Long Term Conditions Support - Toitū Takata FAQs

 

Below are questions and answers that you might find helpful. We will keep adding to these and if you have any questions, please don’t hesitate to contact your primary care relationship manager.

 

What is Long-term Conditions Support - Toitū Takata?

Toitū Takata provides additional funding to practices to allow them to provide additional support to patients who have long term health conditions. The expectation is that the additional time spent with patients will allow clinicians to work alongside patients and improve their understanding and self-management of their long term conditions. The goal is to maximise equity, improve health outcomes and allow those with long term conditions to live well.

 

Which conditions have we focused on, and why?

Chronic health conditions are responsible for the majority of ill health in New Zealand. Māori and Pacific people experience higher rates of chronic health conditions and develop these conditions 10 - 20 years earlier than non-Māori and non-Pacific populations. The conditions which make the greatest contribution to this inequity are diabetes, gout, cardiovascular disease, respiratory disease, and stroke. These are the conditions that Te Pae Tata / Interim New Zealand Health Plan 2022 have identified as a priority in improving health outcomes across Aotearoa.

Cardiovascular disease and diabetes rates are particularly high in those with severe and enduring mental illness and are a leading cause of death within this population.

We recognise that not all patients who would benefit from Toitū Takata will fit into the above categories. For those patients who have a long-term condition and who will benefit from Toitu Takata we have included ‘Other LTC’ as one of the eligibility criteria. To maintain the focus of Toitu Takata on the priority conditions it is expected that enrolments of patients into this category are limited to roughly 10% of your allocated spaces.

 

What can be included as other Long-term Conditions?

Patients who have a condition that is ongoing, long term or recurring and that has a significant impact on their life and who would benefit from the support provided by Toitū Takata can be included. Examples may include arthritis, frailty or cancer.

 

Allocation and eligibility

Long-term Conditions Support -Toitū Takata has defined eligibility criteria which will focus on those with these conditions; those with the highest needs. Click here for further information.

While many patients are eligible for the programme based on the criteria, the national funding for this programme has not increased for several years. We have had to limit the funded ‘spaces’ for each year.  Like previous programmes, WellSouth has allocated these spaces to practices based on the individual practice population demographics i.e. the percentage of enrolled patients who will meet the criteria for Toitū Takata. We have also considered how the programme addresses the inequity of health outcomes that exist for many New Zealanders.

There has been a recent increase in the total number of spaces and increased available on Toitū Takata. This means that more than 10,000 patients can access either Toitū Takata or Hāpai Atu in a 12-month period. To put that in context, in the biggest year of CLIC there was 8481 CLIC and Quick CLIC claims in total, so this is nearly a 20% increase in access overall. In addition to this we have introducing a separate funding stream for advance care planning. This means that the overall funding available for long-term conditions care has increased across the region, meaning more people can access the care they need.

While many patients are eligible for the programme based on the criteria, the national funding for this programme has not increased for several years. We have had to limit the funded ‘spaces’ for each year.  Like previous programmes, WellSouth has allocated these spaces to practices based on the individual practice population demographics i.e. the percentage of enrolled patients who will meet the criteria for Toitū Takata. We have also considered how the programme addresses the inequity of health outcomes that exist for many New Zealanders.

There has been a recent increase in the total number of spaces and increased available on Toitū Takata. This means that more than 10,000 patients can access either Toitū Takata or Hāpai Atu in a 12-month period. To put that in context, in the biggest year of CLIC there was 8481 CLIC and Quick CLIC claims in total, so this is nearly a 20% increase in access overall. Next year we will be introducing a separate funding stream for advance care planning as well. So, we are increasing the funding available for long-term conditions care in the region, meaning more people can access the care they need.

 

Why is equity important?

Equality (treating everyone the same) is often considered to be the ‘fair’ approach, but it fails to consider the different levels of advantages within New Zealand. By treating everyone the same, we perpetuate inequities.

Focusing delivery of services on equity acknowledges the different levels of advantage in New Zealand Aotearoa and treats everyone according to their need to ensure equitable outcomes for all.

 

Why is WellSouth committed to equity?

WellSouth’s commitment to equity is aligned with national, regional, and local aspirations to improve outcomes for those who have unfair and unjust differences in health. It is also a legislative requirement under the Pae Ora (Healthy Futures) Act 2022 for all primary health organisations to facilitate the provision of equitable services in primary care.

 

What does that have to do with my practice?

The position of the Royal New Zealand College of General Practitioners is that appropriate and accessible primary health care is a key aspect of reducing health inequities in New Zealand. General Practices are in a unique position to take a population health approach, focused on proactive and preventative care. The college also supports the concept of General Practices working alongside community health services to support whānau.

Click here for our equity resources. There’s a very good video you can watch here.

 

What support can you expect from WellSouth?

  • Support to provide best practice clinical care

  • Clinical Education & programme training

  • Equity and cultural safety training

  • Guidance on how to use funding

  • Best practice behavioural health approaches to LTC management through Tōku Oranga

  • Support to make connections with community providers

  • An LTC outcomes framework

  • Improved Thalamus Dashboards

  • Links to useful, local community services/programmes

 

How do patients benefit?

  • Patients should receive best-practice clinical care via some funded appointments

  • Appropriate care planning

  • Connections with Tōku Oranga and other WellSouth-funded services

  • For Māori or Pacific patients, connecting with and working alongside the Community Provider

 

How do we identify patients?

The thalamus dashboard will support you, along with your knowledge of your patients, to identify those who may benefit from being on the programme.
The dashboard is available here: Thalamus 
Recording of a webinar about the Toitū Takata dashboard is here:


What kind of support can I offer those who don’t meet the criteria?

Focused Care - Hāpai Atu is available for all patients with an LTC, regardless of demographic criteria. Patients, if eligible, can also avail of other funded programmes such as diabetes annual reviews, women’s health, and sexual health.

 

Who designed this programme, and how?

WellSouth has designed this with input from patients and whānau, general practice, and community providers. A working group was established in November 2022 to support the re-design, and is made up on primary care clinicians, secondary clinicians, and non-clinicians. The programme has been reviewed by WellSouth’s Clinical governance Group, Clinical quality Committee, and the WellSouth Board.

 

Where can I find out about training and education?

Recordings of the Toitū Takata webinars are available here. 

 

What are the expectations of the level of care provided on Toitū Takata for the funding?

Patients enrolled on Toitū Takata should receive additional support to help them improve their health outcomes and allow them to live well, for example, working to improve health literacy and self-management of their long-term condition. Patients should also engage in patient-led care planning.

WellSouth’s minimum expectation for patients who are enrolled on Toitū Takata is that they receive two Practice Nurse visits, one GP or Nurse Practitioner visit and one care plan throughout the year.

This care may be delivered in a variety of ways; traditional face-to-face consultations, telehealth, group appointments etc.

What about Care Planning?

Care planning should be patient centered and address the individual needs of your patient. Care Plans include:

·         Personalised Care Plans: Supports patients to identify and achieve their health and wellbeing related goals. A Personalised Care Plan can be saved on HealthOne

·         Action Plans: These are given to the patient and provide them with a plan for managing their condition including how to manage exacerbations, when to seek medical health etc

·         Acute Care Plans: An acute plan is saved on HealthOne and provides information about a patient’s health needs, it will facilitate rapid and safe management of high needs patients across health services.

·         Advance Care Plans: On HealthOne, this allows patients and family/whanau to discuss and document their wishes about the type of medical care they wish to receive in the future, in particular, when they are unable to make their own decisions.  See WellSouth Advance Care Plan programme sheet for more information about funding for advance care planning.  Advance-Care-Plan.pdf (wellsouth.nz)

 

How do I ensure that my patient has received the minimum expected funded visits?

We have created ‘Zero Funding’ Service Codes for Toitū Takata funded visits. These will allow you to keep track of the number, and type, of Toitū Takata funded visits that your patient has attended. You will be able to report on these using the Enrolled Patient report in the Thalamus Dashboard.

The Toitū Takata Service Codes are available here: Toitu-Takata.pdf (wellsouth.nz)

 

Why does the Toitū Takata form duplicate some information?

Why does the Toitū Takata form duplicate some information, for example asking for the dates of the diabetes annual review, retinal screening and foot checks when this has already been asked on the Diabetes Annual Review form?

This is included to highlight any overdue screening and maximise the opportunities for diabetics to receive all their screening checks. Current data shows:

  • 61% of diabetes across the region have a current Diabetes Annual Review.

  • 40% of patients do not have a current annual foot check

  • 46% of patients who have up to date retinal screen have no record of either a DAR or a foot check.

 

My patient has a severe and enduring mental illness & would benefit from Toitū Takata but she is too young for a funded CVDRA. The enrolment form is asking for a CVDRA, how do I complete the form to get her enrolled on Toitū Takata?

  • Those with severe mental illness have an increased risk of developing cardio vascular disease and require ongoing monitor of this.

  • A CVDRA is recommended for patients with a diagnosis of severe mental illness from age 25yrs. Cardiovascular Disease Risk Assessment and Management for Primary Care – Health New Zealand | Te Whatu Ora

  • WellSouth will fund CVDRA for these patients from age 25yrs. To claim this the assessment must be commenced as a New Non-Funded Assessment, once Severe Mental Illness is ticked, the claim will update to a New Funded Risk Assessment. See the WellSouth Service Sheet here :  CVD-Risk-Assessment-.pdf (wellsouth.nz)

  • For patients with severe mental illness who are under 25yrs of age the Toitū Takata form can be submitted without the CVDRA being completed.