Improving the health of older adults.
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Our current health system is not always well adapted to patients with complexity and frailty. In particular, current care may be reactive and episodic rather than proactive and planned. The health and wellbeing needs of older patients often require a more intensive approach than is possible within a series of traditional 15 minute consultations with their GP.
The Kare Project addresses this need by delivering a highly supporting and proactive model of care to those in the community who need it the most.
The initiative was made possible by Well Foundation through the generous support of the Blockhouse Bay Senior Citizens and District Association. This support was then amplified by Te Whatu Ora Health New Zealand committing the additional funds required to benefit at least 200 patients throughout West Auckland over a three-year period.
The Kare Project is currently being rolled out across a selection of primary care organisations, including Health New Lynn (100 patients) and Green Bay (80 patients). All of the practices have identified a GP clinical lead, employed Kare nurse(s), and have started to assess and develop plans for Kare patients. The Kare project delivers workshops to nurses and GPs to help the practices deliver the programme. These workshops include an orientation of the Kare project, how to implement it, and presentations from a range of services on what they offer and how to refer. A clinical pharmacist provides training on how to optimise prescribing of medicines in older adults.
The Kare project has enabled Health New Lynn to holistically assess older adults and ensure that both their social and medical concerns are assessed, as lack of time is commonly a barrier to assessment.
The feedback received from patients has been extremely positive. They have found that these programmes have given them more confidence and improved health outcomes. The integration with social groups has helped their social interactions as they have previously commented they often have felt isolated. Through these activities, patients have felt they have become more connected to the community, family and friends.
“Mrs X came in for her first consultation with the nurses after being referred by the doctor. She told the nurse that she had had a few near misses with falls and had stopped doing a lot of activities especially her weekly walks with friends. These reduced social activities had left Mrs X feeling socially isolated. She was referred to the HIP and Health coach, Stronger for Longer classes, and social groups that she could join, such as the Health New Lynn walking group. At the 6 month follow up, Mrs X stated that she had not had any falls since her initial appointment and felt the Stronger for Longer classes had been extremely helpful. She is also seeing the Physiotherapist and doing exercises at home. After joining the walking group, she has now been able to walk around the retirement village”
“A Kare assessment identified a rapidly declining cognitive impairment leading to an atypical dementia diagnosis in a patient which then helped the GP open up conversations with her family. This has meant that she now has input from a specialist. EPOAs were organised and extra home care support has been put in place to keep her safe until such time as she will have to move into residential care”
