What we did and what we learned
Over the past year, St Martins Medical Practice has been reviewing and strengthening how we support patients who may benefit from more proactive, coordinated care.
This work focused on improving practice systems, so that people are less likely to miss important physical health checks and are better supported to access care in ways that work for them.
What we changed
As part of this work, we made several practical changes across the practice, including:
- introducing more planned, team-based discussions to support proactive care
- strengthening continuity of care, supporting patients to see the same GP and nurse wherever possible
- improving how we identify when routine health checks or screening are due
- strengthening follow-up and recall systems so opportunities for preventative care are less likely to be missed
- increasing flexibility in how care is offered, including longer or differently structured appointments when helpful
- improving coordination between GPs, nurses, pharmacists, health coaches, and other members of the care team
- improving collaboration with patients’ support networks, including whānau, community services, and secondary care teams
These changes help us plan ahead, rather than responding only when problems arise.
What we learned
Through this work, we learned that proactive planning makes it easier to keep physical health care on track. Longer or more flexible appointments can make a real difference for people who find standard appointments challenging.
Strong relationships, continuity, and trust support better engagement with care, and working as a team helps provide safer, more consistent, and more coordinated care.
We saw that strengthening our systems reduced missed opportunities for routine checks and screening, and supported earlier identification of physical health concerns.
We also learned that closer collaboration across care teams — within the practice and with whānau, community services, and secondary care — improves communication, coordination, and follow-up, helping reduce gaps in care and support earlier identification of physical health concerns.
What this means for patients
You may notice that we are more proactive with recalls or reminders, that different members of the team are involved in your care, or that we suggest longer or follow-up appointments at times. We may also check in more regularly about physical health and preventative care.
These changes are part of our commitment to equitable, whole-person care. Any care decisions are always discussed with you and tailored to your needs and preferences.
If you ever have questions about why something has been recommended, or would like to talk about your care, our team is always happy to discuss this with you.
You can read more about our Equally Well approach, our team, and how we work alongside patients and whānau on our Equally Well page.