Care Plus is a nationwide clinical programme to assist people with chronic health conditions, acute medical or mental health needs, or terminal illness who are high users of General Practice.
The programme’s benefits are twofold. People with high health-care needs can access the care they need while keeping their costs low; and primary health care providers can use the programme to co-ordinate their care management and teamwork.
There were almost 3000 Rotorua Area Primary Health Services (RAPHS) patients enrolled in early 2008, of which almost half were from low socio-economic backgrounds (Quintile 5).
Enrolled patients are eligible for Care Plus for 12 months, and remain eligible provided:
- they are on active review for elective services, and
- interact with the practice at lease once per quarter, and are
- explicitly assessed as needing the higher level of care to continue.
Our Care Plus programme is funded by Health Rotorua PHO and is available to all eligible patients who are enrolled in a RAPHS practice and assessed as meeting the following criteria:
- The patient is assessed as being expected to need ‘intensive clinical management’ (i.e. at least two hours) over the following six months, and
- The patient fulfils at least one of the following criteria:
- Has two or more chronic health conditions, and each condition is one that:-
- Is a significant disability or has a significant burden of morbidity, and
- Creates a significant cost to the health system, and
- Has agreed and objective diagnostic criteria, and
- Continuity of care and a primary-health-care approach has an important role in management.
- Has a terminal illness (i.e. has advanced, progressive disease whose death is likely within 12 months).
- Has had two acute non-surgical admissions in the past 12 months.
- Has had six first-level service primary care visits in the past 6 months (including emergency department visits).
- Is on active review for elective services.
RAPHS manages a waiting list for patients who meet the criteria for enrolment in the programme. It is possible, because of the current enrolment percentages for various categories, that some patients will be granted ahead of others who have been on the waiting list longer.
For more information, contact Clinical Facilitator, Tim. Click here for his contact details.