Long term success for long-term conditions
Toitū Takata, the WellSouth long-term conditions programme, was launched earlier this year across many general practices in our Southern health district. Nurse-led, it is empowering clients to self-manage, it is breaking down barriers to accessing care and it is offering an integrated model that will have greater long-term success for those who need it most. WellSouth went to meet a Toitū Takata nurse champion, Kate Black, at Te Hau o Te Ora in Invercargill, to find out why she rates Toitū Takata so highly.
Kate, a Kiwi, recently moved back to Aotearoa/New Zealand from Australia to join the team at Te Hau o Te Ora as the programme was being introduced.
She is a registered nurse and the point of contact for patients who enrol into Toitū Takata. Kate will make the initial call, hosts the first appointment, hearing about clients’ conditions and hopes for the programme, and helps them navigate the associated appointments on their personal plan.
“Our goal is to help the patient achieve their goal,” she says.
“It’s great seeing our patients on the programme move through the steps to achieve their goals, and for us to build a relationship with them.
“There are a range of reasons for patients signing up. One patient wants to stop smoking, another said they just wanted to stay out of hospital, while another spoke of having the time and health to better understand his whenua, whakapapa and travel to where his whānau are from.”
Kate was a little surprised that the programme was so new.
“In Australia, they do advanced care and long-term conditions treatment well. I was surprised they didn’t have the same available in New Zealand. In fact, I would have been a bit gutted if we didn’t have something like Toitū Takata. It’s great!”
What has made it a success?
Kate says it is a team approach, including working with the health coach who has helped identify patients and even bring patients in.
“Within a week of us working together, an additional 10 more patients signed up to the programme,” she says.
“Being a nurse means we are more accessible to some patients that may not feel totally at ease with a GP.
“The clinical pharmacist has also played a big part, being able to offer a medication review the same day as the patient was referred to them, which really sparked that patient’s re-engagement as well.”
Some patients have had a telehealth appointment seeing a virtual GP and using the Tyto system, which Kate says works well.
“Needs Assessment Referrals also allow us to think about the patient's needs at home.”
“The programme definitely works,” says Kate.
Challenges
Kate starts with a phone call, telling people; “You’ve got a long-term condition that we’d like to monitor and you’re eligible for this program focusing on your long-term health.”
Only a handful of patients are not keen, she says. An example of why, in one instance, is for financial reasons. The patient is unable to bring their account balance up and therefore doesn’t feel comfortable attending the clinic, something Kate says she is working on trying to overcome with that patient.
She says that when a patient first comes in, enrolment can take a long time.
“Especially the self-reflection tool because when you’re asking them personal questions, this can lead to long conversations when we’re relatively short on time. We sometimes use a scoring card (select 1-10) which the HIPs and health coaches showed me how to use.”
How Kate works
“I am the first point of contact. Together, we come up with a plan which will include an entry and exit visit as well as 5 clinical appointments that are usually 3 nursing and 2 GP appointments. In addition, they can see a health coach and/or HIP, which is free.”
She says that so far, about 50% of patients have used these resources.
A win
One of our patients has COPD, explains Kate.
“Our action plan included visits to GP or NP in one case to do a back pocket prescription. The patient stuck to his action plan, took his steroids, and ended up managing to stay out of hospital, which was such a win for all of us.”
Tips and advice
· Kate strongly advocates that it should be nurse led and involve health coaches, as patients often feel more comfortable working with these people.
· The self-reflection tool is useful for helping patients open up, which in turn facilitates better relationship building. The use of cue-cards helps the nurse keep the patient’s focus on their stories and supports them to stay open with the nurse. A scoring system during self-reflection can help if you are short on time.
· We’ve been putting alerts on patients’ files, so their file identifies them as part of the programme. This is also helpful as a tracker, as patients do need reminding, they are part of Toitū Takata, and it takes a moment for them to realise that this is a “thing”.
· The pamphlet really helps raise awareness of the programme to patients.
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