Introduction

Te Awakairangi Health Network manages a group of programmes which are available to all valley-wide  Te Awakairangi Health Network practices. These programmes are aimed to reduce health inequalities and improve health outcomes for the people of Hutt Valley. They are designed for use in General Practice with a strong focus on supporting the Practice to implement these programmes. Each programme has specific criteria and is generally restricted to patients who are enrolled with a Hutt Valley PHO and /or resident in the Hutt Valley.

The aims of each programme vary. Some are designed specifically to reduce health inequalities due to financial barriers, and are therefore targeted at the lower income population. Other programmes address high health needs, such as people with diabetes. Service Providers generally include General Practices, Marae based healthcare workers, and other Primary Care Providers.

Valley-wide Programmes include: 

Community Radiology Programme

The Primary Care Community Radiology Programme provides referred clients with timely access to a quality service that facilitates a prompt, cost effective and accurate diagnosis of clinical problems and conditions. The programme excludes procedures that are covered under ACC, maternity services, Nuclear & MRI scans and the breast screening programme (there are some exceptions for breast screening and patients should discuss these with their GP)

Referred patients make their own appointments and are invited to choose either The Hutt Valley Imaging Service or Pacific Radiology.

Compliance Packaging Programme

The Compliance Packaging programme assists patients to manage their medicines by improving their compliance and thereby maximising the health benefits of their medication. Patients must be a resident of the Hutt Valley, enrolled in a Hutt Valley PHO and hold a Community Services Card.

Referrals into the programme must be made by a GP or Pharmacist operating in the Hutt Valley. A clinical pharmacist at Te Awakairangi Health Network will confirm availability for placement on the programme for new referrals and will notify the GP and/or Pharmacist

Chronic Disease Pathway

The Chronic Disease Pathway is a suite of 3 programmes comprising:
•Community Respiratory
•Cardiac continuum of Care
•Diabetes Action (and Community Podiatry)

The Chronic disease Pathway aims to educate and reinforce lifestyle changes and increase the patient's ability to manage their condition. These 3 programmes are also intended to support primary care providers to specifically target services to high needs Māori and Pacific people. Services delivered under this programme are 'wellness' events and should be separately scheduled from visits for illness or with Care Plus appoints.

Patients are eligible to enter any of the 3 programmes if they are resident in the Hutt Valley and or enrolled in a Hutt Valley PHO and have indicated they wish to participate in the programme. Patients are excluded from free education sessions if they are receiving the same service from Specialist Hutt Valley DHB services, PHO Care Plus or other providers of the services.

Community Respiratory Programme

The Community Respiratory Programme aims to:
•improve the management of patients with asthma/COPD and foster or increase the patient's ability to self-manage their condition
•reduce hospitalisation due to asthma/COPD related illness

The Programme offers nurse led education and support, post hospital GP review. A Voucher is issued upon hospital discharge for the patient to redeem at his/her GP Hutt Valley practice.

Cardiac Continuum of Care Programme

The cardiac Continuum of Care Programme focuses on people in the Hutt Valley either with risk factors for cardiac disease or who have a diagnosed cardiac condition. The programme offers support and education sessions with practice nurses and a post hospital GP review following a hospital admission for a cardiac condition. A Voucher is issued upon hospital discyharge for the patient to redeem at his/her GP Hutt Valley practice.

Diabetes Action Programme (and Community Podiatry)

The Diabetes Action Programme aims to:
•Promote Self management
•Provide education for patients with Type 2 Diabetes. The Programme offers nurse let education and support.
•Under the Diabetes Action programme Hutt Valley practices may also refer patients newly diagnosed with Type 2 diabetes to an approved community podiatrist for onepodiatrist assessment. If further sessions are required the community podiatrist will refer the patient to the HVDHB podiatry department who will then refer back into the Community Podiatry maintenance programme.

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Warfarin Monitoring Programme

The Warfarin Monitoring Programme provides a reliable, safe and effective Warfarin management service to those residents of the Hutt Valley for which Warfarin medication is indicated. The service provides:
•A free GP visit for patients discharged from Hutt Hospital and newly initiated on
Warfarin - the patient will receive a Voucher from the Hospital specialist services entitling them to the free GP visit
•GP or Practice Nurse education and support sessions for the patient. Patients can receive an initial education and support session followed by one follow-up session dependent on the needs of the patient at the discretion of the Practice.

The service is available for all people resident in the Hutt Valley and enrolled in a Hutt Valley PHO who are receiving treatment on Warfarin.

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Primary Care Skin Lesion Programme

The Primary Care Skin Lesion Programme aims to provide high quality skin lesion removal services within primary care; reduce waiting times for skin lesion removals and reduce the burden of non-melanoma skin cancer on secondary services.

The primary care skin lesion service can be provided to patients who have an eligible skin lesion, hold a Community Services Card or High User Health Card and reside in the Hutt Valley or enrolled in a Hutt Valley PHO.

Only approved providers may remove skin lesions under this programme.

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Youth Sexual Health Programme

The aim of the Youth Sexual Health Programme is to improve the sexual and reproductive health of people in the Hutt Valley by providing a free primary care service to youth and other high needs people in exceptional circumstances. The type of sexual health conditions covered under this programme are:

Contraception

Pregnancy test

Emergency contraception

Pregnancy options

Sexual health – STI’s, sexuality and other sexual health issues

Patient eligibility:

The programme can be provided to young people who are aged from 12 years up to 21 years domiciled in the Hutt Valley.

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Diabetes Care Improvement Package

From 1st of July 2012, the Get Checked programme was replaced with the Diabetes Care Improvement Package. This is a primary care based programme building on core diabetes services with a stronger focus on patient education and reaching people who are at particular risk of missing out on the support and care required to keep them healthy and well.

General practice teams will continue to actively engage people who are living with diabetes, aiming to offer them regular checks, advice and education as part of their on-going and routine care plans.

Funding is available to enable practices to engage people they consider to be at particular risk and who may have difficulties attending routine care. This may cover the cost of a brief assessment and follow up education to ensure these people have a care plan they can follow. Specific local criteria need to be met to access this support.

Many people with diabetes will be enrolled on Care Plus – a programme aimed at providing additional support for people living with long term health conditions. Your practice nurse will discuss this with you if they think this may be helpful. The programme offers support to the practice to enable them to offer you additional education, follow up and care reducing the cost to you.

The team at Te Awakairangi Health Network are there to support practices around the Hutt Valley, with claims administration, resources and information on these and other programmes.

More information on the Diabetes Care Improvement Package and “Get Checked Programme” is available on the Ministry of Health website http://www.health.govt.nz/our-work/diseases-and-conditions/diabetes/diabetes-care-improvement-package

More information on Care Plus is available in another section on this website.

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Professional Development for Nurses

Nurse led education and support under the Valley-wide Programmes can be provided by primary care practice nurses who have successfully completed relevant training and undertaken support programmes. Completion of the base line Te Awakairangi Health Network facilitated professional development for primary care nurses, and the relevant updates, is considered appropriate to deliver and claim funding for education sessions under Valley-wide Programmes.

Primary care Nurses who have completed other recognised or similar level professional development, or have previous experience in the delivery of Respiratory, Cardiac and Diabetes education to patients can also participate in delivering and claim funding for education sessions under the Valley-wide Programmes.

Enrolments and Enquiries

Enrolment Forms are sent to all Hutt Valley PHO GP Practices via the Te Awakairangi Heatlth Network weekly Mailout prior to each Course. To pre-enrol or for more details please contact:

Administrator - Valley-Wide Programmes Professional Development for Nurses: 04 566 5320

The following outlines the Valley-wide Programmes Courses facilitated by Te Awakairangi Health Network:

Diabetes Action Course

This is a two-day Course delivered by the Diabetes Nurse Specialist team at the Hutt Valley DHB.   It enables nurses to provide diabetes education and support to their enrolled patients. The Course involves some pre-reading.

Diabetes Update Course

The half-day Course delivered by the Diabetes Nurse Specialist team at the Hutt Valley DHB. The Course provides updates on the Diabetes Action programme and advances in Diabetes management. It is recommended, once the Diabetes Action two-day Course has been compeleted, Nurses attend one Diabetes Update half-day Course each year.

Respiratory Course

This is a two day curse delivered by the Respiratory Nurse Specialist team at the Hutt Valley DHB. It enables nurses to provide education and support to enrolled patients with either newly diagnosed asthma or chronic respiratory disease. Each day will focus on asthma or COPD

Respiratory Update Course

The half-day Respiratory Update Course is delivered in conjunction with the Respiratory team at the Hutt Valley DHB. Each update will have a core focus of asthma or COPD.

Cardiac Continuum of Care Course

This is a two-day Course delivered in conjunction with the Hutt Valley DHB Specialist service. Day One, which also serves as a refresher, is specifically designed for Primary Care Nurses and has a focus on Cardio Vascular Risk Assessment. Day Two is delivered by the Specialist Cardiac team at the Hutt Valley DHB.

Warfarin Course

This Course is delivered by the Clinical Pharmacy team at Te Awakairangi Health Network. This Course offers training that will enable primary care practice nurses to provide support and comprehensive Warfarin education to their enrolled patients.

Sexual Health Course

The Sexual Health Course is facilitated by the Wellington Sexual Health Service and Compass Health Network. Te Awakairangi Health Network promotes these courses and sends enrolment forms to all Hutt Valley GP practices via the weekly mail out.

For further information regarding any of these courses please e-mail info@TeAwakairangihealth.org.nz

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