Persistence + teamwork + continuous improvement = impressive cervical screening & childhood immunisations results

With more than 17,000 enrolled patients, Bakerfield Medical and Urgent Care serves a diverse South Auckland community. Many of their patients face barriers to access care including cost, work and family commitments, recently moving to Aotearoa, and low health literacy.

For the Bakerfield team, these realities reinforced a simple principle: make every visit count. That philosophy has helped drive strong population health results, particularly in cervical screening and childhood immunisations.

Making every visit count!

The key to Bakerfield's success has been making opportunistic screening part of everyday care.

Whenever an enrolled patient attends a GP or urgent care appointment, staff check the Medtech Evolution dashboard and look for overdue health needs that can be addressed while the patient is already in the clinic. This may include cardiovascular risk assessment blood tests, immunisations, smoking and vaping status updates, alcohol screening, cervical screening, breast and bowel screening reminders, diabetic foot checks, and other preventative care measures.

Ally Voschezang, Lead Nurse at Bakerfield shares how taking the new, opportunistic approach has proven more effective than relying solely on recalls.

"We have a very low response rate to recalls, so opportunistic care achieves the fastest health outcomes with the least amount of staff time. We still do recalls, but the lists are shorter and much more manageable."

Improving cervical screening

One of the practice's biggest successes has been the increase of cervical screening. The introduction of HPV self-testing, combined with opportunistic screening, has made a significant difference. The practice has a dedicated bathroom set up with posters and everything needed for patients to complete the test privately.

Urgent care nurses check every overdue enrolled patient while they are waiting to see a doctor, while another nurse reviews the next day's appointments and highlights women who are due for screening.

These simple processes have helped make screening more accessible and easier to complete.

Consistency is key

The journey wasn't easy and the team say: "The biggest challenge was getting everyone on board while managing staffing shortages and the many demands of primary care."

In the early stages, almost every patient had overdue health needs, creating a significant extra workload for the nursing team.

Nurse Ally says, "We won’t sugar-coat it. It was discouraging and frustrating for our staff, and it has taken almost three years to get to where we are now."

Over time, regular reminders, audits, and sharing graphs helped make dashboard checks part of normal workflow. Management encouraged staff to aim for a 100% success rate, helping build consistency across the practice.

The effort extended beyond the nursing team. Health Coaches, Health Improvement Practitioners, and reception staff helped update smoking status information, while weekly immunisation reviews and targeted cervical screening follow-up became routine.

New patients were also offered a nurse appointment to ensure their health information was up to date from the start.

The impact

More patients are now receiving important screening and preventative healthcare without needing another appointment or clinic visit.

The team says it's been rewarding to see both patient outcomes and practice performance improve.

"It’s been great to see the graphs turn green! We love using the [ProCare] reports to track our progress and they're a great visual. It is now much easier to maintain the results and they’re motivating for our staff to see our clinic doing well and to have recognition for it.”

Bakerfield is particularly proud of the role opportunistic screening has played in reducing inequities for Māori and Pacific patients by making preventative care easier to access.

The practice has also achieved a 100% childhood immunisation rate among whānau who are not documented ‘immunisation decliners’, something the team says would not have been possible without the support of ProCare’s Ara Hauora service in following up non-responders.

Looking ahead

While proud of what they have achieved, the team is already focused on the next challenge: diabetes management.

"It's a tough one as it requires our precious doctor time and there are a lot of long-term challenges and barriers for this health goal."

Bakerfield is exploring how its pharmacist, Health Coach, nursing team, and GPs can work together to better support patients living with diabetes.

Their success shows that improving health outcomes doesn't always require a major new initiative. Sometimes, it comes from consistently making the most of every opportunity to support patients when they're already in front of you.