From a GP

“ I had an elderly gentleman patient who was naturally quite shy and reserved. He had filled in a Care Plan and in the “About Me” section had written that he was a keen rock fisherman. One evening he ended up in ED and the doctor had looked at his Summary Shared Record in Concerto and they got into a conversation about fishing, which they both enjoyed. This made him feel much more relaxed and confident about the doctor. Whakawhānaungatanga in action.”

“I have a patient who’s always been a bit flat and anxious. He has diabetes, so I’d given him a Whānau Tahi Care Plan to fill in for me. He told me that what matters to him was helping out his children financially and so his goal was to sort out his gambling addiction. Despite having known him for 20 years I never knew he had a gambling problem and it explained a lot about his mood problems. I referred him to Gambling Anonymous and a counsellor, and next time I saw him he said things were going much better from the gambling point of view and then said “what was it you wanted me to do about my diabetes?”

From a Consumer: https://www.northlanddhb.org.nz/your-health/health-resources/shared-care-whanau-tahi/

From Health of Older People

“We receive referrals for the more complex frail Health of Older People patients to be followed up post-discharge, to ensure their transition back home is successful. We have to triage patients based on the info we receive from the referrer and the discharge summaries. We had a patient that we were reviewing re follow-up. We discovered in their shared care record that they had a shared care plan initiated by the practice nurse. We were able to see that the patient actually attended the gym three times a week and was very motivated to be active. Looking at the info we received in the initial referral and the discharge summary this was a pleasant surprise. We would never have picked that the patient was well enough to do this type of activity; and we were able to triage the patient a lot more accurately with this additional information from primary care.”

From Falls Prevention

“Our NDHB falls prevention team has been working closely with one of the GP practices who are providing the physio for an In-Home Exercise Programme. The GP Practice is now loading physio assessments into Whānau Tahi documents, which previously would not have been made available to the NDHB team; they would have only stayed in the patient’s general practice records. The NDHB team can now view this information on the patient and see how their exercise programme is going. This has been very helpful to NDHB team members who are currently also involved in the patient care (Occupational therapists, specialist nurses). We have not needed to phone up to get an update from the practice which can lead to phone tag and inefficient use of time.”

From a Health Navigator

“My patient formalised her Whānau Tahi, which has her standardised treatment plan embedded in it. This means that when she presents at any one of her health providers, she receives the same treatment. She now has weekly appointments with her GP, and has a marked reduction of presentations to ED since her Whānau Tahi has been in place.”