Outreach Service Mid North

Objectives
Moerewa Medical Services provides an outreach nursing service targeting under serviced high risk patients in addition to routine  general practice services

Project
Between 450 and 500 patients are seen each quarter through this initiative.  The patients are predominantly Māori living in areas of high deprivation

The outreach Nurse provides support to patients for the following

• Post Hospital Discharge Care
• Hospital Out-Patient Appointments
• Patients not self-managing their agreed care particularly with chronic care conditions
• Maintaining patient attendance and providing home support for the Respiratory and Podiatry clinics held at the practice
• Care Plus patients – rare but relate to crises that occasionally occur – these all relate to care outside the three monthly checks
• Target families in need --  with regular supervision – can range from young families to elderly couples (over 80) living in isolated areas
• Mental Health – many social problems have mental health aspects but often do not fit into this area per se
• Immunization Outreach
• Networking specifically to improve outcomes both ongoing and as individual cases demand wider community participation
• Next day follow up of serious cases seen at the medical practice

Significant outcomes achieved
Outreach support has resulted in improved post hospital discharge management.  There has been improved attendance at various Hospital outpatients, Kiwi Weight Watchers, Green Prescription and MMS Respiratory and Podiatric Clinics.
Progress continues on developing a Community Wide Family Support Service, and there is increasing and more effective networking over an ever widening group of many different community workers especially in the health and social area.