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About us

The Integrated Care Collaborative Alliance Leadership Team provides strategic oversight and governance of initiatives that aim to make hospital and community health services more joined up and better for patients. The Alliance Leadership Team’s objective is to provide integrated health services with a ‘best for patient, best for system’ approach.


Members of the Alliance Leadership Team have a wide range of skills and clinical expertise within the Capital & Coast District Health region. They represent hospital, primary and community health services and includes Māori and Pacific representatives. Members hold a wealth of health system knowledge and currently work in a variety of roles throughout the health system from GP practice to hospital services. The membership is expanding as more services become part an integrated health system.

Click here for the Alliance Leadership Team membership list


The Integrated Care Collaborative Alliance Leadership Team is an advisory and governance group that provides strategic oversight and clinical leadership. It decides and advises on what is recommended from the working groups. While the Alliance Leadership Team does not hold any direct funding accountability, it oversees programmes and projects of work.

Working groups are made up of Alliance Leadership Team members, consumers, clinical experts and Māori and Pacific representative’s. Their purpose is to understand the needs of the target population and to design health services around the needs of those that use them. This is often through technology improvements and community based health services. The working groups stay well connected with community groups, health providers and other agencies.

Examples of our work

Health Care Home

The health care homes model was rolled out in primary care practices in 2016. It is a joint initiative between Capital Coast District Health Board and Primary Care Organisations. Approximately 80% of the region have access to more services through their local GP practice. This means that people can receive the care they need in a primary care setting and in some cases save a trip to their GP altogether. Patients can expect:

  • Urgent ‘same day’ appointments
  • Extended practice hours
  • View test results online
  • Message their GP
  • Receive specialist advice and treatment through local practices.

Click here for more information about health care homes.

Diabetes Care

The Diabetes Clinical network was established in 2012 to change the way diabetes care was managed to reduce disparities and help prevent the onset of other related illnesses. More diabetes care has moved into primary care practices, closer to people’s homes. A diabetes nurse specialist team works closely with general practices to identify what support the patients need. Patients are receiving a more tailored approach to their diabetes case and people are empowered to better manage the condition.

Our goal is for people with diabetes to have most of their care managed through their Primary Care General Practice team, with input from the Specialist Service as required, through an integrated collaborative approach to service delivery. Over time the Specialist Service will develop into a high end consultation service that is able to deliver targeted care closer to people with diabetes. There is a focus on the delivery of services according to peoples’ needs, in particular for Māori and Pacific populations. Diabetes management and outcomes are not the same for Māori and Pacific people as the rest of the population.

Diabetes care presentation

The CCDHB diabetes model’s key components will include:

  • Collaborative case service in priority practices – The specialist team will visit the selected priority practices on a regular basis and work with the Primary Health Care team to participate in case discussions, combined clinics, practice education, collegial support and peer review. Priority practices will be selected based on those with the highest number of Māori and Pacific populations
  • Nurse practice partnership – A diabetes clinical nurse specialist has been partnered with each primary care practice to provide the first point of contact for specialist advice, upskill practitioners, support the development of practice diabetes plans, support insulin starts and reduce barriers to care
  • Practice population management – Each primary care practice receives diabetes population based funding to provide effective diabetes care tailored to their population. The funding is weighted further based on the practices number of Maori and Pacific populations.
  • Specialist service focused on complex, Type 1, paediatric, gestational and renal diabetes – The Specialist Service will deliver a high quality specialist service and consultation service that is able to deliver targeted care closer to people with diabetes. The service will provide expert consultation service that actively returns peoples care back to primary care.
  • Self-Management Groups - Community based structured group self- management programmes, based on the CCDHB model “Your life, Your Journey” is being delivered across geographical locations.
  • Workforce development – Each primary health care team has team members identified as Diabetes Champions in their practices and completed the education programme aligned with the National Diabetes Knowledge & Skills
  • Combined Primary and Secondary Diabetes Clinical Network – Includes clinical leads from across the sector across a range of disciplines. As part of the ICC, they lead the ongoing support for the collaborative and integrated approach to effective diabetes care across the primary and secondary sectors of CCDHB

Health Pathways

Health Pathways make it easier for GPs to assess, manage and refer patients to hospital or specialist services. There are now more than 420 localised health pathways available. The pathways are developed by consensus and collaboration between hospital clinicians and general practice teams from the Wairarapa, Hutt Valley and Capital & Coast DHB areas. It is a well used resource with around 2,200 page views on average a day.

Patient Portal

Patients can log on and access their health information and interact with their general practice through patient portal. This makes life easier for those who have ongoing health needs and support those with long term conditions. People are able to use the patient portal from their phone or computer to have electronic consultations, book appointments, order prescriptions and check on test results. Tens of thousands of people across the CCDHB region have access to it.

Last updated 29 May 2019.