Patient Information
What is Care Plus?
Care Plus is a new service being introduced through PHOs from 1 July 2004 onwards. It's aimed at people who need to visit their family GP 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.
Who is eligible for Care Plus?
A person is eligible for Care Plus 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 care 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 system; 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
- To promote quality and consistency of services
- Is on active review for elective services.
How do I enrol for Care Plus?
Firstly talk to your usual family doctor or nurse to find out if they are offering Care Plus. At the moment not every PHO is offering the service but there are plans for every PHO to offer Care Plus over the next few years. Your family doctor or nurse will assess you to see if you are eligible for Care Plus. If you are not eligible it may be that they can help you in other ways or review your existing care.
What difference will I notice with Care Plus?
People who use Care Plus will get an initial comprehensive assessment when they visit their practice. An individual care plan will be developed to set realistic, achievable health and quality of life-related goals, with regular follow-ups. People using Care Plus will get effective management of chronic health conditions, better understanding of their conditions and support to make lifestyle changes.
How much will Care Plus cost me?
These services will be provided at a low or reduced cost.
Can people who are not enrolled in a PHO practice get this new service?
No.
Is Care Plus replacing the High User Health Card?
Not immediately. Over time, Care Plus will replace the High Use Health Card (HUHC) as the means of targeting high-needs patients. Where Care Plus differs from the HUHC is that Care Plus is a comprehensive approach to improve outcomes for people with chronic conditions, including lower cost access, whereas the HUHC is a subsidy approach tied to GP visits.
Will High User Health Card patients automatically transfer to Care Plus?
No, not automatically. When HUHC patients come for their annual review, they should be assessed to see whether they are eligible for Care Plus. If they are, they will be transferred.
How many PHOs are offering Care Plus?
From October 2004 onwards 40 PHOs will offer Care Plus and 12 will be preparing to.
Careplus in the Manaia Health PHO Area
Eligibility for Care Plus in the Manaia Health: PHO 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 care team) over the following six months; and either Has two or more chronic health conditions so long as each condition is one that:
- 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 care 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 system; and
-- has agreed and objective diagnostic criteria; and
-- continuity of care and a primary care team approach has an important role in management
For the present time eligible patients must have at least one of the following conditions: COPD, Diabetes, CHF or high cardiovascular risk as their primary problem. The other eligibility criteria are not applicable at this time E.g. terminal illness, mental health related conditions or active review for elective services.
A key component of CarePlus in the Whangarei District is the use of the Counties Manukau Chronic Care Management (CCM) system. This involves linking of each practice to the Counties Manukau DHB server for chronic care decision support. This system uses the MedTech-32 programme.
Other options will be put in place for practices using different programmes. Counties Manukau resource manuals have also been made available to the Manaia Health: PHO practices. Two resource nurses are available from Manaia Health: PHO to offer support and advice to practice nurses on the running of the CarePlus clinics. Overview and governance of the program is held by the Manaia Health: PHO Clinical Board with a CarePlus coordinator appointed as a point of contact for the practices.
