Bringing together the healthcare professionals to collectively care for patients in the community.

The more complex a person’s health is, the greater the number of health providers and agencies likely to be involved in their care. This project aims to improve and strengthen the links between healthcare providers so they can deliver a unified approach to patient care within the community.

The project will initially be trialed with existing Health Care Homes practices, using their co-ordinated health services. It will focus on patients with complex health needs and create wrap-around support services for them based on their individual needs. These teams, comprising of health professionals from across the sector, will work with patients to deliver their healthcare.

•  Enabling integrated healthcare and working across health disciplines results in improved outcomes for patients

•  Greater co-ordination between health professionals will increase responsiveness and enable proactive care

•  Involving families, carers and community health professionals in planning and delivering care helps people feel more in control of their health

•  Co-ordinated care and the creation of individual proactive care plans will reduce the likelihood of escalating health issues and admissions to the emergency department.

First stage:

1.  Nelson Marlborough Health will work with other healthcare organisations to develop a district-wide model for co-ordinated care.

2. The model will be trialed at existing Health Care Home practices linking with other community health and social organisations.


The project will initially be trialed in the following Health Care Home practices:

•  The Doctors Motueka
•  Greenwood Health/ Motueka Community
•  Stoke Medical Centre
•  Omaka Health
•  Civic Health/ Marlborough

This project aims to make a significant contribution to the following Models of Care programme principles:


SCC significant contribution TWO ROWS

 Read more information about the Models of Care principles

The results of the trials will inform future care co-ordination efforts as the model is introduced across the Nelson Marlborough region.

To find out more email [email protected]