Canterbury's plan defines several key areas of required activity under the heading of Long Term Condition Management.

The goal is to reduce the growth in the number of people with, and improve the outcomes of those who have, long term conditions including diabetes, cardiovascular disease and respiratory disease, contributing to the targets of:

• Avoided and deferred rest home admissions (under the Aged Care Workstream)
• Reduced growth in ED and acute hospital admissions (under the Urgent Care Workstream)
• Achievement of DHB primary health care targets for long term conditions.

 Key initiatives to achieve the goal:

• Apply the model of care population analysis to each integrated health and social service cluster to determine the correct mix and levels of service for each population segment in the cluster’s community.
• Assist each cluster to configure its services to the mix and levels appropriate to their population needs.
• Continue development of the Canterbury-wide integrated respiratory service model. As at 1 July 2010, this will feature the following services previously only available as specialist hospital services:
  • 20+ approved community sleep assessment/oximetry providers
  • 6+ approved community spirometry providers, plus mobile rural and urban services
  • 8+ community pulmonary rehabilitation programmes
  • Community based specialist respiratory physician providing services as an extension of general practice and alongside community providers (patient assessments and practice education)
  • Clinical pathways for COPD, chronic cough, dyspnoea, haemoptysis, sleep disorders, spirometry (web-based on HealthPathways)
  • Dedicated Respiratory GP Liaison, linking primary and secondary care.
• Throughout 2010-13 ‘bed-in’ the integrated respiratory service:
  • Embed quality frameworks to ensure GP teams and community providers can maintain the increased capacity and capability to sustain the changes to meet projected demographic changes
  • Encourage communities to play a greater role in rehabilitation programmes
  • Align community respiratory services with the integrated health and social service clusters and the cluster methods of integrating teams.
  • See 'Respiratory' for more information.
• In 2010, apply the methods and lessons from the establishment of the integrated respiratory service to commence similar developments in diabetes and cardiovascular disease management. Additionally, implement the following:
  • Centralise the retinal screening database to include all private retinal screens to reduce the number of patients identified as not having had a retinal screen performed
  • A diabetes and cardiovascular screening programme with Maori community providers and general practice teams
  • Centrally coordinated and systematic management of diabetes and CVD.
  • A ‘report card’ for the Maori Health Advisory Group and Pacific Reference Group that summarises the current state of these populations in key areas such as: diabetes, attendances at general practice; Care Plus, Sexual Health and other funding utilisation; B4 School Check and immunisation data
  • Support for the respective action plans for Maori and Pacific health.
•  Encourage patient participation in self-management and developing their health plans:
  • Align with programmes such as, Stay On Your Feet, Smoking Cessation, Appetite For Life, One Heart Many Lives, etc.
  • Align health promotion and wellness activities and spend across Canterbury to meet the needs of all population groups, but especially for Maori, Pacific, and Asian communities.

 A new model of care for long term conditions management is the Shared Care philosophy, where a multi-disciplinary team develops a cohesive plan for patients particularly with high or complex health needs.