Introducing the At Risk Individuals Programme

Readers of this blog will remember George, a patient whose story was captured through our 20,000 Days Campaign. Sadly George ended up in hospital 28 times in the course of a year. That’s more than once a fortnight. This is indeed scary to contemplate when you consider that approximately 60,000 people in Counties Manukau live with long-term conditions. Clearly we cannot accommodate them all ending up in hospital as frequently as George has done in the past.

We’ve made huge improvements with patients like George through the work of our Very High Intensive Users (VHIU) programme over the last few years, helping to keep them well and out of hospital as much as possible. But now it’s time to extend this approach to a wider cohort of primary care patients.

Up to 30,000 people are what we term ‘At Risk Individuals’ – those with one or more long-term conditions and other risk factors, such as inadequate housing or low health literacy. People in this group are at a greater risk of poor health outcomes, including unplanned hospitalization, and they use a disproportionate amount of healthcare services. Through our 20,000 Days Campaign, we know that care for these individuals is not always proactive or well coordinated, and that this leads to poor health outcomes for the individual and higher hospital costs.

Today marks the introduction of our At Risk Individuals (ARI) programme – the next big step in our whole of system transformation. The ARI programme is designed to provide earlier intervention and planned, proactive, patient-centred care by helping primary care identify our ‘at risk’ patients and better co-ordinate their services.

One of the biggest benefits of the ARI programme is that rather than waiting for ‘at risk’ people to come to us, we will be identifying them and proactively providing the support they need to manage their condition better. But perhaps the best way to convey the benefits is actually to think about the impact the programme will have on a typical ‘at risk’ patient. Let’s call him Saepele – a 52-year-old Samoan man living in Mangere. This short video explains the fragmented care that people like Saepele have been receiving and the more co-ordinated care we are moving towards.

To do this we are making a number of improvements, all of which will be based around the patient’s healthcare home. General practice teams will be identifying ‘at risk’ patients and supporting them through a care co-ordinator (who acts as a key point of contact for care) and the co-development of a care plan (based on the patient’s goals). The care plan will be developed with input from care team members such as SMOs, community nurses, and allied health, all of whom can secure message each other and the patient through the e-shared care record. We’re also introducing an e-Summary Health record, which will be visible to healthcare teams through Concerto. This ensures that key information relating to the patient is visible to the providers involved in their care.


The ARI programme represents a change in how the health system currently delivers health services, which will be further supported by multi-disciplinary team meetings and flexible funding for primary care. It will roll out to all Counties Manukau general practices by the end of June next year and we hope to have 30,000 patients engaged with the programme through a care plan by the end of next year. This will make it one of the largest integrated care programmes anywhere in the world.

As well as improving outcomes for ‘at risk’ patients, ARI will also help us reduce acute hospital demand. I’d like to acknowledge some of the key architects of the programme, specifically Benedict Hefford, our Director of Primary Health and Community Services, Dr Campbell Brebner, our Chief Medical Advisor – Primary Care, and Dr Tim Hou, general practitioner and clinical lead for the programme – all of whom have helped drive this crucial service redesign. I’m also excited to let you know that having targeted 3000 people through our VHIU programme and now rolling out ARI to the next 30,000 people, we will shortly be going further to provide better care to everybody with a long-term condition. Watch this space – I’ll be sharing an announcement on that exciting initiative with you via this blog in the next few weeks.



Author: Geraint Martin

Geraint Martin was appointed Chief Executive Officer of Counties Manukau DHB in December 2006. It is one of the largest District Health Boards in New Zealand and services a population of half a million. He has significant experience over 30 years in national policy & in managing both primary and secondary care . Previously, he was Director of Health and Social Care Strategy at the Welsh Government .He authored a radical 10 year strategy of reform, including the successful “Saving 1000 lives” Campaign.Until 2004, he was CEO at Kettering General Hospital & had held senior positions in London & Birmingham.He has worked closely with clinicians in improving clinical standards,patient safety,chronic disease management & managing acute care to reduce hospital demand.In NZ, He has promoted clinical quality and leadership as central to improving patientcare. This has led to a significant increases in productivity and access, whilst maintaining financial balance. CMH has completed in 2014 a $500 m capital redevelopment programme, the largest in New Zealand. A central part of this is the establishment of Ko Awatea,the Centre for Innovation and Research which will underpin CMH as one of the the leading health systems in Australasia.In 2008, he chaired the Ministerial Review of Emergency Care in New Zealand, and in 2013 was an member of the Expert Advisory Panel on Health Sector Performance. Geraint has an MSc in Health Policy from Birmingham University .His post-graduate work has focused on health economics and Corporate Strategy . He is adjunct Professor of Healthcare Management at AUT and Victoria University, Wellington Elected in 2006 as a Companion of the Institute of Healthcare Management, previously he was an Associate Fellow at Birmingham University.He is is Chair of the Auckland Philharmonia Orchestra, a member of the Institute of Directors, on the Board of the NZ Institute of Health Management & previously the Board of The NZ Health Quality and Safety Commission.

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