Working smarter: the rise of Extended Care Teams

From Tairāwhiti to Taupō and across to Taranaki, Pinnacle Extended Care Teams (ExCTs) in the Midlands Health Network are experiencing increased referral demand and growing support from general practices.

The multi-disciplinary approach to community healthcare is also being championed by health practitioners as a model that allows them to work at the top of their scope, and extend their practice by learning from other areas.  

ExCTs are made up of healthcare professionals from different disciplines. Depending on location, an ExCT might include dietitians, clinical nurse specialists, social workers, clinical pharmacists, exercise consultants and hauora kaimahi, as well as others. 

These teams work in the local community alongside general practice, taking a patient-centred approach to meet the needs of people with complex, long-term health conditions.

Collective knowledge benefits patients and staff

Taranaki’s current ExCT includes dietitians, clinical pharmacists, social workers and diabetes community coordinators/hauora kaimahi (a joint initiative with Diabetes NZ). In the five years the team has been operating, it has also previously had a podiatrist to provide foot care for people with diabetes, and a falls prevention team funded through ACC. 

Pinnacle regional services co-ordinator - Taranaki, Sarah Wood, says the knowledge and expertise shared between the different disciplines ensures a holistic approach to patient care from the outset. 

“We work together to assess what a patient might need and pull in other team members to provide that support,” says Sarah. “For patients, we are one service – one team that they can engage with to get the care they need. It breaks down that time and cost barrier for people, which has a big impact on equity. 

“The beauty of practitioners working alongside multiple disciplines in the same physical location means there’s a lot of care co-ordination that happens, and we’re all learning from each other all the time.” 

Tracy Fergus, ExCT clinical manager in Tairāwhiti, agrees. The more recently formed Tairāwhiti team currently includes a social worker, clinical nurse specialist (diabetes), clinical pharmacist, child health nurse, smoking cessation co-ordinator, cardiac pulmonary rehab nurse and kaiawhina, all providing different viewpoints and expertise. Internal referrals are also made to their primary mental health team for brief intervention counselling. 

“Team discussions and informal conversations create a more diverse knowledge base for everyone,” says Tracy. “That, along with the ability to easily access other disciplines to fully support a patient, allows ExCT practitioners to focus on their area of expertise.

“We are able to consistently work to the top of our scope, alongside others who are doing the same.”

Relationships and referrals

Relationships with general practices and GPs are at the heart of the ExCT service. Sarah says when GPs see the value of what the ExCT offers, referrals flow and local community initiatives for patients start to happen. 

“One of our Taranaki practices saw the need for people with pre-diabetes and early stage diabetes to do group work with their GP and our dietitian.

“We did a shared medical appointment group with young women over several weeks, with great success. We’d love to support more practices and patients in this way.” 

The Taranaki ExCT works with more than 30 general practices across a large geographic area. So, building those relationships requires an intentional focus. COVID-19 restrictions over the past two years have added to the challenge, at times curtailing face to face GP visits and trainings with some care moving on line.  

The Tairāwhiti ExCT has had similar success stories and challenges. “We’re always working on building relationships with our GPs,” says Tracy. 

For the Tairāwhiti team, COVID-19 restrictions have generated more referrals. “Since lockdown, GPs have begun to realise what we can offer, especially with a social worker on our team who can help with connecting to other services.” 

“Some practices see the benefit of referring patients to our service because we visit people at home in the community, and can often see things they don’t get to. One practice has a long-term conditions nurse and our ExCT clinicians will often work in collaboration with them to provide specialist assessment and joint planning of care.” 

“We’re also planning to do more development and education with practice nurses, as soon as we are able to get into practices again.” 

Huge opportunity

One thing both the Taranaki and Tairāwhiti ExCTs have in common is the belief that there is so much more they could do. There is huge opportunity out there to do even more to support their communities through ExCTs. 

So, building the team is something the Tairāwhiti ExCT service is also focused on, particularly in the diabetes space. 

“We often look at other ExCTs in the Midlands region to see what they’re doing, and what would be great for our team and we are exploring some new roles at present,” says Tracy.

Cross-locality partnerships between all Pinnacle ExCT services as the network grows is something both areas would like to see more of. “Collegial relationships with others doing similar jobs across the network is really valuable,” says Sarah. 

“Being able to do things like shadowing others in the same discipline when new roles are added to a team could work well.” 

Across the board, there is an overarching feeling of pride in the ExCT model, and anticipation of how the services will continue to evolve. “I’m so proud of what these guys do,” says Tracy. “We gather more strength and momentum the longer we operate.” 

“The ExCT is an amazing group of innovative people who have the patient always at the centre,” says Sarah. “Their real strength is that they truly do care.”

In December 2021 an outcomes framework was developed to try and better understand the impact of the extended care teams on supporting and improving health and wellbeing for patients and whānau.

As noted by Bevan Bayne, Pinnacle regional services lead, "Early data from our Patient Voice survey tells us that 79 per cent of people we support have whānau, or others, involved in their care – an important indicator in patient recovery and implementing change. Patients overall rated their interaction with the extended care teams as 8 out of 10 for both helpfulness during their visit, and having the confidence to progress their wellbeing plan.

Read ExCT patient stories in the recently released Pinnacle Annual Performance Report linked below.