The Community Mental Health team in Buller, the West Coast primary health organisation (PHO) and the Buller Medical Centre have partnered together to increase physical health and wellbeing for people living in the West Coast. The focus is to support people who experience mental health or alcohol or other drug (AOD) issues. 

The new initiative uses the Long-Term Conditions (LTC) funding, introducing mental health as a new ‘condition’. For LTC Level 2 funding, individuals may receive four free GP visits a year and are placed on a recall system.

The initiative came about from a growing realisation that the physical needs of the population with mental health needs were not always being met. Barriers to good medical care included not just the social determinants of health, but the setup of the health system itself, as well as individual factors. 

Sue Wells, a mental health nurse at Buller Medical Centre, employed by West Coast DHB, is responsible for co-ordinating the Mental Health Long-Term Conditions programme. People who qualify for the programme initially meet with Sue, a practice nurse and their GP to discuss how they can work together to increase their physical health and wellbeing.

“Individuals often did not have regular access to a nurse or GP and were unwilling to come into the practice. When they did, there was no consistent follow-up, they experienced fears and had financial issues that prevented them from attending. As in the implementation of any new initiative, the support of the leaders and managers is essential,” says Sue. 

Sue works alongside practice nurses to bring in all the current and discharged service users of the Buller Community Mental Health team to see the doctor or nurse for an initial review. For the current service users, the case manager is invited to attend, discuss the programme and work together for an ongoing care plan. For the discharged service users, people new to the practice or people with significant mental health issues, Sue rings the service user to explain the purpose of the programme and ask them to attend. 

“The medical staff attend to the physical health issues in the same way, while I offer them mental health follow-up and advise that it is free for them to come and see me anytime. The recalls for future visits are automatic on the practice electronic patient information system. Support workers are involved if the patient wishes, as are cultural support workers and the Whanau Ora nurse,” says Sue.

“Thankfully the clinical manager is a strong advocate, having worked alongside the manager of Buller Community Mental Health and both primary and secondary teams to help create this initiative. The programme provides a structured care management plan that is shared with the patient, systematic follow-up and provides education to patients about their risk factors. The potential for this to be extended to such things as diverse as standardising monitoring recommendations for antipsychotic medications with metabolic screening through to mind-body practice is exciting.” 

The programme has been going for eight months and the feedback has been positive. 

“This is very much a ‘learn as we go’ process. There are issues that have come up, but we are confident that through working together we can improve the physical wellbeing of our people.”