex needs.
Kjestrup, a nurse for 30 years and a nurse leader at Masterton Medical since 2007, says the model was already evolving when Tihei Wairarapa’s successful Better Sooner More Convenient (BSMC) business case in 2010 opened up the opportunity for change.
Wairarapa had been early adopters of Care Plus, with six per cent of the population signed up to the funding stream, and Masterton Medical, the region’s largest practice by far, had nurses operating dedicated clinics for patients with diabetes, respiratory disease, or cardiovascular disease every working day, plus a marae-based Māori health clinic and nurses who went into people’s homes.
However, frustrating barriers arose for Kjestrup such as the funding compliance red tape, a case where a newly diagnosed diabetic was seen twice in short succession (rather than the Care Plus requisite of three months apart), and the inability to offer intensive support to patients when it could make the most difference.
It was the bulk-funding of Masterton’s Care Plus funding that gave the centre the freedom to decide when Care Plus eligible patients receive the care they are funded for – with the first visit and follow-up phone call free and a part charge of $15 for the next three visits – plus the flexibility to offer more or less visits depending on need and uptake.
Kjestrup says when the centre first started Care Plus, the focus was on the highest need LTC patients with multiple and complex conditions. This small group of patients made up the ‘top of the triangle’ and soaked up the most resources. She says its focus has now “dragged into the middle of the triangle” to offer more support to the next tier of newly diagnosed, at risk patients before they become high needs.
“You get better bang for your buck.”
Thirteen of Masterton Medical’s nurses are now delivering its guided model of care (GMC) to patients (with two or more long-term conditions) in collaboration with the patient’s GP and the rest of the specialist nursing team. The nurses all work part-time for the GMC programme and together make up the equivalent of 3.1 full time equivalent (FTE) GMC positions.
“They are practice nurses as well … so they are specialised in areas but also work across the floor as well, which really spreads the knowledge beautifully,” says Kjestrup.
One of the GMC nurses, newly approved NP Anna Reed, specialises in working in the community to coordinate the care and create wrap-around services for the high needs over-65s patients with LTC who may be recently out of hospital or referred to her as needing acute intensive support. Once the patient is stable and settled, she will hand them over to the two other nurses working with this group of older patients at the “top of the triangle”.
A key to the Masterton model is also good communication and information sharing between all health providers so its nurses attend multi-disciplinary team (MDT) meetings at the hospital to feedback information to the practice team.
Kjestrup says its GMC model is a community response to meet its community needs, influenced by a number of chronic conditions philosophies and models, and is a “pretty simple recipe really”.