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Integration Community Nursing Project

Simplifying and developing community nursing care: a future-focussed approach


Whilst the community nursing care system supporting our region has provided excellent service over many years, the needs of those we care for are both growing and changing. It has become clear that we need to prepare our community services for the size and complexity of these future demands. This will include evolving and adapting to best serve our patients and their family/whānau.

Beginning in November 2014, a comprehensive review of the community nursing system (involving those that deliver the service) identified a number of areas for improvement. Though large and far-reaching, the review has been guided by a simple question:

'Will this improve a person's wellbeing?'


The essence of the new approach is to provide a patient and family/whānau-centred service which is well-coordinated and simple to navigate. Its goal is that - working collaboratively as a health system - we will create healthy, thriving communities by addressing our patient and family/whānau's needs with services delivered as close to home as possible.

So what are some of the changes proposed?  

  • Simplify the system by providing a single place for accessing community nursing care, information and support.
  • Holistic approach - caring for the person and not just the disease. A person's wellbeing is about more than a health condition and all the determinants of health should be considered in decision-making.
  • Patient and their family/whānau to have a greater say in directing care and support.
  • Sharing of information with all those who are involved in a patient's care, including the patient and their family/whānau.
  • Flexible care. People's needs change and the new service should have the ability to change with them, increasing or decreasing care as appropriate. The old system was rigid and fixed for longer periods of time.
  • A focus on coordinating services for those with complex care needs.
  • A focus on responsiveness to acute nursing needs and supporting people to return or remain at home.
  • Increased care and targeted support for people experiencing the greatest health disparities.

The Model of Care which has been created as a result of the work to date can be accessed here.

Further information click here for a detailed service description.

Initial implementation areas

Three initial priority implementation areas have been agreed:

  1. Establish a single place for referral and prioritisation of community nursing care - Community Care Coordination
  2. Introduce a common patient and family/whānau community nursing assessment across service providers.
  3. Reconfigure community nursing Routine Care with a twofold approach.

Implementation work will begin in May 2017.

Why were these three areas prioritised?

Community Care Coordination - establishing a single place for referral and prioritisation is the first step towards integrating community nursing across the Bay. It provides a place for referrers and patients alike to access care information and a platform for wider community care coordination.

Common patient and family/whānau community nursing assessment - establishing a patient's needs, preferences and goals are essential to delivering coordinated care. With this information specific types of nursing care can be identified to best support those needs. Common assessment will enable service providers to commence the integrated community nursing model of care.

Reconfiguring community nursing Routine Care has two purposes. The first is to empower people to manage their own health and wellbeing through support, education and sharing of knowledge. The second is to support GP nurses to perform more routine nursing care, thereby freeing up community nurses to undertake acute and complex nursing care in the community.


The integration of community nursing care across the Bay of Plenty is an evolutionary, ambitious and collaborative process and will continue to be guided by the input of all concerned.

It will involve three major implementation phases, the timing of which will be released as the project progresses. The long-term aim however is that by the end of 2018, we will be well on our way to implementing an integrated, coordinated and timely community nursing service. This cohesive primary and community workforce will support family/whānau to live well, stay well and get well.

Click here for more about the Routine Wound Care 'test of change'


If you have any questions relating to this project please email Integrated Community Nursing Project Coordinator Sarah Nash on

Last updated: June 10, 2019