1. Innovative and courageous general practice? You be the judge! Linda Dubbeldam, Clinical Director Sue Dykes, Clinical Nurse Specialist Dr Delamy Keall GPsi, Dr Pauline Blackmore GPsi, Lisa Martin RNsi

2. The Tararua District

3. Tararua Health Group Established 2009 4 sites general practice, community health services and a community hospital 100 staff 60 clinical – 37.5 FTE 14,570 enrolled patients Single networked PMS 90kms of fibre-optic cabling

4. Barraud Street Health Centre Pahiatua Medical Centre Te Rongopai Dannevirke Community Hospital

5. Critical Success Factors Inspired leadership Virtual integration - Single networked PMS Shared back room functions Operational Management Team – doctors doctor, nurses nurse Clinical Excellence Group – Clinical Director Workforce development

6. Health of Older People Service Non-acute interdisciplinary care for frail older people with moderate to high health needs Maori and Pacific 55yrs+ Other ethnicities 65yrs+ Comprehensive health assessments Case management Aspirational targets

7. (some of) Our Team Alex Graham - Community Pharmacist; Michelle Burgess - InterRAI Assessor/Practice Nurse Pahiatua Medical Centre; Pauline Blackmore - GPsi/GP Barraud Street Health Centre; Fiona Moscrop - CPHO Clinical Pharmacist; Delamy Keall - GPsi/GP Pahiatua Medical Centre; Linda Dubbeldam – Clinical Director; Lisa Martin - RNsi; Sue Dykes - CNS.

8. The THG way Best use of available resources Assessment Care and support Medical and medicine management Shared consults, sharing learning Short term focused intensive mobile General practice based

9. THG Practice Profile 17/01/10 – 16/01/11 Age, ethnicity, # long term meds, ARC residency, # acute admissions, # reported falls, living status, # primary care presentations, care plus status Applied weighting to flag those most at risk of harm or injury

10. Our Older People AgeMaoriPacificOtherTotal 55-591291130 60-6474478 65-6965540605 70-7446472518 75-7934350384 80-84131275289 85-897192199 90-9447983 95-9911718 100-10433 Total373619282307 16.2%0.3%83.5%

11. Weighting Scores

12. Weighting by Ethnicity

13. Primary Care Presentations

14. Polypharmacy

15. Living Alone?

16. The THG Way Proactive approach to referrals Clinical pharmacist review Joint MUR CNS/community pharmacists Community pharmacists full access to THG MedTech Multi-dis case management Standardised SOs ARC Falls assessment

17. Sustaining Innovation Exploring the seamless sharing of information between THG and Tararua ARC facilities Involvement of physical activity educators → Physio-led falls prevention programme Applying some science to the weighting scores Summer student/Masters project

18. Visionary? Innovative? Courageous? You be the judge