Clinical Services


CarePlus is a government initiative which was introduced nationally through PHO’s from 1 July 2004. The service is targeted towards people who need to visit their General Practitioner or nurse often because of significant chronic illnesses such as diabetes or heart disease, have acute medical or mental health needs, or a terminal illness. It was envisaged that people using CarePlus will get effective management of chronic health conditions, better understanding of their conditions and support to make lifestyle changes.

As described on the Ministry of Health (MOH) website (2004), a person is eligible for CarePlus if they are enrolled in a PHO and who:

  • Is assessed by a doctor or nurse at their general practice and who could benefit from “intensive clinical management in primary care”(at least two hours of care from one or more members of the primary health team) over the following six months; and either
  • Has two or more chronic health conditions so long as each condition is one that: is a significant disability or has a significant burden of morbidity; and creates a significant cost to the health service; and has agreed and objective diagnostic criteria; and continuity of care and a primary care team approach has an important role in management; or
  • Has a terminal illness (defined as someone who has advanced, progressive disease whose death is likely within 12 months) or;
  • Has had two acute medical or mental health related admissions in the past 12 months (excluding surgical admissions); or
  • Has had six first level service or similar primary care visits in the past six months (including emergency department visits); or
    It was intended that CarePlus would:
  • Fund and protect practice team time and resources to enable planned time to be spent with CarePlus patients which is directed at better health outcomes and which would focus attention on the health status of patients and their personal health related goals
  • Enable systematic attention to objective measures of health status of patients, defining carefully their health needs and risk factors (physical, social, lifestyle and behavioural), creating with them a composite management plan, and re-measuring their health outcomes after set periods of time
  • Provide an opportunity to implement interdisciplinary and clinical/cultural approaches to primary health care
  • Provide an opportunity to improve or develop relevant tools, processes and guidelines to support this systematic approach to delivering and measuring health care services.

Local Implementation

CarePlus was introduced in Manaia Health PHO in October 2004, with the underlying premise that a carefully planned and supported rollout was essential.

Key principles which have guided the initial and on-going implementation of CarePlus within Manaia Health PHO include:

  • Maintaining the integrity of the purpose of CarePlus through a well structured and carefully managed roll-out – the focus has always been on quality as opposed to meeting arbitrary enrolment targets.
  • Being clear that the central focus is on the patient and his/her family/whanau
  • Encouraging and supporting a team approach to CarePlus implementation, both at the general practice level, and across the primary/secondary interface.
  • Ensuring the general practice team is well supported ~ this includes multiple strategies to support IT and administrative functions, as well as the General Practitioner and Practice Nurse roles
  • Ensuring that tools, resources and education provided to support CarePlus are based upon best practice guidelines