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Long-term conditions programme helps patient be more involved in own health care

Thursday 24 December 2020

Retired serviceman Hemi Martin is not one who wants any added attention, but the extra support and care he receives thanks to the long-term condition programme CLIC may just be an exception to the rule for the 67-year-old Invercargill resident.

A central part of CLIC (Client Led Integrated Care) is one-hour Comprehensive Health Assessment (CHA) that captures the patient’s bigger picture health needs –  medical conditions, as well as information about social circumstances, goals and any barriers that may be holding the patient back from improving quality-of-life and managing health conditions.


He Puna Wairora Wellness Centre practice nurse Christina Driver, who saw Hemi for his CHA, says the assessment gathers all the clinical information to help in the management of long-term conditions, but affords an opportunity to have better understanding of the person.

“It’s also a conversation, a discussion that really lets us get to know patients and learn what’s important to them,” she explains. 

For Hemi, who has arthritis, the longer appointment encouraged him to think about how his condition affected his life, and what he could do to improve his health and wellbeing.

“I set the goal of walking one kilometre without pain,” he says, noting it was the time with the nurse that made him really think about what he wanted to achieve. “I enjoyed our time together. I felt listened to.”

Having identified that pain was holding Hemi back, Christina arranged for a GP appointment to address pain management, while also introducing Hemi to community providers and programmes, including group exercise classes, which have the added benefit of increasing social engagement for Hemi, a widower of two years.

“I have been to Tai Chi twice now. There are people there much older than me and lots of younger people too,” he says. 

In addition to his goal of walking without pain, Hemi, with Christina’s help, identified continuing to live independently and fishing for blue cod with his mates as other priorities he wants to maintain.


“It’s important for people to stay connected to their general practice and to be supported to manage their own health conditions,” Christina explains. “CLIC gives us the freedom to spend more time with a patient, which is why most of us do this kind of work in the first place.”

Wendy Findlay, WellSouth Director of Nursing, says Hemi’s experience is a great example of how the extra time and resources provided by the CLIC programme can have a real impact on people’s health and their lives.

“Time and understanding are an important part of the health care we can provide. Patients needn’t  be passive recipients of health care,” Wendy says. “CLIC is designed to give extra help to the people who need it most and gives practices the flexibility to be able to provide the support they know is needed.”

 About CLIC

The long-term conditions programme, CLIC is available to enrolled patients of all general practices in WellSouth Primary Health Network. Delivered through GP practices, CLIC is a funded programme of care for people with long-term conditions like diabetes, heart conditions, or mental health issues. It’s aim is to help patients to have more say in their treatment and be actively engaged in their own programme of care, self-managing their condition well, in partnership with their primary health care provider.

Along with the Comprehensive health assessment, CLIC provides patients and the practice team with the opportunity to plan care and support based on the identified needs and priorities of the patient.  The programme is designed to support patient needs, rather than the patient needing to fit in to the priorities of the health system.

The CLIC programme has recently been enhanced to provide practices with more flexibility to allocate their funding, while offering the same support for patients. A new Quick CLIC option is an abridged version that provides clinician with the ability to provide short term support (up to 6 months) for patients, enhancing their ability to return to supported self-management.


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