Equally Well Kaikoūra Health profile

Kaikoūra Health: Te Hā o Te Ora is a partnership between general practice and Canterbury DHB’s acute and inpatient services and is led by the Kaikoūra Health Steering Group and Clinical Advisory Group. They’ve been implementing Equally Well initiatives since February 2019 and formally joined the collaborative just recently. Their Equally Well initiative began when the Kaikoūra Health Clinical Advisory Group discussed the need to improve the health outcomes of people experiencing addiction and mental health issues.

In February 2019, an initiative commenced to achieve physical health equity in people accessing their service.  Led by Stephen Howie (Specialist rural mental health nurse) and Fiona Blair (Nursing team leader and nurse practitioner candidate), they decided to promote regular physical health screening using the following process: 

  • Define the cohort from their enrolled patient population
  • Identify patients both by diagnosis (schizoaffective disorders, bi-polar disorder, psychosis and will consider severe refractory depression), and by prescribed medications: Olanzapine, Risperidone, Haloperidol, Quetiapine, Paliperidone, Lithium, Benztropine and possibly Lamotrigine. Use the MedTech query build search engine, the pharmacy records and lists of patients currently seen for serious mental health and addiction issues. 
  • The practice nurse would then review the patient notes for completeness of physical health checks, identify gaps and call patients in for funded consultations. If the gap is minor ie they have been reviewed within the last 12-months, a highlighted note will be placed on the record for the next visit.
  • Funding is accessed for this work and the consultation via Pegasus PHO Equally Well initiative, SIA (Service to Improve Access) and eCap (Enhanced Capitation) as required.
  • Utilise a combined Practice Nurse and GP/Nurse practitioner model to assess, screen, investigate, refer and treat patients, and establish an individualised health plan.
  • Complete a screening tool at the first consultation with will be searchable and add a recall date for annual physical health review.
  • Work alongside our CDHB rural mental health specialist team and enlist their expertise to identify and assess patients.
  • Work in a multi-disciplinary model, referring to: External local Iwi provider, Te Hā - Waitaha smoking cessation, physiotherapist, dental services, nutrition services and addiction services or internally to social worker, community support workers or other local clinicians.
  • Review the project after 3-months or the first five patients.

It is still a work in progress, but plenty of visible progress has been made – their clinical team was expanded to include a mental health nurse, social worker and community support workers. This led to improved mental health outcomes for people accessing the service in this isolated rural area with people being seen by skilled clinicians within a week of referral and subsequent interventions being delivered in or close to the person's home.

This led to improved mental health outcomes for people accessing the service in this isolated rural area with people being seen by skilled clinicians within a week of referral and subsequent interventions being delivered in or close to the person's home.

Work has been done to identify the initial cohort of patients and set processes in place to identify those people who have not had regular health checks. Once identified, the person will be contacted and offered a funded nurse and GP consultation, an alert will be entered on the MedTech dashboard to alert clinicians to the need for a physical health check, and a 12-monthly recall will be set up.

As an example of the impact that is already happening, one person who is also under the care of specialist mental health services, was identified as having had no physical health checks since 2015. As a result of this initiative, this person is now receiving regular district nursing input for the identified health issues.

Stephen keeps up to date with Equally Well issues and initiatives in his region by attending a primary care Equally Well working group in Canterbury, as the nursing representative.