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Note: Northland has low or no data since April 2025. Tairāwhiti have lower inpatient volumes from March 2025. West Coast have lower inpatient volumes from July 2025.

Continuity of care dashboards

This indicator helps us see how well Te Whatu Ora district services and NGO mental health providers work together to support tāngata whai ora before, during, and after an acute inpatient stay.

This indicator was developed in response to feedback from tāngata whai ora, who said they often experience disconnected or inconsistent care. It is designed to support reflection, learning, and improvement across the mental health sector.

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The settings for this indicator are inpatient and community.

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Why continuity of care matters

When tāngata whai ora move between services, for example, from an NGO setting into an inpatient unit and back into the community, it’s important their care stays connected and consistent. Good continuity of care means people are supported by the right services at the right time, without gaps or confusion.

When district services and NGOs work well together, it can lead to fewer readmissions, shorter hospital stays, better recovery and wellbeing outcomes, stronger whānau and community support

This indicator helps identify where those connections are strong and where services can improve how they work together.

Other Indicators

Technical Details

Data source

The data in this dashboard is sourced from PRIMHD.

‘Continuity of care’ as indicated through NGO engagement before, during and after acute inpatient Health New Zealand | Te Whatu Ora division stays.

The indicator is a measure to support services understand continuity of care between Te Whatu Ora division and NGO mental health services so they can identify where improvement is required to contribute to better wellbeing outcomes for tāngata whai ora who access acute inpatient Te Whatu Ora division services.

The indicator includes data for tāngata whai ora with recorded NGO activity in the 28 days before an acute inpatient stay.

Indicator rationale

Tāngata whai ora report inconsistencies in the connectedness, or continuity of care they receive between Te Whatu Ora division and NGO mental health services.

Denominator

Open NGO referral at time of admission to inpatient unit.

Referral Start Date at least one day before, Referral End Date at least one day after an inpatient stay.

Activity pre inpatient – 1 to 28 days before inpatient admission.

Numerator

Activity within inpatient stay – inpatient admission to discharge date.

Activity post community care – 1 to 8 days after inpatient discharge.

Inpatient criteria

Meet the criteria for post discharge community care (7-day follow up).

‘Referral from’ is not psychiatric inpatient (PI).

Activity data selected for indicator inclusion

  1. ActivityTypeCode not in T08, T35, T32
  2. ActivitySettingCode not in WR, OM, SM
  3. ActivityUnitType=CONTACT
  4. TeamType=Community Team
  5. NGOs.

Current data exclusions / known limitations

  • Services focused on housing and employment currently excluded.
  • Phone based services currently excluded from the data.
  • Residential services currently excluded.
  • The current ‘within’ category includes the day of admission and discharge. Inclusion could infer that NGO engagement happens on the day of admission or discharge.
  • If there are more than two NGOs with a referral open at inpatient admission and with activity in the 28-days before admission, they can be counted more than once.

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