Better Sooner More Convenient Primary Care - New Zealand Doctor
Better Sooner More Convenient Primary Care - New Zealand Doctor
Better Sooner More Convenient Primary Care - New Zealand Doctor
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Business Case<br />
<strong>Better</strong>, <strong>Sooner</strong>, <strong>More</strong> <strong>Convenient</strong> <strong>Primary</strong> <strong>Care</strong><br />
February 2010<br />
Business case EoI V38 AC 25Feb10 Page 1
Kua tawhiti ki te haereka,<br />
Kia Kore e haere tonu<br />
He tino nui rawa ou mahi<br />
Kia kore e mahi nui tonu.<br />
We have come too far, not to go further.<br />
We have done too much, not to do more.<br />
Business case EoI V38 AC 25Feb10 Page 2
1 Caveats/status<br />
This business case is a work-in-progress. Many clinicians and managers have contributed to its<br />
development, and to the thinking and analysis that lies behind it. That does not mean they all<br />
agree with everything in it.<br />
The business case has been endorsed by the respective boards of the DHB and the PHO, but<br />
not yet endorsed by the Ministry of Health.<br />
The business case presents a number of options for future delivery of health services. These<br />
are options for consideration and input, rather than proposals ready for formal consultation.<br />
If and when the business case gets to the point of being a proposal, the necessary formal public<br />
and employee consultation processes will be undertaken, prior to any decisions being made in<br />
regards to implementation.<br />
On Thursday 25th Feb 2010 the board of the DHB passed this resolution:<br />
"That the West Coast District Health Board endorses the direction of travel envisaged in the<br />
“<strong>Better</strong>, <strong>Sooner</strong>, <strong>More</strong> <strong>Convenient</strong> <strong>Primary</strong> <strong>Care</strong>” Business Case, subject to necessary further<br />
analyses, development, revision and consultation, and with particular focus on: budgets and<br />
financial sustainability; the West Coast Model of <strong>Care</strong> (Sustainability Project); and governance<br />
arrangement;<br />
and<br />
That the West Coast District Health Board authorises management to proceed with its continuing<br />
development and its submission to the Ministry of Health."<br />
On the same day the PHO board passed this resolution:<br />
"The board endorses the direction of travel envisaged in this business case, subject to necessary<br />
further analyses, development, revision and consultation, and authorises management to<br />
proceed with its continuing development and its submission to the Ministry of Health for their<br />
approval."<br />
Business case EoI V38 AC 25Feb10 Page 3
2 Executive summary<br />
The drivers for change are:<br />
<br />
<br />
<br />
Clinical sustainability: the current model of care in most health centres requires GP<br />
numbers we have not been able to achieve consistently on the West Coast for at least<br />
five years, and leads to long waiting times for appointments (often > three weeks) and<br />
lack of continuity and consistency of care.<br />
Limited integration of community services with primary care leading to lack of<br />
co-ordination and consistency of care and some duplication of services.<br />
Financial: primary care medical practices and community services owned by the DHB<br />
contribute significantly to the DHB overspend each financial year. Hospitals in Reefton<br />
and Buller together also contribute significantly to the DHB overspend each financial<br />
year.<br />
What will be different as a result of implementing this business case?<br />
<br />
<br />
<br />
<br />
<br />
<br />
Three Integrated Family Health Centres (IFHCs) will be established based in Westport,<br />
Greymouth and Hokitika with associated clinics in rural areas. Each of these will become<br />
a one-stop-shop in terms of accessing primary and community health services.<br />
We will bed in a team based partnership model for core general practice care so that<br />
the majority of first contact care and long term condition care is provided by<br />
appropriately skilled nurses supported closely by GPs and, in time, Nurse Practitioners<br />
(NPs). This is likely to mean resident (non locum) GP:patient ratios of 1:2000 and<br />
increased practice/rural nurse:patient ratios from 1:1180 to 1:900 (with additional GP<br />
and nurse time for more rural areas and to reflect teaching commitments).<br />
Development of a Māori team within each IFHC that will focus on improving access and<br />
health outcomes for Māori.<br />
Devolution of community nursing, allied health and mental health services into the<br />
IFHCs, or the IFH system, with integration of reception, appointments, electronic<br />
clinical records, care pathways and discharge planning, and consequent reduction of<br />
duplicate service provision.<br />
Full implementation of a best practice, proactive approach to the management of long<br />
term conditions (LTC), including mental health.<br />
Development of a strong primary care/community care organisation able to lead &<br />
manage the Integrated Family Health System (IFHS) within the available budget.<br />
We are committed to achieving important changes in health care, as reflected in the significant<br />
targets set out below.<br />
Business case EoI V38 AC 25Feb10 Page 4
Current situation By three years<br />
Waiting times for a routine appointment in Average of 10 days Maximum 3 days<br />
general practice<br />
Integrated Family Health Centres 0 3<br />
Fully integrated community nursing and<br />
Not present<br />
In place<br />
primary care nursing<br />
Introduce nurse practitioners to skill mix Many nurses with 3 nurse practitioners<br />
potential as nurse<br />
practitioners interns<br />
Patients supported in the long term<br />
1,419 2,500<br />
condition management<br />
Reduction in Ambulatory Sensitive<br />
Hospitalisations (ASH) & inappropriate ED<br />
attendances<br />
ASH rates at NZ average<br />
ED Triage 5 = 81<br />
patients/week<br />
5% reduction in ASH<br />
rates<br />
35% reduction in ED<br />
triage 5<br />
PHO Performance Programme clinical<br />
79% >90%<br />
indicators met<br />
Financial situation $5.4m deficit $1.4m deficit<br />
2.1 Assessment criteria summary<br />
1. The nature and expected magnitude of benefits that will flow from the proposed service<br />
improvement initiatives, including how the proposal expects to:<br />
Support the delivery of The key health targets are an integral part of this plan. Activities<br />
the Government‟s key to improve our performance and monitor changes have been<br />
health targets;<br />
incorporated in the planning documents as follows:<br />
shorter stays in emergency departments: See Appendix Three:<br />
Acute care<br />
improved access to elective surgery: See appendix Seven:<br />
Integration - HealthPathways<br />
increased immunisation: See Appendix Four: Keeping people<br />
healthy<br />
better help for smokers to quit See Appendix Four: Keeping<br />
people healthy<br />
better diabetes and cardiovascular services. See Appendix<br />
Five: Long term conditions<br />
Business case EoI V38 AC 25Feb10 Page 5
Contribute to health<br />
sector productivity and<br />
quality improvement;<br />
Lead to the rapid<br />
establishment of<br />
Integrated Family<br />
Health Centres in<br />
appropriate locations;<br />
Support the shift of<br />
services from<br />
secondary care to<br />
primary care;<br />
Reduce acute demand<br />
on publicly funded<br />
hospital services;<br />
Health sector productivity will be improved by the following<br />
initiatives:<br />
Change in model of primary care with greater role for nurses<br />
leading to better access to care, (see Appendix Two: Core<br />
general practice redesign).<br />
Closer integration of community based services and primary<br />
care, with a multidisciplinary approach and shared electronic<br />
clinical records will lead to decreased duplication and better<br />
targeting of services : (see Appendix Six: Integration – DHB<br />
community based services).<br />
Stratification and targeting of services for those with long<br />
term conditions so that those with the highest need receive<br />
the most support and those with lesser needs receive lesser<br />
support. (see Appendix Five: Long term conditions).<br />
Increased support for patient self care will lead to less<br />
demand for services. (see Appendix Five: Long term conditions<br />
and Appendix Four: Keeping people healthy).<br />
Use of HealthPathways will streamline referral processes: (see<br />
Appendix Seven: Integration – HealthPathways).<br />
Direct access to radiological investigations with less need for<br />
FSAs: (see Appendix Eight: Improved access to diagnostics)<br />
Development of patient pathways for the frail elderly and<br />
closer links between <strong>Care</strong> Link (West Coast's NASC) and<br />
IFHCs will lead to more focused care. Appendix Eleven: Frail<br />
older people<br />
The approach to quality improvement and safety across the system<br />
and within IFHCs is covered in Section 5.9.<br />
IFHCs will be established covering the whole region within three<br />
years: (see Section 6.2 and Appendix Thirteen: IFHCs – Facilities).<br />
A shift of Community based services to the Integrated Family<br />
Health System is proposed: (see Sections 5.1, 5.4 and Appendix Six:<br />
Integration – DHB community based services).<br />
The Acute <strong>Care</strong> plan will result in less use of the emergency<br />
department for triage 5 patients and more appropriate care in<br />
IFHCs. (see Appendix Three; Acute care).<br />
Currently, the primary care system on the Coast is not in a good<br />
position to take on clinical tasks currently performed in secondary<br />
care settings. Similarly, Greymouth hospital services are generally<br />
Business case EoI V38 AC 25Feb10 Page 6
staffed on a capacity model – in which staff costs do not vary with<br />
reductions in activity. However, in the medium term, with the<br />
strengthening of the primary care sector, and the development of<br />
more activity based staffing for some services, associated with a<br />
closer working relationship with Canterbury DHB, there may be an<br />
opportunity to move some clinical work from the hospital setting<br />
into IFHCs. (see Appendix Seven: Integration – HealthPathways).<br />
Ensure a wider range of<br />
health services are<br />
delivered<br />
A wider range of services that improve access will be available<br />
within IFHCs, leading to better access as described in Sections 5.1,<br />
5.4 and Appendix One: Core general practice redesign.<br />
Support better<br />
management of patients<br />
Long term condition management is a key aspect of this plan. (see<br />
Appendix Five: Long term conditions).<br />
with chronic conditions<br />
to slow disease<br />
progression;<br />
Increase the use of the<br />
wider primary health<br />
care workforce and<br />
This is a key aspect of the development of the IFHCs: Sections 5.1,<br />
5.4 and Appendix Two: Core general practice redesign and Appendix<br />
Six: Integration – DHB community based services.<br />
support<br />
multidisciplinary teams;<br />
Provide for workforce<br />
development, training<br />
and innovation in the<br />
Key initiatives have been developed for recruitment, retention,<br />
professional development and quality initiatives as described in<br />
Appendix Twelve; Workforce.<br />
primary care setting;<br />
Achieve the above<br />
objectives in a way that<br />
is cost effective and<br />
assures quality and<br />
Extensive modeling around the cost effectiveness of primary care<br />
has been carried out: (see Section 9.2.).<br />
Quality and safety issues are addressed in Section 5.9 and<br />
Appendix Twelve; Workforce.<br />
safety for users of<br />
services.<br />
2. The capability and capacity of the respondent to deliver major service improvement<br />
initiatives in support of these benefits, including:<br />
Ownership and<br />
governance<br />
arrangements;<br />
Robust ownership and governance arrangement are core to the<br />
success of this plan and potential options are summarised in Section<br />
7. Both DHB and PHO boards wish to take a considered approach<br />
to this and require a more in depth paper to be developed prior to<br />
their making a decision by 30 April.<br />
Strength and<br />
The PHO has strong clinical leadership:<br />
experience of the<br />
clinical leadership;<br />
Dr Greville Wood, FRNZCGP, Chair Clinical Governance<br />
Committee (also Regional Co-ordination Rural Medical<br />
Immersion Training Programme, University of Otago)<br />
Dr Jocelyn Tracey, FRNZCGP, PhD, PHO Clinical director and<br />
Business case EoI V38 AC 25Feb10 Page 7
Financial strength and<br />
viability;<br />
Change management<br />
ability and experience<br />
in the health sector<br />
across the primary and<br />
secondary sector;<br />
Information<br />
management experience<br />
that enables new<br />
models of care, and<br />
improves quality and<br />
efficiently deliver<br />
services.<br />
<br />
GP Liaison<br />
Helen Reriti, RN, Clinical Manager, WCPHO<br />
Also involved from a DHB perspective have been:<br />
<br />
<br />
<br />
Vicki Robertson, FRANZCOG, Chief Medical Officer<br />
Jane O‟Malley, PhD, Director of nursing and midwifery<br />
Maureen Frankpitt, Nurse manager community and primary<br />
health care<br />
Karyn Kelly, Associate Director of Nursing, Clinical Practice<br />
Development<br />
Janette Anderson, Physiotherapy team leader<br />
(see also Section 5.6).<br />
This business case has been costed on a preliminary basis and<br />
opportunities to reduce expenditure towards breakeven identified.<br />
However, we note that these potential initiatives and costings are<br />
subject to further review and consultation before decision can be<br />
taken.<br />
West Coast DHB is substantially in deficit. Its primary and<br />
community services are responsible for a considerable proportion of<br />
the DHB‟s projected deficit. (see Sections 4.2 and 9.).<br />
The PHO is in a position of financial strength and has allocated<br />
funds for change management. (see Section 10.3.).<br />
Both DHB and PHO senior management have an in depth<br />
understanding of the local situation and of both drivers and<br />
barriers to change. In addition, both organisations draw on outside<br />
expertise as required, including the likes of LECG and PHOcus on<br />
Health. These two organisations have assisted with the<br />
development of this plan, and have extensive experience in change<br />
management in primary and secondary care throughout <strong>New</strong><br />
<strong>Zealand</strong>.<br />
The PHO has a considerable track record of utilizing enrollment and<br />
clinical services data to identify service gaps, and to design and<br />
implement responses/projects to address such gaps. The PHO has<br />
made successful use of the PHO Performance Programme to assist<br />
practices with their continuous quality improvement initiatives. GP<br />
facilitation has been key to this success.<br />
Specific information systems developments have been prioritized,<br />
beginning with the adoption of MedTech 32 as the PMS and clinical<br />
notes platform for all community and primary care services. (see<br />
Appendix Fourteen: IFHCs – information technology)<br />
3. The strength of relationships between the various parties, and partnership<br />
arrangements with key stakeholders, including;<br />
The degree of<br />
engagement and/or<br />
Wide consultation has occurred with front line staff: GPs, primary<br />
care nurses, secondary care clinicians, community nurses, allied<br />
Business case EoI V38 AC 25Feb10 Page 8
support from DHBs,<br />
specialist clinicians,<br />
practitioners from a<br />
range of disciplines;<br />
Experience in<br />
meaningful engagement<br />
with consumers and the<br />
community.<br />
health, and with DHB senior management team (see Section 5.6).<br />
While given the time frames this has not been extensive, input<br />
from community, iwi and Māori providers has been obtained (see<br />
Section 5.7). Each IFHC will establish a community reference group<br />
who can assist in the development of plans for their districts.<br />
These groups will include local mayors (or their representation),<br />
community leaders, business leaders and iwi leaders.<br />
Business case EoI V38 AC 25Feb10 Page 9
3 Table of contents<br />
1 Caveats/status .................................................................................................................................................. 3<br />
2 Executive summary .......................................................................................................................................... 4<br />
2.1 Assessment criteria summary ............................................................................................................. 5<br />
3 Table of contents ........................................................................................................................................... 10<br />
4 Introduction .................................................................................................................................................... 12<br />
4.1 Strategic context ................................................................................................................................. 12<br />
4.2 Financial context ................................................................................................................................... 12<br />
4.3 Secondary services sustainability ................................................................................................... 13<br />
4.4 Population & health status .................................................................................................................. 14<br />
4.5 West Coast PHO .................................................................................................................................... 17<br />
4.6 Changes underway ................................................................................................................................ 20<br />
4.7 West Coast region service delivery issues ................................................................................... 21<br />
5 Future model of care ................................................................................................................................... 23<br />
5.1 The desired patient care pathway/model of care ..................................................................... 23<br />
5.2 Goals for better, sooner more convenient ................................................................................... 25<br />
5.3 Reducing inequalities ........................................................................................................................... 27<br />
5.4 Service specific model of care developments............................................................................. 28<br />
5.5 Enablers .................................................................................................................................................. 35<br />
5.6 Clinician engagement ........................................................................................................................... 36<br />
5.7 Community engagement ...................................................................................................................... 37<br />
5.8 Evidence for this model ..................................................................................................................... 38<br />
5.9 Quality, safety and evaluation .......................................................................................................... 41<br />
6 Business model ............................................................................................................................................... 44<br />
6.1 Business concept .................................................................................................................................. 44<br />
6.2 Locality Integrated Family Health Centres................................................................................. 48<br />
6.3 Service outputs and outcomes ......................................................................................................... 49<br />
7 Governance, Ownership & Management .................................................................................................. 53<br />
7.1 Options .................................................................................................................................................... 53<br />
7.2 Assessing the options ......................................................................................................................... 55<br />
8 Contracting arrangements .......................................................................................................................... 56<br />
8.1 Role of the IFHS ................................................................................................................................. 56<br />
8.2 Annual health service plan ................................................................................................................. 56<br />
8.3 Contracted providers within IFHCs. .............................................................................................. 57<br />
9 Financial sustainability ................................................................................................................................ 58<br />
9.1 Status quo financial situation........................................................................................................... 58<br />
9.2 Addressing affordability ................................................................................................................... 59<br />
9.3 Impact on the DHB .............................................................................................................................. 60<br />
10 Implementation plan ..................................................................................................................................... 62<br />
10.1 Project governance and management ............................................................................................. 62<br />
10.2 Change management ............................................................................................................................ 62<br />
10.3 Investing in change .............................................................................................................................. 64<br />
Business case EoI V38 AC 25Feb10 Page 10
10.4 Key milestones....................................................................................................................................... 65<br />
10.5 Objectives, key activities and workplans ..................................................................................... 66<br />
10.6 Work in progress items ...................................................................................................................... 70<br />
10.7 Risks and Mitigations .......................................................................................................................... 70<br />
Business case EoI V38 AC 25Feb10 Page 11
4. Introduction<br />
4.1 Strategic context<br />
On 10th September 2009, the Chair of the West Coast DHB wrote to the Minister of Health as<br />
follows:<br />
The recently released report by LECG (Analysis of options: Models of care for West Coast<br />
District Health Board, 16 Nov 09) gives some flesh to the bones of the first suggestion - closer<br />
working relationships with Canterbury DHB (CDHB) in the provision of secondary hospital<br />
services, which are increasingly likely to be concentrated in Greymouth.<br />
This business case begins to flesh out the second of the two strategic options suggested in the<br />
above letter to the Minister. It articulates the sector's aspirations for better, sooner and<br />
more convenient primary care services for the residents of the West Coast. It explores how<br />
the medical centres on the West Coast on the one hand, and the various community delivered<br />
services of the DHB on the other hand, might be better integrated so that patients' experience<br />
of the health care they receive on the West Coast is significantly improved. It explores how<br />
primary and community care together, might make a greater contribution to improving the<br />
quality and timeliness of health care, while helping save scarce resources. It outlines how a<br />
different mix of clinical skills will be aligned in a service delivery model to more efficiently and<br />
effectively match a variety of patient needs for care.<br />
4.2 Financial context<br />
A major system wide problem for the West Coast health care system is its parlous financial<br />
situation. West Coast District Health Board (WCDHB) was allocated $106m of government<br />
funding in 2009/10, but is projected to spend more than $114m.<br />
Business case EoI V38 AC 25Feb10 Page 12
Annual government health funding per person on the West Coast is over $1,000 higher than the<br />
NZ average ($3,255, compared to $2,248).<br />
On top of this, WCDHB spends another, additional $250 per head (cf. national average of $50<br />
per head overspend).<br />
That is, West Coasters actually receive $3,500 per head, as spent by their DHB, well ahead<br />
(>50%) of the NZ average of $2,300 per head.<br />
The WCDHB's current financial forecast for 2009/10 is as follows:<br />
Provider revenue - 73,468,409<br />
Provider expenses 88,141,662<br />
Provider deficit 14,673,253<br />
Funder surplus - 5,422,748<br />
DHB total deficit 9,250,505<br />
As a result WCDHB is under significant pressure to reduce expenditure.<br />
4.3 Secondary services sustainability<br />
A series of independent reviews have identified core critical mass problems in providing acute<br />
secondary services on the West Coast. WCDHB is currently consulting on a set of<br />
recommendations from LECG proposing greater integration of secondary care with Canterbury<br />
DHB and movement to a rural hospital centre of excellence focus. There is a developing<br />
Business case EoI V38 AC 25Feb10 Page 13
consensus that significant change is required to maintain clinically and financially sustainable<br />
hospital services. It is important that the community and primary services receive the same<br />
level of scrutiny and leadership.<br />
4.4 Population & health status<br />
The West Coast is a region of contrasts; on one hand it is a region of great natural beauty but<br />
on the other hand is home to one of the most socio-economically deprived populations in <strong>New</strong><br />
<strong>Zealand</strong>. The geographic nature of the region, being bordered by the towering Southern Alps on<br />
the east and the Tasman Sea on the west, leads to the West Coast being the most rural and<br />
isolated region in <strong>New</strong> <strong>Zealand</strong>. The total land area covered by the West Coast District Health<br />
Board is 23,283 square kilometres and great distances separate many towns, with the distance<br />
between Karamea in the north and Haast in the south being 516 kilometres. The West Coast<br />
and its people are also very much influenced by the history, environment and climate of the<br />
region.<br />
Health Profile<br />
Consistent with the above demographic and socio-economic issues is the picture of higher<br />
morbidity and mortality rates and lower life expectancy on the West Coast compared with the<br />
<strong>New</strong> <strong>Zealand</strong> average. However, life expectancy in the West Coast DHB area improved between<br />
1995/97, 2000/02 and 2002/2007 for both males and females and the overall mortality rate<br />
for the West Coast DHB reduced from 8.6 deaths per 1,000 population in 1995/1997 to 6.2<br />
deaths per 1,000 population in 2005/2007. However, over the last decade the West Coast<br />
DHB‟s overall mortality rate remains above the national average rate. Westland District had<br />
the highest mortality rate in 1995/97 but this had reduced to the lowest in 2000/02 and<br />
remains the highest in 2005/2007. (However, this apparent large reduction for Westland<br />
District may be partly due to high variability in mortality rates, which often occurs for small<br />
populations). Analysis of mortality data for West Coast DHB residents between 2001 and 2005<br />
reveals that the leading causes of death were cardiovascular disease, respiratory disease,<br />
cancers (particularly lung, colorectal, prostate and breast) and dementia (these cases have<br />
increased in recent years due to the aging population).<br />
The overall rate of hospitalisation is also high. Analysis of hospitalisation data showed that<br />
there were nearly 7,500 discharges of West Coast DHB residents from publicly funded<br />
hospitals in 2007. (This includes West Coast DHB residents discharged from hospitals outside<br />
the West Coast DHB area). Some of the leading causes of hospitalisation were diseases of the<br />
digestive system (13.3%), diseases of the circulatory system (8.8%), injury, poisoning and<br />
certain other consequences of external causes (8.8%), and pregnancy, childbirth and the<br />
puerperium (7.8%).<br />
Business case EoI V38 AC 25Feb10 Page 14
Ambulatory Sensitive Hospitalisations (ASH) are hospital admissions that could potentially have<br />
been avoided through community-based or primary health care services. Standardised<br />
Discharge Ratios for 0-74 year olds show that ASH rates for the West Coast DHB do not tend<br />
to differ significantly to the rates for <strong>New</strong> <strong>Zealand</strong> as a whole. Lead causes of ambulatory<br />
sensitive admissions for the West Coast population over the recent years in terms of total raw<br />
hospitalisations are angina and chest pain; cellulitis; upper respiratory and ENT infections;<br />
diabetes; congestive heart failure; dental conditions; myocardial infarction; gastroenteritis;<br />
pneumonia; asthma; skin cancers; epilepsy; kidney and urinary tract infections; and stroke. This<br />
pattern has largely continued in the twelve months to 31 December 2008.<br />
The West Coast Māori Health Profile 2008[1][1] revealed that West Coast Māori have a similar<br />
social profile to the West Coast non Māori but in terms of health, West Coast Māori have a<br />
poorer overall health status than the non Māori in the region; this is demonstrated by a range of<br />
indicators, including cardiovascular disease, cancer, diabetes and respiratory disease indicators.<br />
Though in many instances West Coast Māori have lower mortality and morbidity rates than<br />
Māori nationally, it is to be noted that the West Coast Māori are under-represented among<br />
primary care utilization data and have higher rates of smoking, which is a key risk factor for a<br />
range of morbidities such as cancer and cardiovascular and respiratory diseases. Discrepancies<br />
between hospitalisation and mortality rates for cardiovascular disease, and registration and<br />
mortality rates for cancer, point to these being additional important areas of unmet need for<br />
West Coast Māori.<br />
The health status of children and young people on the West Coast is poorer than the <strong>New</strong><br />
<strong>Zealand</strong> average. In particular, children have among the worst oral health status in the country,<br />
and the West Coast has the lowest rate of caries-free five-year-old children in <strong>New</strong> <strong>Zealand</strong>.<br />
The relatively high rate of dental decay in young children is a concern, especially with the<br />
absence of fluoridation. For children aged 0-14 years the leading causes of death are extreme<br />
immaturity (pre-term and low-birth weight babies), respiratory distress syndrome and<br />
meningitis. For young people aged 15-24 years motor vehicle crashes account for half of all<br />
deaths, and other injuries and accidents account for one third of all deaths. The main causes of<br />
ambulatory sensitive hospitalisation for West Coast children aged 0-4 years are respiratory<br />
infections (29%), gastroenteritis (20%) and asthma (12%).<br />
West Coast residents have higher smoking rates compared with other areas in <strong>New</strong> <strong>Zealand</strong>.<br />
The 2006 Census showed that a higher proportion of West Coast DHB residents (23.4%) were<br />
regular smokers compared with <strong>New</strong> <strong>Zealand</strong> as a whole (18.9%), with Buller District home to<br />
the highest proportion of smokers (25.7%). The recent <strong>New</strong> <strong>Zealand</strong> Health Survey 2006/07**<br />
showed that 28.2% of West Coast residents are current daily smokers compared to 19.1% of<br />
<strong>New</strong> <strong>Zealand</strong> as a whole. Amongst West Coast Māori, 43.3% of women and 39.6% of men smoke.<br />
[1][1] West Coast „Te Tai O Poutini‟ Māori Health Profile 2008, prepared by Community and Public Health West<br />
Coast<br />
Business case EoI V38 AC 25Feb10 Page 15
A 2007 Ministry of Health report[2][2] suggested that tobacco smoking, alcohol consumption,<br />
oral health status and avoidable hospitalisation are among the key health issues for the West<br />
Coast DHB as these rates are high compared with <strong>New</strong> <strong>Zealand</strong> as a whole. The West Coast<br />
cryptosporidiosis rate is also high compared with <strong>New</strong> <strong>Zealand</strong> as a whole but this may not be as<br />
serious. Notifiable disease rates vary due to factors other than disease prevalence, such as<br />
variations in the extent to which these conditions come to the attention of medical<br />
professionals and variations in the completeness of reporting. With these data limitations<br />
noted it is still possible that the high cryptosporidiosis notification rate indicates that there is<br />
a water quality issue in the West Coast DHB area that may affect population health.<br />
Population Profile<br />
The West Coast occupies 8.5% of <strong>New</strong> <strong>Zealand</strong>‟s total landmass and is home to a growing<br />
population of 32,200 people[3][3]. The population is distributed across three Territorial Local<br />
Authority (TLA) areas: Buller, Grey and Westland Districts. The West Coast DHB is the most<br />
sparsely populated DHB in the country with a population density of 1.3 people per square<br />
kilometre, less than 10% of the <strong>New</strong> <strong>Zealand</strong> average. A total of 57.7% of the West Coast DHB<br />
population live in urban areas, the main population centres being Greymouth, Westport and<br />
Hokitika. Between 2001 and 2006 the West Coast DHB population increased by 3.4%, with<br />
Westland seeing the fastest growth rate (8.1%). Some Census Area Units had growth rates of<br />
over 25% between 2001 and 2006 including Waiho, Totara River, Arnold Valley, Otira, Fox<br />
Glacier, Coal Creek, Hokitika Rural and Greymouth Rural.<br />
Notwithstanding, the long term population projections indicate that the West Coast region as a<br />
whole will observe declining population numbers but with a growing older population. Population<br />
estimates suggest that the child and youth populations decreased slightly between 2001 and<br />
2006 but during the same time period there was significant growth among the older adult<br />
population (40-64) and older people (65+). The West Coast DHB population has a slightly older<br />
age structure compared with <strong>New</strong> <strong>Zealand</strong> as a whole, with a higher proportion of people aged<br />
65 years or more compared with the national average. The Māori population on the West Coast<br />
shows a different age structure and growth pattern however; nearly one in ten of the West<br />
Coast population is Māori and there are more Māori aged under 45 years. Subsequently this will<br />
be reflected in the expected future increase for all Māori age groups over 25 years of age.<br />
<strong>More</strong> detailed ethnicity data analysis of the West Coast population shows that over 300 people<br />
identified as being of Asian ethnicity, nearly 200 were Pacific Island people and nearly 70<br />
identified as Middle Eastern/Latin American/African (MELAA). Overall 9.3% of the population<br />
identify as Māori, Pacific people make up less than 1% (0.9%) of the region's population, with<br />
the balance falling into other ethnicity groups<br />
[2][2] “An indication of <strong>New</strong> <strong>Zealand</strong>ers Health” (Ministry of Health, 2007)<br />
[3][3] Statistics NZ Quarterly Regional Updates, March 2008. This number indicates a growth of 0.5% since the<br />
2006 census count.<br />
* A Portrait of Health. Key Results of the 2006/07 <strong>New</strong> <strong>Zealand</strong> Health Survey, 2008.<br />
Business case EoI V38 AC 25Feb10 Page 16
The base populations of the three districts are shown below.<br />
Table 1: Population & Age Distribution at 2009 (based on 2006 census) by TLA<br />
TLA Age group Number Percentage<br />
Buller District 0 - 14 1850 18.5%<br />
15 - 39 2600 26.0%<br />
40 -64 3850 38.5%<br />
65+ 1700 17.0%<br />
Total 10000 100.0%<br />
Percentage of West Coast population 31%<br />
Grey District 0 - 14 2850 20.7%<br />
15 - 39 4100 29.7%<br />
40 -64 4850 35.1%<br />
65+ 2000 14.5%<br />
Total 13800 100.0%<br />
Percentage of West Coast population 42%<br />
Westland District 0 - 14 1600 18.1%<br />
15 - 39 2640 29.9%<br />
40 -64 3370 38.2%<br />
65+ 1220 13.8%<br />
Total 8830 100.0%<br />
Percentage of West Coast population 27%<br />
West Coast total 32630<br />
The Buller area has a higher proportion of over 65 year olds and is also more deprived relative<br />
to the district as a whole.<br />
4.5 West Coast PHO<br />
The PHO is a community trust, governed by a board of nine trustees. Its founding document is<br />
its trust deed, which sets out its objectives as being:<br />
(a) "to improve, maintain and restore the health of people living in the West Coast Region;<br />
(b) "to provide or ensure the provision of accessible primary health care services to the community of<br />
the West Coast Region;<br />
(c) "to provide or ensure the provision of effective, high quality integrated health services for the<br />
community of the West Coast Region;<br />
(d) "to assist members of the community of the West Coast Region (particularly those on low<br />
incomes and with high health care needs) who have difficulty gaining timely and appropriate<br />
health services;<br />
(e) "to work with the West Coast District Health Board and community groups within the West Coast<br />
Region to achieve any of the above Objects;<br />
(f) "to support any institution, society or other body of persons whether incorporated or not whose<br />
objects are similar to the objects of the Trust set out above, provided that any such entity is<br />
established for charitable purposes in <strong>New</strong> <strong>Zealand</strong>."<br />
Business case EoI V38 AC 25Feb10 Page 17
It's trustees are derived from three sectors as follows: community, Māori and providers (three<br />
from each):<br />
three community trustees are appointed from each of the three District Councils<br />
two Māori trustees are appointed from each of the two runanga<br />
one Māori trustee is elected - by the Māori health providers electoral college<br />
three provider trustees are elected - each of the general practitioner, practice nurse<br />
and practice administration staff electoral colleges elect one trustee.<br />
The PHO provides some health services itself, but also subsidises patient care through its<br />
substantial funding for the eight medical centres across the Coast. Five of these practices are<br />
owned by the DHB, two by health professionals, and one by the PHO itself.<br />
The PHO's statement of strategy and priorities is:<br />
The purpose of the PHO is to promote and enable better health for the population on the West<br />
Coast and actively work to reduce health inequalities amongst at-risk and disadvantaged groups.<br />
The PHO will strengthen and grow its organisational functions as funder, service provider, and<br />
service co-ordinator within primary care, as a means to achieving this end and in alignment with<br />
the Government‟s <strong>Primary</strong> Health <strong>Care</strong> Strategy (PHCS).<br />
STRATEGIC OBJECTIVES ARE TO<br />
Work with local communities and enrolled populations<br />
Identify and remove health inequalities<br />
Offer access to comprehensive services to improve, maintain, and restore people‟s health<br />
Co-ordinate care across service areas<br />
Develop the primary care workforce<br />
Continuously improve quality using good information and evidence<br />
WE WILL FOCUS ON<br />
Improving the management of patients with chronic care conditions<br />
Closing gaps of inequality for Māori<br />
Improving access to mental health services, including for young people<br />
Improving quality of life, eg. by cancer support<br />
Improving immunisation rates<br />
Enhancing disease prevention programmes<br />
Improving the co-ordination of services both within and across services<br />
BY USING KEY MECHANISMS AND ENABLERS SUCH AS<br />
<strong>Better</strong> engagement with the community, families/whanau and individuals<br />
Improved collaboration at strategic and planning levels with the DHB and Community &<br />
Public Health<br />
Greater integration with other organisations and NGOs<br />
Supporting GP practice teams<br />
Supporting individuals and whanau<br />
Enhanced health promotion<br />
Adoption of efficient business/service models<br />
Most of the West Coast's resident population is enrolled in the PHO's eight practices. The<br />
distribution in the recent Oct-Dec 09 quarter was as follows:<br />
Business case EoI V38 AC 25Feb10 Page 18
Māori/Pacific Not Māori/Pacific<br />
Dep 5 Not Dep 5 Dep 5 Not Dep 5 Total<br />
Karamea 0 36 17 520 573<br />
Buller Medical Services 192 408 1,790 4,801 7,191<br />
Greymouth Family Health 11 76 147 990 1,224<br />
Greymouth Medical Centre 107 403 703 4,848 6,061<br />
High St Medical Centre 67 288 656 5,214 6,225<br />
Reefton Medical Centre 35 154 206 1,576 1,971<br />
South Westland Area<br />
Practice 0 139 0 1,425 1,564<br />
Westland Medical Centre 122 772 505 4,178 5,577<br />
Total 534 2,276 4,024 23,552 30,386<br />
1.8% 7.5% 13.2% 77.5% 100.0%<br />
The PHO's net equity as at Dec 09 was $1.1m and its recent operating financial performance is<br />
as follows:<br />
Revenue<br />
Financial performance Jul – Dec 09<br />
First level services & practice VLCA 2,387,473<br />
Administration 197,072<br />
Health Promotion 100,516<br />
Services to Improve Access 115,223<br />
Long Term Conditions 344,159<br />
Other clinical services 31,201<br />
PHO Performance Programme 166,186<br />
Rural Premiums & Reasonable Rostering 769,001<br />
Professional & practice development 35,884<br />
Mental Health & MSD 228,878<br />
Cancer Services 146,370<br />
GP Liaison 40,000<br />
HEHA (breastfeeding support) 43,872<br />
LTC Collaborative Funding 37,139<br />
Expenditure<br />
First level services & practice VLCA 2,387,473<br />
Administration 341,157<br />
Health Promotion 83,643<br />
Services to Improve Access 92,159<br />
Long Term Conditions 200,873<br />
Other clinical services 12,936<br />
PHO Performance Programme 87,193<br />
Rural Premiums & Reasonable Rostering 742,784<br />
Professional & practice development 16,281<br />
Mental Health & MSD 198,638<br />
Cancer Services 124,539<br />
GP Liaison 24,819<br />
HEHA (breastfeeding support) 38,766<br />
LTC Collaborative Funding 32,139<br />
4,642,974<br />
4,383,400<br />
Surplus 259,574<br />
Business case EoI V38 AC 25Feb10 Page 19
4.6 Changes underway<br />
A number of initiatives have been implemented over the last three years to address some of the<br />
health needs and service delivery concerns on the West Coast.<br />
PHO based initiatives:<br />
development of health promoting practices and a wide number of high profile health<br />
promotion activities, including Smokefree, Heart Week, men‟s health days, Green<br />
prescription, Tai Chi classes, community activity programmes<br />
breastfeeding co-ordinators and peer support programme<br />
kaiawhina role to improve access for Māori in the Buller district<br />
long term condition management programme incorporating targeted care, self<br />
management support, delivery system redesign and clinical information systems<br />
primary mental health assessments and brief intervention counselling<br />
navigation support for those with cancer<br />
Māori health plan<br />
PHO Performance Programme with GP facilitator<br />
immunisation enhancement.<br />
DHB based initiatives in primary and community care:<br />
Māori health needs analysis<br />
investment in nursing competency and role extension<br />
movement to models of care in which nurses provide front line services where<br />
appropriate<br />
greater use of nurses – with nurse to GP consult ratios being the highest for any DHB in<br />
NZ<br />
closer working relationships with Canterbury in many services<br />
movement to more community based mental health service delivery – with reduction to<br />
five acute inpatient beds on the Coast<br />
delivering a predominately community based mental health service delivery model,<br />
enhancing community based support services delivered by NGOs and reducing acute<br />
inpatient beds to five<br />
establishment of an academic practice to co-train rural GPs and rural nurses and<br />
sourcing CTA support for pilot training programmes<br />
development of an IT platform which provides for a single shared patient record across<br />
DHB practices with access through Healthviews to hospital sourced health information<br />
such as discharge summaries, PACS radiology, lab results<br />
through After Hours funding providing West Coast-wide after hours triage phone<br />
support.<br />
Business case EoI V38 AC 25Feb10 Page 20
4.7 West Coast region service delivery issues<br />
Key problems identified by the steering group, advisory group, reference group and<br />
stakeholders that face the West Coast health care system are:<br />
Workforce shortages<br />
Difficulties in recruiting and retaining staff (especially GPs and allied health staff) has led to<br />
high turnover, excessive reliance on locums and under staffing. This is exacerbated by the<br />
relatively deprived nature of the community, the low population density and high on-call<br />
requirements in rural areas.<br />
Leading to poor access to care:<br />
Difficulty in staffing GP roles has resulted in enrolled patients being unable to book routine<br />
appointments within an acceptable timeframe (waits of longer than 3 weeks are typical in some<br />
practices) and patients new to town unable to enroll in any practice. Difficulty in resourcing<br />
also results in a tendency towards responding reactively to acute presentations and allowing<br />
these to take precedence over proactive, planned care of patients with chronic conditions –<br />
reducing the possibility of managing future demand. Again, the Coast geography mitigates<br />
against easy access, with many people living more than 60 minutes travel time away from major<br />
urban centres.<br />
Service fragmentation<br />
Services operate in partial silos resulting in:<br />
lack of continuity of care<br />
difficulties navigating through the system<br />
duplication of assessment, needless administration, disparate treatment policies and<br />
protocols, and poor sharing of clinical information.<br />
Within primary care, there is frequent use of locums, and high dependence on Emergency<br />
Department (ED) services at Buller and Greymouth. People often see a different GP or nurse<br />
each time and thereby experience poorer quality care. Further, when GP numbers are<br />
insufficient, and nursing staff are used as sole caregivers for most primary care consults,<br />
without changes to the overall model of care to ensure adequate GP support, quality processes<br />
and professional development, there is a risk of people operating outside their scopes of<br />
practice and of avoidable harm to patients.<br />
Services are not co-located in some areas, making it particularly difficult for the frail older<br />
people or those without transport. When services are co-located, they are often not<br />
integrated, meaning that opportunities to schedule, for instance, a physiotherapy appointment<br />
at the same time as a diabetes annual review (to reduce the travel burden) are missed.<br />
Service fragmentation leads to duplication in reporting and management infrastructure – and<br />
siloed funding streams – reducing the ability to innovate and to use funding flexibly.<br />
Business case EoI V38 AC 25Feb10 Page 21
Inequalities in health outcomes<br />
Māori remain under-enrolled in the PHO (particularly in Grey District) leading to poor access to<br />
proactive care for Māori.<br />
<strong>More</strong> generally, lack of community knowledge of the health system in general, and in particular<br />
about:<br />
<br />
<br />
<br />
<br />
<br />
<br />
how best to access care (including after hours)<br />
what enrolment means (enrolment in health system)<br />
what services they can expect.<br />
how to care for self/whanau with common ailments<br />
what constitutes a healthy lifestyle<br />
how to support a whanau member/oneself in managing long term health conditions such<br />
as heart disease and or diabetes<br />
leads to poorer health outcomes and greater use of secondary health resources by Māori and<br />
those living in deprived areas.<br />
Affordability of services<br />
As noted, the current configuration of services is unaffordable for the taxpayer funder, as well<br />
as delivering suboptimal outcomes.<br />
Business case EoI V38 AC 25Feb10 Page 22
5 Future model of care<br />
5.1 The desired patient care pathway/model of care<br />
This section describes the vision for the new model of care that will be in place once the goals<br />
and objectives have been achieved. The intent is that, over time, total transformation will occur<br />
consistent with the "<strong>Better</strong>, <strong>Sooner</strong>, <strong>More</strong> <strong>Convenient</strong>" framework.<br />
From a patient perspective:<br />
Patients are enrolled with an IFHC as their health care home. Within each IFHC are smaller<br />
units of health care teams normally comprising two to four nurses, and one to two doctors<br />
working in partnership to look after a population of people. Patients know the doctors and<br />
nurses in „their‟ health care team, a smaller unit within the IFHC that provides continuity and<br />
consistency of care and builds trusting relationships.<br />
The care provided is patient centred and holistic. All patients of all ethnicities and<br />
socio-economic groups feel valued and respected. Service is personal and friendly; patients do<br />
not feel lost in a large impersonal health centre.<br />
Patients know how to access care, the hours of opening, after hours arrangements, types of<br />
appointments available, and are happy to be guided as to which health professional can best<br />
meet their needs on any occasion. For acute care and long term condition management their<br />
first port of call is usually one of the nurses in „their‟ team, and they know that back up from<br />
GPs is available when required. For complex consultations longer appointments are available with<br />
their GP. Patients with serious problems are able to be seen within twenty-four hours, or sooner<br />
– particularly for children and frail older people whose condition is unstable. Routine and<br />
preventive care appointments are provided within three days. Laboratory tests samples are<br />
collected on site and x-rays nearby and, if the pharmacy is not on site, home deliveries are<br />
available.<br />
For Māori, particularly those who have disengaged from the system, there will be a Māori nurse,<br />
and supporting kaiawhina or health navigator in each IFHC, who can provide outreach services<br />
and support whanau to access care, and have their health needs met in a culturally appropriate<br />
manner that incorporates Māori models of care such as Te Whare Tapa Wha 1 , and Te Wheke 2 .<br />
Often people manage their own health problems, following nurse phone advice from national<br />
health lines, accessing information on recommended websites, or following their written care<br />
plans. Pharmacists assist patients with the management of minor ailments. Many people will be<br />
involved in community programmes provided by the IFHS, such as Green Prescription, smoking<br />
1 Durie, M. Mauri Ora, Wellington. 1990<br />
2 Cited at: http://www.Māorihealth.govt.nz/2004/taaria_1.php#<br />
Business case EoI V38 AC 25Feb10 Page 23
cessation, self management education groups. Others are helped to access NGO support and<br />
community group activities.<br />
Messages about keeping healthy are everywhere in the community: libraries, shopping centres,<br />
pharmacies, schools and IFHCs. While health promotion messages and displays are zany and fun,<br />
people will also have the information they need to make healthy lifestyle choices. It is the<br />
norm to eat healthily, breastfeed one‟s babies, be physically active and not to smoke. Children<br />
are immunised, older people and those with long term conditions have annual flu vaccinations, and<br />
those in the at risk age groups have annual or five yearly cardio vascular risk assessments and<br />
diabetes screening. Smokers are screened for chronic respiratory disease.<br />
For those with complex health problems there is a range of extra care available. The IFHC<br />
is considerably more comprehensive than the traditional medical centre; it incorporates a range<br />
of medical, nursing and allied healthcare professionals some of whom are permanently based in<br />
the IFHC as part of the wider multi disciplinary team and others who may visit on a daily or<br />
sessional basis. Whether staff are employed by the IFHC, the DHB, the PHO, another NGO, or<br />
in private practice, patients know that the shared electronic health record means they do not<br />
need to repeat their story to each new person they see, and that their care is well co-ordinated.<br />
Nor do they need to wait for referrals to be processed and prioritised: appointments to see<br />
other members of the multi disciplinary team (MDT) can be made on the spot, and can be<br />
scheduled all for the same trip to the IFHC.<br />
People with complex needs, such as those with LTCs and frail older persons, are assessed by<br />
<strong>Care</strong> Link (West Coast's NASC) assessors at the IFHC and have a plan made for how the<br />
different members of the MDT can contribute to their care. They have a key worker they can<br />
rely on to co-ordinate their care and if they need help in navigating the health system and<br />
accessing the social support and benefits they need, they will also have a health navigator to<br />
Business case EoI V38 AC 25Feb10 Page 24
support them. Help with understanding medications is available from pharmacists via medication<br />
reviews.<br />
Those with mental health problems are assessed by a mental health co-ordinator within the<br />
IFHC who will help them select the package of care they need to get well, ranging from<br />
community support, through brief intervention counseling, to admission to community mental<br />
health services. They receive their care in the IFHC and this lessens their sense of<br />
stigmatization. Their GP knows what care they are receiving and is able to provide support and<br />
ensure their physical needs are not neglected.<br />
The community knows that their health centre has been Cornerstone Accredited, has quality<br />
systems in place and is keen to receive feedback so that the services can be steadily improved.<br />
Community, business and iwi leaders meet regularly with senior clinicians and management to<br />
work together to improve health services and increase community understanding.<br />
If hospital based care is required, information flows electronically to and from specialists, and<br />
the care provided is consistent with, and a continuation of, that provided in the IFHC.<br />
And most of the time, for most people and their families, with most problems, whatever their<br />
age, their GP and nurse team will be there, helping them on their life journey.<br />
5.2 Goals for better, sooner more convenient<br />
The vision of <strong>Better</strong>, <strong>Sooner</strong>, <strong>More</strong> <strong>Convenient</strong> primary care is one that, if implemented well, will<br />
address the current issues with health care delivery on the West Coast.<br />
The following eight goals arise from this vision:<br />
1. Partnership with the community<br />
2. <strong>Sooner</strong>: improving access to primary care<br />
3. <strong>Better</strong>: improving continuity of primary care<br />
4. <strong>Better</strong>: improving consistency of care<br />
5. <strong>Better</strong>: improving co-ordination of care between general practices, hospitals and<br />
community providers<br />
6. <strong>More</strong> convenient: community based care in integrated family health centres<br />
7. Greater clinical leadership<br />
8. Living within the available funding.<br />
For each goal objectives and key activities were developed. Then as a tool to managing change<br />
towards the desired model of care, a number of working groups were established, each working<br />
towards the overall goals and objectives and developing a different aspect of the model of care.<br />
Clinical leaders from all disciplines, as well as PHO, DHB and provider arm managers were<br />
Business case EoI V38 AC 25Feb10 Page 25
involved in the working groups. Each group developed a detailed plan that includes deliverables<br />
(implementation phase, year one, two and three and output and outcome measures). The working<br />
groups will continue to take responsibility for the implementation of these plans so that the<br />
goals and objectives of this business case can be realised and a new model of care implemented.<br />
The work plans cover the following aspects, and are included in full in the appendix.<br />
Work plans that relate to care delivery:<br />
core general practice redesign<br />
acute care<br />
keeping people healthy<br />
long term conditions<br />
integration: Health Pathways<br />
integration: DHB community based services<br />
improved access to diagnostics<br />
referred services<br />
mental health<br />
frail older people.<br />
Plans for the enablers - support, systems and facilities - required to deliver the new model of<br />
care:<br />
workforce<br />
<br />
<br />
<br />
IFHCs – facilities<br />
IFHCs - information & communications technology<br />
change management.<br />
The following schema shows the way that the various work plans support the strategies, targets,<br />
goals and vision of this plan:<br />
Business case EoI V38 AC 25Feb10 Page 26
LEVERS<br />
VISION<br />
<strong>Better</strong>, sooner, more convenient<br />
To improve health outcomes for the West Coast community, within the available budget<br />
OUTCOMES<br />
Targets Goals<br />
<strong>Better</strong><br />
Community / patient<br />
focused care<br />
Improved health<br />
outcomes for people<br />
with long term<br />
conditions<br />
<strong>Better</strong><br />
Continuity, consistency,<br />
coordination of care<br />
Increased<br />
immunisation and<br />
screening rates<br />
Shorter wait times to be<br />
seen by GP/PN team<br />
<strong>Sooner</strong><br />
Improved access to care<br />
Reduced levels of<br />
Ambulatory Sensitive<br />
Hospitalisations / ED<br />
attendances<br />
<strong>More</strong> convenient<br />
Integrated care in IFHCs<br />
Services live within<br />
available funding<br />
STRATEGIES<br />
Bed in team based delivery<br />
model for primary care<br />
- Improving multi-disciplinary<br />
teamwork<br />
- Increased collaboration between<br />
general practices<br />
- Move to 1:2000 GP ratio, 1:900<br />
PN ratio<br />
Service specific strategies<br />
- Long term conditions<br />
- Frail elderly<br />
- Mental health<br />
- Integration<br />
- Acute care<br />
- Keeping people healthy<br />
Workforce<br />
Integrate PHO and DHB<br />
community services<br />
- Integrated clinical pathways<br />
- Reduced administration and<br />
management costs<br />
IFHCs<br />
- Develop 3 IFHCs at Westport,<br />
Greymouth & Hokita<br />
- 1 stop shop for community &<br />
primary care<br />
- Shared health record<br />
Clinical<br />
relationships<br />
Delegation to<br />
PHO/Trust<br />
Flexible<br />
outcomes<br />
based contract<br />
The objectives, key activities and associated work plans for each of the eight goals are set out<br />
in the change management section.<br />
5.3 Reducing inequalities<br />
This plan aims to improve services for Māori in that it:<br />
has an emphasis on reducing inequalities between the health outcomes of Māori and<br />
other <strong>New</strong> <strong>Zealand</strong>ers<br />
builds on Māori staff capacity and capability to improve the uptake of services<br />
commits to building the capacity and capability of non Māori staff to improve the uptake<br />
of service by Māori<br />
links in with Māori community based programmes<br />
includes initiatives that will improve access for Māori<br />
utilizes accurate ethnicity data and reports separately by ethnicity so as to stimulate<br />
effective service delivery for Māori.<br />
The Health Equity Assessment Tool was used to identify how the development of IFHCs could<br />
decrease inequalities in access and health outcomes. The results are shown in the Appendices.<br />
Business case EoI V38 AC 25Feb10 Page 27
The DHB Māori Health Unit reviewed the plans from the various workstream, providing guidance<br />
on how they could be better designed to reduce inequalities. The work plans in the appendices<br />
each contain a section on how the plan will reduce inequalities.<br />
5.4 Service specific model of care development s<br />
5.4.1 Future general practice model of care<br />
Specific developments related to general practice are set out in „Appendix Two: Core general<br />
practice redesign‟. This describes a process whereby practice teams will work together to<br />
develop improvements/alternatives to what is currently not working - in terms of access, safety<br />
of care and financial viability.<br />
An important realisation is the likely need to deliberately move to a strategy whereby<br />
experienced practice and rural nurses see most general patients (including dispensing under<br />
standing orders), and GPs provide back up support, supervision and are available to see complex<br />
patients whose diagnosis and care plan is less clear. Currently a version of this model of care is<br />
in place at some practices, but often in an unplanned way – as an ad hoc response to a shortage<br />
of GPs. The new model of care accepts that the West Coast generally has ratios of 1 GP to<br />
2000 patients, and provides the necessary supports in the form of additional practice nurses<br />
and consistent policies and processes to make this model safe and rewarding for patients and<br />
staff. However, this model is not yet set in stone and if alternatives are proposed that have as<br />
good or better outcomes in terms of access, safety of care and financial viability, they will be<br />
considered.<br />
We have calculated the likely activity levels and associated FTE requirements to support this<br />
model of care. Detailed FTE calculations are presented in the Business model section of this<br />
report. Of note, we calculate that the number of current GPs on the Coast would be about right<br />
(particularly with this number as permanent GPs), whereas we find that we are under resourced<br />
in practices nurses and rural nurses to deliver the new model of care. In general, the model<br />
assumes that most people see a practice nurse, and then, if necessary a GP. This will require<br />
changes to the way GP and nurse time is scheduled and will take some time to implement fully,<br />
with some practices being more ready to move to this model than others.<br />
Importantly, we expect that GPs will continue to see around 65% of patients presenting with an<br />
undifferentiated condition (general consults). Most will be seen briefly – as a 5 minute adjunct<br />
to a practice nurse consult, but we have also allowed for 25% of patients (the more complex) to<br />
have a 20 minute consult with the GP.<br />
5.4.2 Multidisciplinary approach<br />
Patients will remain „under the care of their general practice team‟ within the IFHC, even when<br />
health professionals other than the GP and practice/rural nurse, are significantly involved in<br />
care for particular patients (and, in some cases, members of the 'expanded team' may well be<br />
Business case EoI V38 AC 25Feb10 Page 28
providing the majority of care). That is, referral to and/or engagement of workers, other than<br />
the GP and practice/rural nurse, in a patient's care, will not see a transfer of responsibility for<br />
care away from their general practice team. Nor will the involvement of more health<br />
professionals see the proliferation of separate sets of clinical notes, or of parallel but<br />
disconnected care pathways.<br />
The augmented workforce of medical, nursing and allied health care professionals will<br />
nevertheless see themselves, and be seen by others, primarily and intrinsically as part of that<br />
IFHC team; they will talk about „us‟ rather than „them‟ when referring to these centres.<br />
The patients‟ health needs will be cared for, according to their complexity/severity, by the<br />
member(s) of the IFHC team best suited to meeting these needs as per the following diagram 3 :<br />
As members of a single primary/community services team, health professionals at the IFHC will:<br />
have the same catchment population boundaries for the purpose of workload and<br />
resource planning<br />
use common appointment booking systems (eg. rather than referring patients to each<br />
other, will be able to book appointments directly)<br />
use a single common clinical record<br />
develop patient pathways for those requiring multidisciplinary care<br />
develop shared policies and processes<br />
work together in a partnership model.<br />
An IFHC might comprise a multi-disciplinary team that looks like this:<br />
3<br />
Sourced from <strong>Primary</strong> Health <strong>Care</strong> Advisory Council. Progress Report of the Council‟s work to provide advice to the<br />
Ministry of Health and District Health Boards on <strong>Primary</strong> Health <strong>Care</strong> Service Models. Nov 2009<br />
Business case EoI V38 AC 25Feb10 Page 29
5.4.3 Future well child service model<br />
Currently well child service provision is fragmented between Plunket, primary care, Māori health<br />
NGO providers, LMCs and Community nursing services. The advent of IFHCS creates the<br />
opportunity to bring these carers together, so that care is streamlined, information is shared<br />
and families get the right level of follow up.<br />
Initial discussions with NGO service providers indicate a willingness to collaborate in order to<br />
achieve better health outcomes and better use of resources. <strong>More</strong> detailed discussions and<br />
project planning will occur in year one of the implementation phase.<br />
5.4.4 Future mental health service model<br />
[NB. The Mental Health component of this plan was written on the basis of funding being<br />
available to employ Mental Health Co-ordinators in each IFHC. It became apparent on 23 rd<br />
February that this funding was not going to be available. While aspects of this plan may still be<br />
able to be implemented within existing resources and funding, this will require discussion with,<br />
and support from, clinicians from community mental health services, primary mental health<br />
services and primary care. Given the time now available a revision to this plan was therefore not<br />
attempted; this review will done by June 30, 2010.]<br />
Significant changes are proposed for mental health services. Most secondary mental health<br />
services provided by the West Coast DHB are, in fact, community based. Over time it is<br />
proposed that these will increasingly be based in IFHCs to enhance the connection with core<br />
primary care. This process will commence in 1 July 2010 with the devolution of funds for three<br />
primary care based primary mental health co-ordinators who, over time, will conduct almost all<br />
Business case EoI V38 AC 25Feb10 Page 30
The<br />
Community<br />
Health<br />
System<br />
Delivery System<br />
Design<br />
Clinical<br />
Information<br />
Systems<br />
Equity in<br />
Health<br />
assessments for patients with mental health conditions, irrespective of whether patients are<br />
then referred for primary or secondary mental health interventions. Currently, there is one<br />
assessment role in primary care, and it only assesses patients for entry to brief intervention<br />
counselling provided by the primary mental health team.<br />
This devolution will reduce the separateness of (and associated stigma that typically goes with<br />
referral to) secondary mental health services, prevent patients falling through the 'gap'<br />
between primary and secondary mental health services, and further strengthen the provision of<br />
mental health services in primary care settings.<br />
After year two, provided developmental milestones are achieved, it is anticipated that mental<br />
health services will be fully devolved to the PHO/community provider, to enable further<br />
integration of service delivery.<br />
5.4.5 Future management of long term conditions<br />
The WCPHO and DHB have invested significantly in development of a best practice framework<br />
for management of long term conditions (LTCs). The developments to date, and future targets<br />
are detailed in „Appendix 5 Long Term conditions‟. The framework is summarized in the<br />
schematic below.<br />
Chronic conditions management – the WCDHB<br />
framework,<br />
The Patient’s Journey<br />
Environment<br />
Healthy<br />
At Risk<br />
Acute<br />
Event<br />
Initial<br />
management<br />
Long term<br />
clinical and<br />
Self<br />
management<br />
End of Life<br />
<strong>Care</strong><br />
Healthy public<br />
policy and<br />
creation of<br />
supportive<br />
environments<br />
Non-italics=<br />
existing service<br />
Italics= proposed<br />
service<br />
Healthy<br />
Schools;<br />
Smoke free;<br />
HEHA:<br />
Community<br />
events;<br />
Breast feeding;<br />
Men‟s health;<br />
Green Rx;<br />
Health<br />
promoting<br />
practices<br />
CVD and<br />
diabetes<br />
screening,<br />
follow up<br />
for those at<br />
highest risk<br />
Smoking<br />
cessation<br />
Diagnosis,<br />
hospital<br />
admission<br />
Pre-hospital<br />
fibrinolysis<br />
Diabetes<br />
Pulmonary<br />
rehabilitation,<br />
Cardiac<br />
rehabilitation,<br />
Arthritis and<br />
diabetes<br />
education/<br />
support<br />
groups<br />
PHO LTC: Focus on,<br />
CVD, diabetes ,<br />
COPD: clinical and self<br />
management support<br />
<strong>Care</strong>Link and AT&R<br />
assessments and MDT<br />
review for more<br />
complex<br />
Cancer<br />
navigators<br />
Palliative<br />
care<br />
funding in<br />
primary<br />
care<br />
UNDERPINNED BY THE WEST COAST‟S 7 PILLARS OF CHRONIC CONDITIONS MANAGEMENT<br />
Business case EoI V38 AC 25Feb10 Page 31
The programme is both based on the Wagner Chronic <strong>Care</strong> model 1 (self-management support,<br />
community support, delivery system redesign, clinical information systems and decision support)<br />
and the Kaiser Triangle stratified care approach 4 . The Programme meets the National Health<br />
Committee‟s objectives 5 of providing effective chronic care management and co-ordination<br />
through using a population health approach to care delivery, based on level of need, both clinical<br />
need and need for self-management support. There is a focus on those with conditions that are<br />
frequent or severe, and these are addressed by national evidence based clinical guidelines and<br />
are responsive to enhanced primary care management, and have outcomes that can be tracked<br />
over time to measure improvement (cardiovascular disease [CVD], diabetes, and Chronic<br />
Obstructive Pulmonary Disease [COPD]).<br />
The DHB and the Ministry of Health both approved the content of the long term conditions<br />
(LTC) management programme in late 2008, including giving permission to allocate all LTC funds<br />
(diabetes annual review, <strong>Care</strong> Plus, some Section J contract lines and some SIA funding) into a<br />
global budget for this programme.<br />
The programme is based on all patients with diabetes, CVD or COPD having an annual review<br />
from the time of diagnosis, and then based on their clinical condition and ability to self manage,<br />
a decision is made as to the level of care they require for the following year, based on clinical<br />
need and self management competency.<br />
Implementation of the programme has gone well in 2009 using the IHI Breakthrough Series<br />
methodology. A recent evaluation 6 of the implementation showed high acceptance by practices<br />
and increases in the numbers of patients with LTCs managed in a proactive and planned manner –<br />
now 1419 in <strong>Care</strong> plus, 1061 in level 1, 300 in level 2 and 27 in level 3.<br />
The key objectives of the next stage of LTC management are:<br />
<br />
<br />
<br />
<br />
<br />
To increase implementation of the programme so that over 70% of all patients with<br />
COPD, CVD and/or diabetes have an annual review followed by a timely package of care<br />
appropriate for their level of need.<br />
Development of a Māori team within each IFHC who will focus on improving access and<br />
health outcomes for Māori.<br />
To review the management of Level 3 patients and enhance the integration between<br />
general practice care and AT&R, <strong>Care</strong> Link and nurse specialist care and allied heath<br />
To enable and empower people in the community to obtain, process and understand<br />
health information and services needed to make appropriate decisions about their<br />
health.<br />
To develop health navigator support services for Level 3 patients who have difficulty<br />
accessing health care and social services<br />
4 World Health Organisation Innovative <strong>Care</strong> for Chronic Conditions: Building Blocks for Action: Global Report 2002<br />
WHO document no. WHO/NMC/CCH/02.01.<br />
5 National Health Committee People with Long Term Conditions A Discussion Paper National Health Committee<br />
Wellington May 2005<br />
6 North D, Tracey J. Evaluation of the IHI Breakthrough Series Project for West Coast PHO. Jan 2010.<br />
Business case EoI V38 AC 25Feb10 Page 32
To better integrate the support provided to patients by CNSs, allied health and medical<br />
centres, eg. through better communication and information sharing.<br />
To link with the activities described in the health promotion work stream.<br />
The expected outcomes from this programme are set out in the table below.<br />
Outcome measures – for all and for Māori<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
% diabetes HbA1c
staff, allied health, residential care, home care agencies etc. This includes<br />
InterRAI and other assessments.<br />
- A triage function for logging all cases and sending simple routine cases directly<br />
to the appropriate service while ensuring complex cases receive multidisciplinary<br />
assessment,, case management through Chronic Conditions Programme and/or<br />
<strong>Care</strong>Link, and/or referral to specialist services<br />
- Clear, agreed protocols for accessing services<br />
Co-locate <strong>Care</strong> Link with the IFHC, and link staff to specific primary health teams,<br />
thereby giving those teams easy access to expert assessment (interRAI), communitybased<br />
support packages and a case management function for people with long-term<br />
disabling conditions.<br />
Set up a restorative home-based support service based on need, accessed through<br />
<strong>Care</strong>Link and closely linked to primary and community health services,<br />
Make best use of specialist Health of Older People (AT&R) resources:<br />
- set up clear pathways to ensure timely transfer to specialist services for frail<br />
older people and anyone with a stroke<br />
- a greater proportion of AT&R staff time available for consultation and support<br />
for primary health services, home care services and residential care.<br />
A three year implementation plan to achieve these objectives has been developed and is detailed<br />
in the Appendix Eleven.<br />
5.4.7 Link with Secondary services/health pathways<br />
HealthPathways is web-based information system developed by Canterbury DHB Planning and<br />
Funding in conjunction with local clinicians. GPs and hospital clinicians identified the importance<br />
of current information in securing the best care for patients within existing constraints<br />
(workforce and fiscal) and developed HealthPathways to provide this information, with a primary<br />
focus on general practice care.<br />
Currently, the primary care system on the West Coast is not in a good position to take on clinical<br />
tasks currently performed in secondary care settings. Similarly, Greymouth hospital services<br />
are generally staffed on a capacity model – in which staff costs do not vary with reductions in<br />
activity. However, in the medium term, with the strengthening of the primary care sector, and<br />
the development of more activity based staffing for some services, associated with a closer<br />
working relationship with Canterbury DHB, there may be an opportunity to move some clinical<br />
work from the hospital setting into IFHCs.<br />
The main driver for implementing Health Pathways on the Coast at this point is to improve<br />
consistency and quality of care. (see Appendix Seven for further detail).<br />
Business case EoI V38 AC 25Feb10 Page 34
5.5 Enablers<br />
A key aspect of this business case is greater integration of services. Currently, medical centres<br />
on the one hand, and community nursing and allied health and mental health on the other,<br />
operate as mostly separate, parallel systems, even though their respective patient cohorts<br />
overlap significantly. This separateness is underpinned and exacerbated by several structural<br />
factors - the various sets of services use different, unconnected information management<br />
systems (and for different purposes), are housed in multiple, separate buildings, and are owned<br />
& operated by various different entities with very different drivers and constraints. This<br />
project envisages changes in each of these three areas (information technology, facilities,<br />
organisational structures) as key enablers of change.<br />
5.5.1 Future facilities<br />
Renovated or new facilities will be a key enabler of better integration of services in many parts<br />
of the West Coast region. This business case entails two smaller and two larger facility<br />
projects.<br />
The first smaller project is in Greymouth, Grey District, where a proto-IFHC is emerging in the<br />
form of Greymouth Medical Centre's rural primary health training facility. This 'academic<br />
practice' is to be located on the Greymouth Hospital site next to the Emergency Department<br />
(ED). In it, health professionals (and health professionals in training) will work across the<br />
primary practice and the ED. This practice will be operational from 1 July '10.<br />
The second smaller project is in Franz Josef in South Westland, Westland District, where a<br />
joint DHB/St Johns Ambulance facility on St Johns' land is proposed. This facility is larger<br />
than the four other clinics in South Westland, and is likely to become the hub of the South<br />
Westland practice.<br />
The first of the larger projects is in Westport, Buller District, where existing medical centre<br />
and hospital facilities, though located on the same site, are widely dispersed and in various<br />
states of poor repair. The aim is to build a brand new, substantive IFHC, to replace the existing<br />
medical centre and hospital buildings, as the hub of IFHC services district wide for the<br />
foreseeable future. This facility is likely to be a 2011/12 project.<br />
The final project, and the largest and most complex, is the substantive IFHC proposed for<br />
Greymouth. It will subsume/replace the proto-IFHC described above, and is envisaged to bring<br />
the three Greymouth medical centres, various other private providers and the DHB's community<br />
nursing, allied health and community mental health services all together into a single integrated<br />
facility. The IFHC could possibly be located on the Greymouth Hospital site, and even be<br />
physically connected to it. This project, if built on hospital land, would need to dovetail with<br />
the proposed redevelopment of Grey Base Hospital - from which arises some of the complexity<br />
of this project.<br />
Business case EoI V38 AC 25Feb10 Page 35
Appendix Thirteen gives considerably greater detail re these proposed facilities, together with<br />
associated development timelines & funding sources.<br />
5.5.2 Future information systems<br />
One of the key elements of the West Coast Integrated Family Health Centre project is the<br />
electronic integration of health services, supporting an integrated model of service delivery<br />
across a range of geographically isolated service delivery locations.<br />
We will ensure that the right level of access to clinical information is available at each point of<br />
care encountered by patients, and that all appropriate clinical information follows the patient<br />
from carer to carer as they travel through a patient centred network of care, all in a way that<br />
minimises waste and duplication and whist safeguarding patient privacy. Activities to support<br />
this approach include shared electronic clinical records between primary and community<br />
providers, hospital clinicians being able to access primary care clinical records, primary clinicians<br />
accessing summary information in the secondary care system (eg. discharge summaries,<br />
diagnostic results), medical telemetry (eg. videoconferencing, remote consultations and remote<br />
diagnosis).<br />
An individual‟s health information is a taonga – it has great value and is sacred to them. It is<br />
therefore essential to ensure that health information is secure and that a patient's wishes are<br />
adhered to regarding its availability. The PHO and DHB will develop clinical audit protocols and<br />
processes that ensure use is monitored and inappropriate access detected.<br />
This fits with national strategies around the development of integrated Electronic Health<br />
Records (EHR) and with patient access to the same. However, West Coast does not propose to<br />
be a leader in these major developments. Our approach is more tactical, as described in<br />
Appendix Fourteen, but this approach places us well to implement integrated EHR when it<br />
becomes available.<br />
Further information on IT support is provided in Appendix Fourteen.<br />
5.6 Clinician engagement<br />
A wide range of clinicians from general practice, community nursing, allied health and secondary<br />
care have been involved in the development of this plan:<br />
Establishment of large advisory group including range of disciplines from community and<br />
hospital based services that met weekly over three months to provide input and<br />
feedback.<br />
Involvement of a large number of clinicians in each workstream (see details within each<br />
work plan in the appendices).<br />
Business case EoI V38 AC 25Feb10 Page 36
Two rounds of meetings with front line general practice teams, particularly focusing on<br />
models of care.<br />
Wide dissemination of draft documents for input.<br />
Input over three meetings of the PHO Clinical Governance Committee which includes<br />
clinicians, lay and iwi representatives.<br />
Input from the <strong>Primary</strong> Secondary <strong>Care</strong> Liaison (GP Liaison) committee at two meetings<br />
that focused on the EoI.<br />
One-on-one meetings with private practice owners.<br />
Meetings with community pharmacists.<br />
Two open meetings with Senior Medical Officers.<br />
Open meeting with all hospital based clinical leaders.<br />
Of note in this process was the acceptance by the majority of clinicians of the need to change,<br />
the willingness to embrace new models of care that provide better care (continuity, consistency,<br />
co-ordination), sooner care (improved access with decreased waiting times) and more convenient<br />
care (one stop shop approach). While there were some understandable concerns about what this<br />
might mean for future roles and working conditions, there was very little patch protection, a<br />
willingness to look outside the square, and a commitment to work together to develop new<br />
systems and processes of care.<br />
Change management strategies are described further in Section 10.2. Project advisory and<br />
reference group membership is detailed in Appendix Fifteen.<br />
5.7 Community engagement<br />
Given the time frames of this EoI direct community engagement has been less than ideal.<br />
However the following consultation activities were able to take place:<br />
Presentation and discussion of the EoI with the DHB Board at two board meetings.<br />
Detailed discussion of the EoI papers at three PHO board meetings (on the board are<br />
representatives from the three Coast TLAs, representatives from both runanga and the<br />
Māori provider).<br />
Input over three meetings of the PHO Clinical Governance Committee which includes<br />
community, and iwi and Mori provider representatives.<br />
Representation on the EoI Advisory group from NGOs, Māori providers, DHB General<br />
Manager Māori.<br />
Open meeting with NGOs to explain the process and receive their feedback.<br />
Meeting with Greymouth mayor.<br />
If and when the business case is approved, wider community consultation will need to be<br />
undertaken regarding a number of the aspects that this business case envisages and/or<br />
proposes should change (in line with the DHB's statutory requirements). Given the West Coast<br />
Business case EoI V38 AC 25Feb10 Page 37
community's keen interest in their health services, and the scale of changes proposed, it will be<br />
important to engage fully with the community.<br />
In the implementation phase, each IFHC will establish a community reference group or link into<br />
established community engagement groups who can assist in the development of plans for their<br />
districts. These groups will include local mayors (or their representation), community leaders,<br />
business leaders and iwi leaders.<br />
5.8 Evidence for this model<br />
A number of reports and papers have informed the development of the overall model of care:<br />
The 2008 WHO report on <strong>Primary</strong> care: Now more than ever 7 stresses the overall importance<br />
of a strong primary heath sector and in particular the need to bring care closer to the people,<br />
the importance of primary care taking responsibility for the health of a defined or enrolled<br />
population, and the need to strengthen the primary care providers‟ role as co-ordinators of care.<br />
The paper on primary healthcare service models, produced by the <strong>Primary</strong> Health <strong>Care</strong> Advisory<br />
Council 8 , was helpful in developing a model for stratifying the different types of care needed by<br />
the population. Well people with simple problems need fast and efficient care by either a GP or<br />
nurse. Complex long term problems need a proactive approach, often the input of a<br />
multidisciplinary team and a defined key worker. The trick is to keep the efficiencies of<br />
traditional general practice while moving to a model of care that works better for those with<br />
complex problems.<br />
In regard to nurses taking on roles traditionally done by GPs, much as been written that<br />
suggests that moves in this direction can be safe and appropriate for patients. Horrocks et al 9<br />
concluded that for patients requesting same day appointments for minor illness that health<br />
outcomes were equal and patient satisfaction better for nurse practitioners than for GPs.<br />
Consultations were longer and more investigations ordered. On the other hand Cochrane<br />
recently published an extensive review that concluded 10 :<br />
“The findings suggest that appropriately trained nurses can produce as high quality care<br />
as primary care doctors and achieve as good health outcomes for patients. However, this<br />
conclusion should be viewed with caution given that only one study was powered to assess<br />
equivalence of care, many studies had methodological limitations, and patient follow-up<br />
was generally 12 months or less.<br />
7 WHO report on <strong>Primary</strong> care: Now more than ever, 2008. Pg52<br />
8 <strong>Primary</strong> Health <strong>Care</strong> Advisory Council. Progress Report of the Council‟s work to provide advice to the Ministry of<br />
Health and District Health Boards on <strong>Primary</strong> Health <strong>Care</strong> Service Models. Nov 2009<br />
9 Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can<br />
provide equivalent care to doctors. BMJ 2002; 324: 819-23.<br />
10 Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care.<br />
Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001271. DOI: 10.1002/14651858.CD001271.pub2.<br />
Business case EoI V38 AC 25Feb10 Page 38
While doctor-nurse substitution has the potential to reduce doctors' workload and<br />
direct healthcare costs, achieving such reductions depends on the particular context of<br />
care. <strong>Doctor</strong>s' workload may remain unchanged either because nurses are deployed to<br />
meet previously unmet patient need or because nurses generate demand for care where<br />
previously there was none. Savings in cost depend on the magnitude of the salary<br />
differential between doctors and nurses, and may be offset by the lower productivity of<br />
nurses compared to doctors.”<br />
The results of the changes of the model of care outlined in this plan will be monitored carefully<br />
in regards to both patient safety and cost to the health system.<br />
The need for new models of integrated care for the aging population and those with long term<br />
conditions has been well described by Rosen and Ham 11 :<br />
“With an aging population and an increasing prevalence of chronic disease, ever more<br />
people require care and support services from organisations that cross the boundaries<br />
of health, social care, housing and voluntary organisations. A wealth of studies report<br />
that people with chronic, complex health problems – particularly older people – are often<br />
confused by the array of services they are faced with, receive duplicate interventions,<br />
and find it hard to understand where to turn with specific problems. They value<br />
initiatives to co-ordinate care and simplify their journey through the health and social<br />
care systems.<br />
Equally, with pressure to deliver elective care in community settings and prevent<br />
avoidable ill health, integration and collaboration between generalists and specialists –<br />
GPs, consultants, specialist nurses and other clinicians – is increasingly important.”<br />
They advise that any project involving integration of services:<br />
Makes improved patient care the main objective of every proposal.<br />
Develops clearly articulated and shares goals.<br />
Involves local primary care networks and clinicians in developing the strategy.<br />
Takes time and effort to build the relationships, trust and clinical leadership required in<br />
integrated teams.<br />
Measures clinical and social outcomes so that the effect of changes can be reviewed and<br />
programmes modified.<br />
Is careful to unbundle the true costs of any services before devolution occurs.<br />
Develops robust governance arrangements from the start.<br />
Establishes the right incentives for services and clinicians to want to be involved.<br />
11 Rosen R, Ham C. Integrated <strong>Care</strong>: lessons from evidence and experience. Report of the 2008 Sir Roger Bannister<br />
Annual Health Seminar by R Rosen, Nuffield Trust , C Ham, University of Birmingham<br />
Business case EoI V38 AC 25Feb10 Page 39
Similarly Glendenning 12 observes that integration is more likely when the following are present:<br />
<br />
<br />
<br />
<br />
<br />
joint goals<br />
tight knit highly connected professional networks<br />
high degree of mutual trust<br />
joint arrangements which are part of „core business‟ rather than marginal integration at<br />
the edges<br />
joint arrangements covering operational and strategic issues and shared or single<br />
management arrangements.<br />
Degeling and Erskine 13 describe the importance of changing governance arrangements if true<br />
integration of services is to occur:<br />
“Efforts to establish and maintain networks [voluntary connections across<br />
organisational boundaries] are often purely rhetorical. …all too often tangible<br />
achievements on the ground are minimal …” (pg 35) … “Despite their membership in a<br />
network, for most network partners their employing organisation remains their primary<br />
affiliation.” (pg 36)<br />
“Put simply, effective joined-up “local-to-local” collaboration requires equivalent joinedup<br />
governance at the centre …” (pg 36)<br />
“… there is evidence showing how trust and network stability depend on the extent to<br />
which network partners (by way of contracts) have formalized what they can expect of<br />
each other and have established robust governance arrangements through which<br />
partners can be held to account. … These findings suggest that a network‟s<br />
effectiveness depends to a large extent on the degree to which its membership has<br />
been able to institutionalize both its internal operations and its independent existence<br />
from its sponsoring organisations.” (pg 37)<br />
“… the more that service settings (as between primary, acute, community and social<br />
services) are constituted as separate and distinct organisations, the more beliefs will<br />
differ about what should be done and who is best placed and equipped to do it. The<br />
“service gaps” than then result are unlikely to be resolved by, for example, “better<br />
networking”. Because the new service models for long-term conditions of necessity<br />
challenge the biases of existing approaches to service delivery in acute, community and<br />
social care settings, mere administrative solutions (such as the establishment of a<br />
network) are rarely able to produce what is required. Rather policy and funding<br />
authorities are likely to find that success will depend on the extent to which they have<br />
set in place new institutional arrangements and patterns of resource allocation … that<br />
will support the required forms of service integration between different service<br />
settings.” (pg 41)<br />
12 Glendenning, C (2002) „Breaking down barriers: integrating health and care services for older people in England‟,<br />
Health Policy 65: 139–151.<br />
13 Degeling P, Erskine J. Chapter 2. <strong>New</strong> models of long-term care and implications for service redesign. In Rechel B,<br />
Wright S, Edwards N, Dowdeswell B, McKee M. Investing in hospitals of the future. World Health Organisation, on<br />
behalf of the European Observatory on Health Systems and Policies Investing in hospitals of the future. 2009<br />
Business case EoI V38 AC 25Feb10 Page 40
Nick Goodwin, Kings Fund 14 , in his recent presentation to the Ministry of Health concluded from<br />
the international literature that:<br />
“There is a lack of rigorous evaluations of polyclinics in other countries. Contextual<br />
differences are important.<br />
Co-location of professionals is not sufficient to guarantee integrated care - in the<br />
same polyclinic, and between polyclinics and hospitals.<br />
Risks to professional development and motivation.<br />
Issues of patient choice and continuity of care, and how these are to be<br />
safeguarded within a polyclinic-based system<br />
Caution needs to be exercised in basing policy on international experience. “<br />
His advice for successful integration was:<br />
“Strong clinical leadership – quality focus<br />
Team working<br />
Cluster services & diagnostics around patient needs<br />
Investment in change management & process redesign<br />
Maximise benefit of new technologies and IT”<br />
The writings of these people have guided the development of the models of integrated care in<br />
this business case.<br />
In addition a large number of other reports and journal articles are referred to in the Evidence<br />
section of each of the work plans in the appendices.<br />
5.9 Quality, safety and evaluation<br />
Quality philosophy<br />
The integrated family health system will take a quality improvement and systems<br />
approach to all activities.<br />
Quality improvement will be an integral part of the annual business plan, for each IFHC<br />
and the overall organisation.<br />
The focus will be on activities that relate directly to improved health outcomes and<br />
reducing inequalities.<br />
Quality framework<br />
The framework used to categorize quality improvement activities is as follows 15 :<br />
14 Nick Goodwin. Powerpoint presentation to Ministry of Health, Wellington. 15 March 2010<br />
15 Adapted from the Voyage 2 Quality in primary care framework being developed by the Wellington School of Medicine<br />
Business case EoI V38 AC 25Feb10 Page 41
Structure Process Outcomes<br />
Facility environment Clinical care<br />
Health status<br />
Facility systems<br />
Relationships<br />
Equity<br />
Patient experience<br />
Cost<br />
The following table demonstrates expands on this by identifying which aspects of the quality<br />
framework are addressed by the various work plans:<br />
Domain Quality activity Work plan<br />
Structure – facility environment Cornerstone accreditation of each IFHC Workforce<br />
Structure – facility systems QI teams and clinical governance systems<br />
in each IFHC<br />
<strong>Better</strong> after hours arrangements<br />
Process - clinical care HealthPathways care guidelines<br />
Electronic decision support for LTCs<br />
<br />
<br />
<br />
MDT Professional development activities<br />
Active feedback loops<br />
Patient pathways<br />
Process - relationships Core general practice teams<br />
Facilitated planning sessions<br />
MDT teams<br />
<br />
<br />
Shared mental health assessments<br />
Integrated health promotion activities<br />
Outcomes- health status PHO Performance Programme indicators<br />
Long term condition programme<br />
indicators<br />
Public health indicators<br />
Outcomes - equity All access and clinical indicators reported<br />
for Māori and rest of population<br />
Outcomes – patient experience Measure access delays<br />
Develop a community satisfaction<br />
questionnaire<br />
Outcomes - cost Align clinical and financial incentives<br />
Monitor effects of changes to model of<br />
care on finances<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Workforce<br />
Acute care<br />
HealthPathways<br />
Long Term<br />
Conditions<br />
Workforce<br />
Workforce<br />
Integration:<br />
community based<br />
services<br />
Mental Health<br />
Frail elderly<br />
Direct access to<br />
diagnostics<br />
Core general<br />
practice care<br />
Integration:<br />
community based<br />
services<br />
Mental health<br />
Frail elderly<br />
Mental Health<br />
Keeping People<br />
Healthy<br />
Workforce<br />
Long Term<br />
Conditions<br />
Keeping People<br />
Healthy<br />
Core general<br />
practice care<br />
Long Term<br />
Conditions<br />
Core general<br />
practice care<br />
Referred services<br />
Business plan<br />
Business case EoI V38 AC 25Feb10 Page 42
Quality domains<br />
Each new initiative will be assessed to ensure that the following domains of quality have been<br />
addressed 16 :<br />
evidence based<br />
<br />
<br />
<br />
<br />
patient centered<br />
organisational and staff competency and capacity<br />
outcomes and Continuous Quality Improvement approach<br />
financial viability.<br />
Safety<br />
The following safety initiatives are part of this plan:<br />
Significant event auditing (a required aspect of Cornerstone Accreditation).<br />
<br />
<br />
<br />
Safe clinical care: all primary and community providers caring for the same patients use<br />
the same electronic clinical notes.<br />
Safe prescribing: hospital discharge medications copied to pharmacies and adopting<br />
electronic prescribing when available.<br />
Safe feedback: The development of active feedback loops so that any concerns about<br />
the quality of patient care will be fed back to the health providers concerned in a<br />
constructive, educational environment.<br />
Monitoring and evaluation<br />
The PHO has a strong track record in evaluating programmes regularly (either internally or<br />
externally) particularly any new or resource intensive initiative.<br />
The work plans in the appendices all have associated output and outcome measures (with<br />
baselines and targets) that can be used for both quality improvement and evaluation purposes.<br />
Regular monitoring and reporting against these measures will become part of the regular PHO<br />
quarterly report.<br />
In addition every six months a half day 'review of progress' workshop will identify any early<br />
risks to the successful implementation of the plan, and address any issues that have arisen.<br />
We have supported the application to the Health Research Council by Dr Jeff Foote and<br />
colleagues at the Institute of Environmental Science and Research (ESR) Ltd to carry out a<br />
systems analysis on the effectiveness of this business case.<br />
16 Adapted from the RACGP Quality framework http://www.racgp.org.au/qualityframework<br />
Business case EoI V38 AC 25Feb10 Page 43
6 Business model<br />
6.1 Business concept<br />
The business concept involves the development of Integrated Family Health Centres (IFHCs)<br />
based at Westport, Greymouth and Hokitika, with satellite clinics at the surrounding rural<br />
centres. The IFHCs would be run by the West Coast Integrated Family Health Service (IFHS).<br />
The preferred options for the future organisational structure of the IFHS involve a not-forprofit,<br />
non-government organisation, which may or may not be the PHO in a modified form, or a<br />
new entity jointly owned by the existing PHO and DHB. For the sake of brevity, these various<br />
options are shortened to "the IFHS" in this document, and that phrase should be read as<br />
"whatever form of NGO/Trust takes on the provision of community/primary services in the<br />
future". The IFHS would employ many staff and contract with others. The IFHS would also<br />
provide district wide community services that are not based at a particular IFHC. Over time<br />
more services would be devolved to the IFHS, as it builds experience and improves<br />
performance.<br />
The range of services to be provided in and through IFHCs comprises:<br />
the services historically provided by general practices - management of acute and<br />
chronic primary presentations by enrolled patients<br />
the services historically provided by the non-hospital/community based subset of the<br />
DHB provider arm - district/community nursing and allied management of complex<br />
patients, including post discharge.<br />
The building of new facilities is likely to be required in Greymouth and Westport, while<br />
renovations will be required in Reefton. Facilities changes in Hokitika and South Westland are<br />
not planned at this stage.<br />
Services will continue to be delivered in each of the three Territorial Local Authority districts:<br />
Buller (Westport), Grey (Greymouth) and Westland (Hokitika). Current smaller/outlying clinic<br />
locations include:<br />
Karamea<br />
<br />
<br />
<br />
<br />
Ngakawau<br />
Reefton<br />
Moana<br />
Whataroa, Hari Hari, Franz Josef, Fox Glacier and Haast.<br />
The approach is described in broad terms in the schematic over page and then reviewed in more<br />
detail below.<br />
Business case EoI V38 AC 25Feb10 Page 44
Preventative<br />
Acute<br />
LTC management<br />
Restorative<br />
West Coast Integrated Family Health Network<br />
West Coast DHB services: Grey Rural Hospital Centre of Excellence, Mental Health, ATR, other secondary services<br />
West Coast PHO District wide community health services: clinical nurse specialists, some allied health,<br />
Buller IFHC<br />
Greymouth IFHC Westland IFHC<br />
Centred on Westport, outreach to Karamea, Ngakawau, Reefton. Pop 10,000, budget $$$$$ Nominal<br />
budget holding for referred services pharms, labs…<br />
Infrastructure: Integrated reception, common scheduling, 1 pt record, 1 manager, 1 nurse leader, 1 GP<br />
leader, integrated policies & processes, common catchment.<br />
Core <strong>Primary</strong> & community team<br />
Staffing<br />
Programs<br />
Medical staff: GPs/rural hospital medicine specialists and nurse practitioners<br />
Nursing staff: practice nurses, rural nurses, district nurses, well child/school<br />
nursing, , enrolled nurse/aids,<br />
Allied health: physiotherapists, midwives, pharmacist, mental health therapist,<br />
MRTs,<br />
Support: community health worker/navigator / kaiawhina roles<br />
Administration: reception, office manager<br />
Service co-ordination: NASC, discharge planning, LTC care management, Immunisation outreach,<br />
MH assessment and co-ordination<br />
Home based care: personal Inpatient beds Pharmacy dispensing services, medication<br />
care, MOW<br />
reviews<br />
Mental health services: local CMHT, link to primary MH, visiting MH specialist teams<br />
Visiting specialist clinics (medical, nursing, allied health).<br />
Visiting Age care AT&R<br />
Centred on Greymouth,<br />
outreach to…, pop 13,500,<br />
budget $$$$$$<br />
As for Buller – services<br />
customised in size & range<br />
to fit local population<br />
needs<br />
Centred on Hokitika with<br />
outreach to …., pop<br />
8,500, budget $$$$$<br />
As for Buller – services<br />
customised in size &<br />
range to fit local<br />
population needs<br />
Shared District Wide Support Services<br />
Clinical leadership: nursing, medical & allied health professional development, clinical governance, supervision, performance review, education, standing orders, etc<br />
Service commissioning: needs assessment, programme development and implementation across localities for LTCs, acute/after hours, mental health, etc,<br />
Corporate services: Finance, IS, HR, property, supply chain management.<br />
= provided by DHB = provided by IFHS<br />
Business case EoI V38 AC 25Feb10 Page 45
Preventative<br />
Acute<br />
LTC management<br />
Restorative<br />
West Coast Integrated Family Health Network<br />
West Coast DHB services: Grey Rural Hospital Centre of Excellence, Mental Health, ATR, other secondary services<br />
West Coast PHO District wide community health services: clinical nurse specialists, some allied health,<br />
Greymouth IFHC<br />
Buller Westland<br />
Centred on Greymouth, some outreach to Reefton?. Pop 14,000, budget $$$$$ Nominal budget holding for referred services pharms, labs…<br />
Infrastructure: Integrated reception, common scheduling, 1 patientt record, 1 manager, , 1 nurse leader, 1 GP leader, integrated policies &<br />
processes, (common catchment); charter committing multiple tenants in facility to collaborate on model of care<br />
Core <strong>Primary</strong> & community team<br />
Staffing - 3 separate medical centres initially, divided into teams of 5-7 (i.e., with 2-3,000 patients per team)<br />
Programs<br />
Greymouth Family Health<br />
2,000 patients; 1 team<br />
Medical staff: 1 GP<br />
Nursing staff: 2 practice nurses<br />
Greymouth Medical Centre<br />
6,000 patients; 2-3 teams<br />
Medical staff: 3 GPs<br />
Nursing staff: 6 practice nurses<br />
High St Medical Centre<br />
6,000 patients; 2-3 teams<br />
Medical staff: 3 GPs<br />
Nursing staff: 6 practice nurses<br />
Nurse practitioners<br />
Nursing staff across the 3 practices: district nurses, well child/school nursing, enrolled nurse/aids,<br />
Allied health (public & private) across 3 practices: physiotherapists, midwives, pharmacist, MH therapist, MRTs<br />
Support across the 3 practices: community health worker/navigator/ kaiawhina roles<br />
Administration across the 3 practices: reception, office manager<br />
Service co-ordination: NASC, discharge planning, LTC care management, Immunisation outreach, MH assessment and co-ordination<br />
Home based care: personal care, meals on<br />
Pharmacy services, medication reviews<br />
wheels<br />
Mental health services: local CMHT, link to primary MH, visiting MH specialist teams<br />
Visiting specialist clinics (medical, nursing, allied health).<br />
Visiting Age care AT&R<br />
Shared District Wide Support Services<br />
Clinical leadership: nursing, medical & allied health professional development, clinical governance, supervision, performance review, education, standing orders, etc<br />
Service commissioning: needs assessment, programme development and implementation across localities for LTCs, acute/after hours, mental health, etc,<br />
Corporate services: Finance, IS, HR, property, supply chain management.<br />
= provided by DHB = provided by IFHS<br />
Business case EoI V38 AC 25Feb10 Page 46
Preventative<br />
Acute<br />
LTC management<br />
Restorative<br />
West Coast Integrated Family Health Network<br />
West Coast DHB services: Grey Rural Hospital Centre of Excellence, Mental Health, ATR, other secondary services<br />
West Coast PHO District wide community health services: clinical nurse specialists, some allied health,<br />
Westland Virtual IFHC<br />
Buller Grey<br />
Covering both Hokitika and South Westland. Pop 8,500, budget $$$$$ Nominal budget holding for referred services pharms, labs…<br />
Infrastructure:, common scheduling?, 1 pt record, co-ordinated management & clinical leadership (details to be determined), integrated policies &<br />
processes, common catchment; current separate facilities remain (very different geography, and existing modern buildings, make a physical IFHC<br />
unlikely; there's also already a high degree of integration of the nursing workforce in South Westland already)<br />
Core <strong>Primary</strong> & community team<br />
Staffing - 2 separate medical centres – with the Hub and integrated community services at Hokitika<br />
Programs<br />
Westland Medical<br />
5,500 patients; 1-2 team<br />
Medical staff: 2 GPs<br />
Nursing staff: 4.5 practice nurses<br />
South Westland<br />
1,700 patients; 1 team<br />
Medical staff: 1 GP<br />
Nursing staff: 5 practice/rural/(district) nurses<br />
Nurse practitioners<br />
Nursing staff across the 2 practices: district nurses?, well child/school nursing, enrolled nurse/aids,<br />
Allied health (public & private) across 2 practices: physiotherapists, midwives, pharmacist, MH therapist, MRTs<br />
Support across the 2 practices: community health worker/navigator/ kaiawhina roles<br />
Service co-ordination: NASC, discharge planning, LTC care management, Immunisation outreach, MH assessment and co-ordination<br />
Home based care: personal care, meals on<br />
Pharmacy services, medication reviews<br />
wheels<br />
Mental health services: local CMHT, link to primary MH, visiting MH specialist teams<br />
Visiting specialist clinics (medical, nursing, allied health).<br />
Visiting Age care AT&R<br />
Shared District Wide Support Services<br />
Clinical leadership: nursing, medical & allied health professional development, clinical governance, supervision, performance review, education, standing orders, etc<br />
Service commissioning: needs assessment, programme development and implementation across localities for LTCs, acute/after hours, mental health, etc,<br />
Corporate services: Finance, IS, HR, property, supply chain management.<br />
= provided by DHB = provided by IFHS<br />
Business case EoI V38 AC 25Feb10 Page 47
6.2 Locality Integrated Family Health Centres<br />
Each locality IFHC would operate a comprehensive set of locality Multi Disciplinary Team<br />
services under a unified management structure. In the first phase the likely components are:<br />
primary care services<br />
rural A&E services<br />
rural inpatient medical services (other than Grey)<br />
rural nursing services<br />
clinical nurse specialists (incl. diabetes and respiratory education and management)<br />
community / district / whanau / public health nursing services<br />
immunisation services (inc HPV & outreach)<br />
well child services (inc B4 school & VHT)<br />
<strong>Care</strong>link/service co-ordination services<br />
home based care services<br />
community allied health services<br />
mental health brief intervention and co-ordination services<br />
sexual health services.<br />
In those districts where services are co-located, they are also integrated in the following<br />
ways 17 :<br />
single reception for all services<br />
common scheduling, allowing staff to book patient appointments with each team<br />
member, rather than „referring‟<br />
1 patient management system and 1 (electronic) clinical record (using MedTech in the<br />
absence of any other system)<br />
1 operational IFHC manager (no separate „practice manager‟), supported by 1 nursing<br />
leader, 1 GP leader, and team leaders for specific services (eg. mental health), also<br />
supported by an office manager to cover admin requirements<br />
shared clinical and management decision making<br />
integrated policies & processes<br />
shared continuous quality improvement and professional development systems<br />
common catchment population/ boundaries<br />
a single combined services budget, includes nominal budget holding for pharms and labs.<br />
The locus of care is primary and community services, with access to other services (including<br />
hospital services) co-ordinated through these teams. The locality manger is accountable for<br />
financial and clinical outcomes hence all others are either subcontractors or employees of the<br />
IFHC locality manager.<br />
17 In the virtual Westland IFHC some of these integration activities will still be realised<br />
Business case EoI V38 AC 25Feb10 Page 48
The core services are provided or purchased by the PHO. Some visiting specialists services are<br />
provided by the DHB.<br />
A number of other services could potentially be part of the IFHC. It is proposed that while<br />
these may not be included in phase one, initiatives to promote integration and shared decision<br />
making should commence in year one, on the understanding that a number of these might be<br />
devolved to the IFHC in year three. Detailed planning around these will commence in year two.<br />
Service<br />
AT&R services<br />
Maternity<br />
Mental health<br />
services<br />
Outpatient services<br />
NGO services<br />
Aged residential<br />
care<br />
Transport services<br />
Pharms, labs,<br />
radiology<br />
Development<br />
Close working relationships in IFHC, possible future devolution<br />
Close working relationships in IFHC, possible future devolution<br />
Close working relationships in IFHC, future devolution subject to<br />
achieving progress milestones<br />
Input to service planning and development, possible devolution of some<br />
first, follow ups and minor procedures<br />
Close working relationships in IFHC, possible future devolution<br />
Move to partial budget holding in NASC<br />
Interface<br />
Nominal budget holding with gain/loss sharing<br />
6.3 Service outputs and outcomes<br />
We have developed a population based activity model to derive the expected number of visits,<br />
and service provision response for the major service categories given the population of each of<br />
the TLAs, and the proposed model of care. This model requires further validating but provides<br />
an indication of the FTEs required in each IFHC. Note that the model has not yet been<br />
adjusted to reflect different rurality / travel times issues. Expected volumes of services are<br />
shown in the table below:<br />
Summary<br />
Visits /year<br />
Service visits /yr Buller Grey Westland Total<br />
ACC 0.5 4,615 6,415 4,078 15,108<br />
Immunisation 0.3 3,065 4,215 2,612 9,892<br />
Scripts 0.5 5,000 6,900 4,415 16,315<br />
General 3.7 37,900 51,000 31,930 120,830<br />
Diabetes 0.1 668 845 559 2,072<br />
CVD 0.1 760 930 597 2,286<br />
COPD 0.0 328 397 257 982<br />
B4 school chks 0.0 132 204 114 450<br />
Sexual health 0.1 1,300 2,050 1,320 4,670<br />
Pharms reviews 0.1 725 885 581 2,191<br />
cvd risk asst 0.0 393 488 331 1,212<br />
District nursing 0.7 7,080 8,730 5,600 21,410<br />
<strong>Primary</strong> MH 0.1 1,058 1,436 954 3,447<br />
Physio 0.3 2,830 3,770 2,506 9,106<br />
Other - - - - -<br />
Total 6.4 65,854 88,265 55,852 209,972<br />
Business case EoI V38 AC 25Feb10 Page 49
The table shows that general, undifferentiated primary care consults are the biggest single<br />
component of service in the IFHCs.<br />
Based on the model of care described earlier in this paper, estimates of average required<br />
minutes per visit, and the % of visits requiring intervention by the various types of health<br />
professional have been developed for each service line (adjusted for age). This then generates<br />
FTE requirements in total and for each IFHC, based on the district population.<br />
Total required FTEs for the West Coast region are shown below<br />
Summary<br />
DHB total FTEs<br />
Service Admin DN / CN PN GP (brief) GP (full) PharmacistPMH therapist Physio<br />
ACC 1.4 - 3.6 0.5 0.8 - - 0.3<br />
Immunisation 0.9 - 2.8 - - - - -<br />
Scripts 1.5 - 0.4 0.5 - 0.7 - -<br />
General 11.2 - 26.1 3.7 8.7 0.0 - 1.4<br />
Diabetes 0.2 - 0.8 0.1 0.2 0.0 - -<br />
CVD 0.2 - 0.9 0.1 0.2 0.0 - -<br />
COPD 0.1 - 0.4 0.1 0.1 0.0 - -<br />
B4 school chks 0.0 0.3 - - - - - -<br />
Sexual health 0.4 - 1.0 0.1 0.3 - - 0.1<br />
Pharms reviews 0.2 - - 0.2 - 0.7 - -<br />
cvd risk asst 0.1 - 0.5 0.0 - - - -<br />
District nursing 2.0 17.6 - - - - - -<br />
<strong>Primary</strong> MH 0.3 - - - - - 2.3 -<br />
Physio 0.8 - - - - - - 3.1<br />
Other - - - - - - - -<br />
Total 19.4 17.9 36.4 5.3 10.3 1.5 2.3 4.9<br />
GP total 15.6<br />
Total required FTEs for the Buller IFHC are shown below<br />
Summary<br />
Buller FTEs<br />
Service Admin DN / CN PN GP (brief) GP (full) PharmacistPMH therapist PHYsio<br />
ACC 0.4 - 1.1 0.2 0.2 - - 0.1<br />
Immunisation 0.3 - 0.9 - - - - -<br />
Scripts 0.5 - 0.1 0.2 - 0.2 - -<br />
General 3.5 - 8.1 1.2 2.8 0.0 - 0.4<br />
Diabetes 0.1 - 0.3 0.0 0.1 0.0 - -<br />
CVD 0.1 - 0.3 0.0 0.1 0.0 - -<br />
COPD 0.0 - 0.1 0.0 0.0 0.0 - -<br />
B4 school chks 0.0 0.1 - - - - - -<br />
Sexual health 0.1 - 0.3 0.0 0.1 - - 0.0<br />
Pharms reviews 0.1 - - 0.1 - 0.2 - -<br />
cvd risk asst 0.0 - 0.2 0.0 - - - -<br />
District nursing 0.7 5.8 - - - - - -<br />
<strong>Primary</strong> MH 0.1 - - - - - 0.7 -<br />
Physio 0.3 - - - - - - 1.0<br />
Other - - - - - - - -<br />
Total 6.1 5.9 11.3 1.7 3.2 0.5 0.7 1.5<br />
GP total 4.9<br />
Business case EoI V38 AC 25Feb10 Page 50
Total required FTEs for the Grey IFHC are shown below<br />
Summary<br />
Grey FTEs<br />
Service Admin DN / CN PN GP (brief) GP (full) PharmacistPMH therapist PHYsio<br />
ACC 0.6 - 1.5 0.2 0.3 - - 0.1<br />
Immunisation 0.4 - 1.2 - - - - -<br />
Scripts 0.6 - 0.2 0.2 - 0.3 - -<br />
General 4.7 - 11.0 1.6 3.7 0.0 - 0.6<br />
Diabetes 0.1 - 0.3 0.0 0.1 0.0 - -<br />
CVD 0.1 - 0.4 0.1 0.1 0.0 - -<br />
COPD 0.0 - 0.2 0.0 0.0 0.0 - -<br />
B4 school chks 0.0 0.1 - - - - - -<br />
Sexual health 0.2 - 0.4 0.0 0.1 - - 0.0<br />
Pharms reviews 0.1 - - 0.1 - 0.3 - -<br />
cvd risk asst 0.0 - 0.2 0.0 - - - -<br />
District nursing 0.8 7.2 - - - - - -<br />
<strong>Primary</strong> MH 0.1 - - - - - 1.0 -<br />
Physio 0.3 - - - - - - 1.3<br />
Other - - - - - - - -<br />
Total 8.2 7.3 15.4 2.2 4.3 0.6 1.0 2.0<br />
GP total 6.6<br />
Total required FTEs for the Westland IFHC are shown below<br />
Summary<br />
Westland FTEs<br />
Service Admin DN / CN PN GP (brief) GP (full) PharmacistPMH therapist PHYsio<br />
ACC 0.4 - 1.0 0.1 0.2 - - 0.1<br />
Immunisation 0.2 - 0.8 - - - - -<br />
Scripts 0.4 - 0.1 0.1 - 0.2 - -<br />
General 3.0 - 6.9 1.0 2.3 0.0 - 0.4<br />
Diabetes 0.1 - 0.2 0.0 0.0 0.0 - -<br />
CVD 0.1 - 0.2 0.0 0.1 0.0 - -<br />
COPD 0.0 - 0.1 0.0 0.0 0.0 - -<br />
B4 school chks 0.0 0.1 - - - - - -<br />
Sexual health 0.1 - 0.3 0.0 0.1 - - 0.0<br />
Pharms reviews 0.1 - - 0.0 - 0.2 - -<br />
cvd risk asst 0.0 - 0.1 0.0 - - - -<br />
District nursing 0.5 4.6 - - - - - -<br />
<strong>Primary</strong> MH 0.1 - - - - - 0.6 -<br />
Physio 0.2 - - - - - - 0.8<br />
Other - - - - - - - -<br />
Total 5.2 4.7 9.7 1.4 2.7 0.4 0.6 1.3<br />
GP total 4.1<br />
The table below shows modeled versus current FTEs for the whole region.<br />
Total DHB<br />
Actual Budgeted Modelled c.f budget c. f. actual<br />
GPs 16.4 24.3 15.6 -8.7 -0.7<br />
Practice/rural nurses 26.3 33.0 36.4 3.4 10.1<br />
reception /admin 22.0 22.0 19.4 -2.5 -2.5<br />
District nurses 18.9 19.3 17.9 -1.4 -1.0<br />
Business case EoI V38 AC 25Feb10 Page 51
Generally the modeled FTEs, although they are a reduction on budgeted GP numbers, reflect<br />
current actual FTEs overall. However, some practices are well under the required GP numbers,<br />
and some are over. This will take some time to work through.<br />
Business case EoI V38 AC 25Feb10 Page 52
7 Governance, Ownership & Management<br />
This business case assumes that a West Coast based entity, (probably not-for-profit,<br />
non-government, e.g., a community trust) assumes responsibility for the operation of the<br />
community based, non hospital services, currently operated by the DHB, including primary care<br />
services. Such an Integrated Family Health Services (IFHS) entity will be able to implement<br />
the degree of integration required to achieve the proposed model of care and realise the<br />
required financial savings.<br />
7.1 Options<br />
Four governance, ownership and management options have been considered:<br />
Option A – status quo<br />
Option B - DHB cancels PHO contract, and absorbs PHO role into its own structures.<br />
Option C - PHO assumes responsibility for current DHB primary and community services<br />
and runs IFHCs and (former) DHB wide community services; PHO trust deed<br />
and the make-up of its governance board changes to reflect its different role;<br />
DHB retains planning & funding, and secondary (hospital) services delivery<br />
roles.<br />
Option D - DHB/PHO „joint venture‟ or (in the interim) alliance contract for delivery of<br />
primary & community services; DHB retains planning & funding, and secondary<br />
(hospital) services delivery roles.<br />
The status quo option is not further described, as the prima facie case is that two entities<br />
running parallel structures is not cost effective.<br />
These options B, C and D are depicted in schematics below.<br />
Business case EoI V38 AC 25Feb10 Page 53
Option B: DHB takes over current PHO functions<br />
DHB Board & CEO<br />
DHB<br />
funder<br />
DHB<br />
secondary<br />
services<br />
Shared<br />
corporate<br />
services<br />
GM primary &<br />
community<br />
Region-wide services<br />
IFHCs<br />
Under this option the DHB cancels the PHO contract and takes full responsibility for delivery<br />
of integrated primary and community services.<br />
Option C - PHO assumes responsibility for current DHB <strong>Primary</strong> & Community services<br />
DHB Board & CEO<br />
PHO Board<br />
DHB<br />
funder<br />
DHB<br />
secondary<br />
services<br />
Shared<br />
corporate<br />
services<br />
GM primary &<br />
community<br />
Region-wide services<br />
IFHCs<br />
Under this option the DHB devolves to the PHO responsibility for delivery of integrated<br />
primary and community services. The makeup of the PHO board, and its associated trust deed,<br />
would need to adapt to this expanded role.<br />
Business case EoI V38 AC 25Feb10 Page 54
Option D: PHO/DHB jointly owned <strong>Primary</strong> & Community services entity<br />
DHB Board / CEO<br />
PHO Board<br />
DHB<br />
funder<br />
P & C Trust or<br />
alliance contract<br />
DHB<br />
secondary<br />
services<br />
Shared<br />
corporate<br />
services<br />
GM primary &<br />
community<br />
Region-wide services<br />
IFHCs<br />
Under this option the DHB and PHO Boards form an alliance either using contractual<br />
arrangements or a joint venture entity, to achieve integrated management of primary and<br />
community services. Over time, the continued need for the parent bodies could be assessed.<br />
7.2 Assessing the options<br />
In any of options B, C and D, a West Coast based entity assumes responsibility for the operation<br />
of the community based, non hospital services, currently operated by the DHB, including primary<br />
care services, and the current functions of the PHO.<br />
The option of the PHO disappearing, and the DHB assuming responsibility for the entirety of<br />
primary and community services (Option B) is not attractive to either the existing PHO or to<br />
private providers. This option is also unlikely to assist the sector in managing within available<br />
funding. It could also lead to less local influence and orientation, should the West Coast DHB's<br />
understandable moves to work more closely with Canterbury DHB, lead eventually to its own<br />
disappearance as an independent entity.<br />
Therefore, most thinking has been focused on developing Options C and D. Both of these come<br />
with some possibilities for interim steps and a staged approach. For example, it may be that the<br />
DHB might continue to employ and remunerate staff, and the focus of effort in the first year<br />
be on integrating actual service delivery (rather than on changing organisational structures).<br />
The PHO and DHB boards have established a joint management and clinical working party to<br />
consider the costs and benefits of the organisational options and to come up with firm<br />
recommendations to their respective boards by 30 April 2010.<br />
Business case EoI V38 AC 25Feb10 Page 55
8 Contracting arrangements<br />
8.1 Role of the IFHS<br />
The Integrated Family Health Service (IFHS) would lead the development of community and<br />
primary care services, and would be accountable to the DHB for the financial and clinical<br />
outcomes of the delegated services. It would work closely with the DHB to achieve a smooth<br />
interface with secondary services, including the development of integrated care pathways<br />
between primary and secondary services (building off the Canterbury DHB pathways). The two<br />
would also share corporate support services in the interim.<br />
The IFHS will both employ staff directly, and will contract with individual providers to achieve<br />
the outcomes. It will establish district development and support services (in many cases jointly<br />
with the DHB) to ensure professional development and support for specific workforce groups<br />
(eg. allied health staff) and will put in place overall policies an processes (eg. use of HML to<br />
triage all after hours calls, use of common standing orders policies). The IFHS will be in a good<br />
position to compare performance between the three IFHCs and address issues at an early stage.<br />
The IFHS also has the role of prioritizing service provision – taking the tough decisions about<br />
what will not be provided so as to live within the available funding. An advantage of an NGO<br />
entity in this respect is its inability to run continuing deficits and to rely on the Government as<br />
a funder of last resort.<br />
8.2 Annual health service plan<br />
The proposal is that an annual health services plan be agreed between the DHB and IFHS,<br />
setting out:<br />
inputs<br />
outputs<br />
outcome targets<br />
reporting schedule<br />
information access arrangements<br />
facilities leases<br />
payments from and to the DHB<br />
services to be provided<br />
quality standards<br />
sharing of corporate costs.<br />
Business case EoI V38 AC 25Feb10 Page 56
The IFHS will need the ability to balance gains and losses across service lines. Hence a flexible<br />
contract arrangement on a funding for outcomes basis is proposed. Specifically the provider will<br />
have the flexibility to use gains in one service area to offset losses in others.<br />
The DHB and IFHS provider will jointly review and reach agreement on major service delivery<br />
decision that will impact on each other, including a review of inpatient services at Buller.<br />
Provided satisfactory progress is being made, then mental health service responsibility will be<br />
contracted to the IFHS from the end of year three. This will allow other changes to be bedded<br />
in.<br />
8.3 Contracted providers within IFHCs.<br />
The proposed approach to engaging the workforce within the IFHCs has three major<br />
components:<br />
Existing private providers continue to operate as semi-autonomous businesses within<br />
<br />
<br />
IFHCs, but will enter into a collective agreement (possibly an alliance style contract)<br />
that involves shared corporate and facility based services, and collective vision, and<br />
alignment of clinical processes, policies and pathways.<br />
Other services within IFHCs will be provided by the IFHS.<br />
In addition, the PHO will play a role as a facilitator of integration within each IFHC.<br />
Business case EoI V38 AC 25Feb10 Page 57
9 Financial sustainability<br />
9.1 Status quo financial situation<br />
As noted in section 1, the WCDHB is projecting a sizeable deficit. The table below shows the<br />
DHB and PHO forecast annual profit and loss for 2009/10 based on the six months actuals to<br />
December 2009, using the proposed new service groupings 18 .<br />
Overhead &<br />
Annual forecast Revenue Expenditure Profit / loss<br />
revenue<br />
allocation<br />
Profit / loss<br />
after Oheads<br />
Buller IFHC - 6,916,966 10,971,593 -4,054,627 311,079 -4,365,706<br />
Grey IFHC - 4,786,998 5,501,697 -714,698 - 377,934 -336,764<br />
Westland IFHC - 2,251,108 2,644,070 -392,962 125,677 -518,639<br />
IFHC distict wide - 2,623,900 2,957,122 -333,222 207,653 -540,875<br />
WCPHO - 5,186,089 4,666,855 519,234 - 519,234<br />
Total primary & community - 21,765,061 26,741,337 -4,976,276 266,474 -5,242,750<br />
Mental Health - 12,503,600 10,665,960 1,837,640 1,644,881 192,759<br />
DHB secondary - 36,143,984 43,823,541 -7,679,557 640,689 -8,320,246<br />
DHB corporate - 7,911,042 11,246,868 -3,335,826 - 3,335,826<br />
0<br />
DHB Funder - 51,726,777 46,304,029 5,422,748 783,782 4,638,966<br />
Total DHB services - 108,285,403 112,040,398 -3,754,995 - 266,474 -3,488,521<br />
Total West Coast - 130,050,464 138,781,735 -8,731,271 0 -8,731,271<br />
Based on status quo revenue and expenditure, each of the IFHCs, plus the district wide service<br />
would make a sizeable deficit. Overall, the estimated deficit for primary and community<br />
services is $5.25 million, approximately 20% of current revenue. The PHO is forecasting a<br />
surplus of around $0.5 million for the year, resulting from lower than anticipated uptake of<br />
some of the LTC and other fee for service programmes – hence the status quo DHB loss on<br />
these services is in the order of $5.75 million for 2009/10. At the same time, the DHB<br />
secondary care services core deficit is about $8 million, partially offset by a DHB funder<br />
surplus.<br />
The reader should note that this projection is based on a 6 month snapshot, updated to<br />
incorporate WCDHB finance team forecast as at end January 2010. Year end actuals for 2010<br />
may vary from those projected. This table also does not incorporate any adjustments for the<br />
expected DAP budget 2010/11 changes.<br />
Overheads and internal revenue have been allocated using the 08/09 national pricing project<br />
West Coast submission with minor adjustments.<br />
If the business case is approved, the DHB and PHO will undertake a more detailed allocation of<br />
direct and indirect revenue and expenditure to fully validate the new service groupings and<br />
refine the P&L forecast.<br />
18 Note that known duplicates in the DHB funder arm and PHO have been eliminated, but some may persist resulting in<br />
double counting of both revenue and expenditure – this does not affect the profit/loss calculation.<br />
Business case EoI V38 AC 25Feb10 Page 58
Of note, a large proportion of the current loss in community and primary care services is driven<br />
from service provision in the Buller/Reefton Territorial Local Authority (TLA). This reflects<br />
losses at both the medical centres and from the provision of hospital and residential care<br />
services.<br />
9.2 Addressing affordability<br />
Clearly the projected losses are unsustainable. The DHB has indicated a target reduction in the<br />
deficit of 50% at the end of three years, and 100% within 5 years. We have adopted a target<br />
reduction of 65% of the primary/community deficit within 3 years, with full deficit eradication<br />
within 5 years.<br />
This will require tough decisions to be taken, and will inevitably involve reductions in services in<br />
some areas, as well as efficiency and effectiveness gains.<br />
The options for achieving these savings are still under discussion, and will be subject to<br />
consultation, but the table below outlines the size of the possible gains that can be made over<br />
three years based on a preliminary assessment.<br />
The financial sustainability initiatives include:<br />
$0.5m estimated to be able to be saved by reducing administration and management<br />
FTEs through primary and community co-location and service integration.<br />
$1.5m estimated to be able to be saved by service reconfigurations, relocations and<br />
reductions.<br />
$1.1m savings through adopting a team based model of general practice care and moving<br />
to a 1:2000 GP ratio, partly offset by costs of $0.6m associated with moving to a 1:900<br />
practice nurse ratio.<br />
$0.23m estimated to be saved through reduced use of secondary care follow ups.<br />
$0.1m from reductions in ASH admissions.<br />
$0.25m from referred services management initiatives.<br />
$0.5m gain to the community provider from a realistic price for rural inpatient bed<br />
services.<br />
Each of the possible initiatives has been scoped at a conceptual level, but will require further<br />
work and some will require consultation and clinical validation before they can be confirmed.<br />
Some savings could be made quite quickly, while others savings will not be realised until new<br />
facilities are in place.<br />
Transitional arrangements<br />
The intention is that the DHB will provide transitional funding on an abating basis to cover the<br />
deficit over the first five years of operation – at the end of which the operations will be<br />
breakeven or better. The transitional funding reduces from $4.6m in year 1 to $1.3m in year 3.<br />
Business case EoI V38 AC 25Feb10 Page 59
In early years, the IFHS community provider is likely to continue to purchase some corporate<br />
services from the DHB, though it may need to assess the viability of doing so beyond the first<br />
year, in order to continue its momentum towards breakeven.<br />
The transitional funding, and resulting forecast revenue and expenditure are set out in the<br />
table below:<br />
Integrated primary & community revenue and expenditure forecast<br />
IFHC + DHB wide community Start point year 1 year 2 year 3<br />
Base revenue - 21,765,061 - 21,765,061 - 21,765,061 - 21,765,061<br />
Service changes - 547,500 - 690,000 - 690,000<br />
Transitional funding - 4,600,000 - 2,100,000 - 1,300,000<br />
Total revenue - 21,765,061 - 26,912,561 - 24,555,061 - 23,755,061<br />
Base expenditure 27,007,811 27,007,811 27,007,811 27,007,811<br />
service changes - 142,500 - 2,479,992 - 3,316,420<br />
Net expenditure 27,007,811 26,865,311 24,527,819 23,691,392<br />
Profit / loss -5,242,750 47,250 27,242 63,669<br />
9.3 Impact on the DHB<br />
The DHB provider arm is currently incurring a loss of some $5.75 million on its primary and<br />
community services. This loss would reduce to nil in year one as both the revenue and<br />
expenditure are transferred to the PHO.<br />
The DHB funder would incur new costs associated with paying the transitional funding amount<br />
(starting at $4.6 million in year 1 and abating to $1.3 million in year 3) and a proposed higher<br />
price for rural inpatient bed services to reflect the actual cost of provision.<br />
Overall, in year 1 there is a net financial gain to the DHB of $0.5 million (representing the PHO<br />
surplus contribution defraying current losses), while by year three the net fiscal gain for the<br />
DHB increases to $3.95 million (ie. the difference between the current loss of $5.75m and the<br />
forecast transitional funding of $1.3m plus about 0.5m in higher bed day prices). This equates<br />
to around a 68% improvement in the fiscal impact on the DHB bottom line for these services.<br />
Over the following two years the transitional funding amount would reduce to zero.<br />
Critical assumptions<br />
Important assumptions in this business case include:<br />
Transitional funding support is made available from the DHB on an abating basis over 5<br />
<br />
<br />
years.<br />
Funding flexibility – to allow savings in one area to offset losses in others.<br />
Savings on referred services and secondary care derived from changes to primary care<br />
are passed back to the PHO/community provider to offset losses.<br />
Business case EoI V38 AC 25Feb10 Page 60
The DHB delegates decision making on the service change/reduction proposals to the<br />
PHO/community provider to expedite decision making (or takes financial responsibility<br />
for any delays in approval).<br />
The DHB will bear the cost of any redundancies of community based staff over the<br />
initial 3 year period. From that point, responsibility will shift to the PHO/community<br />
provider.<br />
The DHB will retain ownership of major capital items such as hospital facilities, and the<br />
PHO will pay for use of the same<br />
Current revenue and expenditure associated with the provision of the identified<br />
community service will transfer from the DHB to the PHO.<br />
Decisions will be taken by 31 July 2010 on those service changes/reductions that will<br />
require community/staff consultation before finalizing – so that changes can be<br />
implemented before the beginning of year two.<br />
Business case EoI V38 AC 25Feb10 Page 61
•<br />
10 Implementation plan<br />
10.1 Project governance and management<br />
If either of Options C (devolution to PHO) or D (new joint entity) are chosen the two boards will<br />
establish a subcommittee led by the two chairs to oversee the change. The subcommittee will<br />
appoint an individual to take over the current PHO CEO and DHB community GM roles and will<br />
oversee the development and implementation of a change plan.<br />
The subcommittee will also establish a Project Office under the direction of the newly<br />
established combined PHO CEO/GM community role to ensure best practice project<br />
management of the intended changes, including:<br />
task sequencing and critical path development<br />
reporting<br />
communications planning<br />
financial monitoring<br />
HR and legal input.<br />
The advisory group that helped to create this business case will be maintained to advice on<br />
aspects of the change programme.<br />
The change programme will be governed using project alliancing principles, including:<br />
transparent information sharing<br />
shared risk/gain<br />
integrated operational management of the change<br />
alignment around a set of mutually agreed goals<br />
agreed decision making processes<br />
shared project values.<br />
These principles will be agreed in a heads of agreement or alliance contract between the PHO<br />
and the DHB.<br />
10.2 Change management<br />
The key drivers for change are:<br />
Clinical sustainability: the current model of care in most health centres requires GP<br />
numbers we have not been able to achieve consistently on the Coast for at least five<br />
years, and leads to long waiting times for appointments (often > three weeks) and lack of<br />
continuity and consistency of care.<br />
Business case EoI V38 AC 25Feb10 Page 62
Limited integration of community services with primary care leading to lack of coordination<br />
and consistency of care and some duplication of services.<br />
Financial: primary care medical practices and community services owned by the DHB<br />
contribute significantly to the DHB overspend each financial year. Hospitals in Reefton<br />
and Buller together also contribute significantly to the DHB overspend each financial<br />
year.<br />
The barriers to change include:<br />
Some primary care providers are overworked and lack energy for change.<br />
GPs not having time to participate in planning workshops.<br />
Some health providers are comfortable working within the current model of care and do<br />
not see the need for change.<br />
There are concerns that changes in the current model of care may lead to a decrease in<br />
the quality of care.<br />
Some staff may be concerned about erosion of current terms and conditions of<br />
employment, and/or reduced support for professional development.<br />
Recruitment on the coast is difficult, whereas health professionals generally find it easy<br />
to get jobs elsewhere if they are not successful engaged in the new models of care.<br />
The key change management task is to communicate to the community and health providers the<br />
vision of Integrated Family Centres that provide better, quicker, more convenient health care.<br />
The Toolkit for Change produced by the primary health care strategy implementation work<br />
programme 19 , promotes the following steps when introducing change:<br />
“Building the case for change, establishing a sense of urgency and using emergent<br />
opportunities as a catalyst for change.<br />
Confirming the vision for the future desired state and achieving widespread ownership<br />
of the change / new vision.<br />
Early engagement with key stakeholders, particularly those likely to be opposed to<br />
change. It will be important to understand the perspectives of key stakeholders and<br />
reframe the message accordingly.<br />
Developing plans with short-term achievable objectives and also longer term objectives.<br />
The short term goals are a stepping stone to the larger vision and create momentum.<br />
Emphasising the win-win nature of the change, but also being transparent with regard to<br />
uncertainties.<br />
<br />
We note that the Toolkit for Change provides a very useful guide for change management in<br />
health, and that it will be used as a guide in implementing the change programme, particularly:<br />
Lewin‟s forcefield analysis, pg 17.<br />
Nilakant‟s change framework, pg 19.<br />
19 <strong>Primary</strong> health care strategy implementation work programme. Toolkit for Change. MoH, DHBNZ. April 2009<br />
Business case EoI V38 AC 25Feb10 Page 63
Kotter‟s change framework, pg 25.<br />
Dealing with the human aspects of change, pg 46.<br />
What‟s in it for me framework, pg 48.<br />
Change checklist, pg 49.<br />
Roadmap for transformational change, pg 52.<br />
10.3 Investing in change<br />
West Coast PHO has agreed to make $750,000 available from its conserved resources to<br />
facilitate change management associated with achieving the changes proposed. Further<br />
resources may be provided if required.<br />
Estimated change management costs are set out in the table below:<br />
2009/10 2010/11 2011/12 2012/13<br />
Project office 20,000 90,000 90,000<br />
HR/organisation redesign 20,000 30,000<br />
Facilitating new models of care 20,000 94,000 70,000 60,000<br />
Implementing service<br />
strategies (particularly<br />
workforce & improved access<br />
to diagnostics work streams)<br />
93,000 100,000 90,000<br />
Analysis of pharms and labs<br />
30,000<br />
spend & strategy development<br />
Information systems<br />
30,000 170,000<br />
development<br />
Other costs (legal, service<br />
40,000 50,000 50,000 0<br />
development, financial<br />
modeling)<br />
Total 130,000 557,000 310,000 150,000<br />
Total over three years $1,147,000<br />
The Ministry of Health is requested to provide funding of $130,000 in 2009/10, and $167,000<br />
in 2010/11 and $100,000 in 2011/12 to facilitate the next steps in the business case.<br />
No capital development costs are included in this business case as yet. Private capital options<br />
to fund facilities development are being explored in the first instance.<br />
Business case EoI V38 AC 25Feb10 Page 64
10.4 Key milestones<br />
The table below shows the important milestones associated with the integration of primary and<br />
community services.<br />
Element Year 1 Year 2 Year 3<br />
Integrating <strong>Primary</strong><br />
and community<br />
services<br />
Team based primary<br />
care<br />
Integrated management<br />
and delivery of primary and<br />
community services<br />
through a single<br />
management structure and<br />
IFHC teams<br />
Refinement of team based<br />
primary care at Buller –<br />
move to 1:2000 GP ratio<br />
and 1:900 practice nurse<br />
ratio<br />
Cross DHB standardisation<br />
of standing orders, use of<br />
HML triage and service<br />
pathways<br />
Affordability Implementation of year 1<br />
savings initiatives,<br />
transitional funding of<br />
$5.5m. Consultation on<br />
service relocations and<br />
reductions and decisions<br />
taken<br />
Facilities and colocation<br />
Information systems Move allied health and<br />
district nurses to<br />
MedTech.<br />
Allow access to primary<br />
and hospital records to all<br />
authorized DHB and PHO<br />
practitioners<br />
Implement privacy audit<br />
arrangements.<br />
Bedding in of new IFHC<br />
teams. Implement new<br />
policies and procedures<br />
across<br />
primary/community<br />
Introduction of team<br />
based care at Grey<br />
practices<br />
Implementation of year<br />
1 savings initiatives –<br />
transitional funding of<br />
$3.5m<br />
Co-location of services<br />
at Buller<br />
Full implementation of<br />
InteRai.<br />
Review possibilities for<br />
integrated health<br />
record in conjunction<br />
with Canterbury.<br />
Integration of mental<br />
health services with<br />
primary and community<br />
health services<br />
Refinement of team<br />
based care at Grey<br />
practices - move to<br />
1:2000 GP ratio and<br />
1:900 practice nurse<br />
ratio<br />
Implementation of year<br />
1 savings initiatives –<br />
transitional funding of<br />
$1.5m<br />
Co-location of services<br />
at Greymouth<br />
Pre- establishment milestones<br />
Prior to 30 June 2010, the following milestones will be achieved:<br />
<br />
<br />
<br />
<br />
<br />
<br />
agreement on organisation/governance option<br />
agreement on project charter/alliance contract<br />
agreement on final list of phase 1 services<br />
agreement on revenue and expenditure to be contracted to the PHO/community provider<br />
agreement on payment to DHB for corporate overheads/services<br />
agreement on transition funding and abatement regime<br />
Business case EoI V38 AC 25Feb10 Page 65
appointment of GM/PHO CEO to oversee the changes<br />
establishment of project office and commencement of detailed project planning<br />
agreement on year one Annual Health Services Plan (including funding, reporting, etc).<br />
10.5 Objectives, key activities and workplans<br />
The tables below map the objectives, key activities and associated workplans to each of the<br />
eight major goals for <strong>Better</strong> <strong>Sooner</strong> <strong>More</strong> <strong>Convenient</strong> health care in the West Coast. This<br />
provides an overall implementation roadmap for the interlinked series of projects.<br />
Goal 1. Partnership with the community<br />
Objectives Key activities Associated work plans<br />
Community focus on wellness<br />
and prevention<br />
<strong>More</strong> self care skills leading<br />
to decreased acute demand<br />
Information campaign about after<br />
hours arrangements<br />
Information campaign about how to<br />
access care at your general practice –<br />
role of nurses etc<br />
Collaborative approach to health<br />
promotion<br />
Focus on smokefree, immunisation and<br />
health living<br />
<strong>More</strong> health promotion in the<br />
workplace<br />
Health promoters based in IFHCs<br />
Enhanced screening programmes<br />
Community education about self care<br />
for common conditions<br />
Access to web based information<br />
Coaching for frequent flyers<br />
Self management support for those<br />
with long term conditions<br />
Core general practice<br />
redesign<br />
Acute <strong>Care</strong><br />
Keeping people healthy<br />
Mental health<br />
Long term conditions<br />
Core general practice<br />
redesign<br />
Keeping people healthy<br />
Long term conditions<br />
Mental health<br />
Frail older people<br />
Goal 2 <strong>Sooner</strong> for patients: improving access to primary care<br />
Objectives Key activities Associated projects<br />
<strong>More</strong> flexible appointment<br />
systems in general practices<br />
Expanded nurse roles<br />
Facilitated workshops with practices<br />
to develop more flexible appointment<br />
systems eg. triage of appointments,<br />
phone appointments, email<br />
appointments, varying appointment<br />
length, extended hours clinics<br />
Nurse triage<br />
Nurses as first contact<br />
Implementation of standing orders<br />
Core general practice<br />
redesign<br />
Core general practice<br />
redesign<br />
Acute care<br />
Business case EoI V38 AC 25Feb10 Page 66
Expanded pharmacy roles<br />
Improving access for Māori<br />
Improved after hours care<br />
Nurse LTC clinics<br />
After hours care<br />
Development of team based<br />
partnership model of care<br />
Treatment of minor ailments<br />
Medication utilisation reviews<br />
Pharmacy facilitation<br />
Māori nurse roles<br />
Kaiawhina support<br />
Lay navigators<br />
HML Triage<br />
Shared nurse and GP rosters<br />
ED sends Triage 5 to GP<br />
Work more closely with St John<br />
Long term conditions<br />
Workforce<br />
Core general practice<br />
redesign<br />
Long term conditions<br />
Workforce<br />
Referred services<br />
Core general practice<br />
redesign<br />
Long term conditions<br />
Workforce<br />
Acute care<br />
Goal 3. <strong>Better</strong> for patients: improving continuity of primary care<br />
Objectives Key activities Associated projects<br />
Patient usually sees same<br />
nurse and GP<br />
Facilitated workshops with practices<br />
to develop systems to enhance<br />
continuity<br />
Core general practice<br />
redesign<br />
Increase number of<br />
permanent GPs on the Coast<br />
and decrease number of short<br />
term locums<br />
Increase retention of staff<br />
Coast wide system for recruiting GPs<br />
and locums for all practices<br />
Rural academic training centre<br />
Support programmes for staff and<br />
families of health providers<br />
Workforce<br />
Workforce<br />
Goal 4. <strong>Better</strong>: Improving consistency of care<br />
Objectives Key activities Associated projects<br />
GPs and nurses support each<br />
other to provide consistent<br />
care<br />
Provide consistent care for<br />
those with LTCs<br />
<strong>Care</strong> provided is consistent<br />
across primary and secondary<br />
care<br />
Processes established in each<br />
practice for dedicated time to<br />
discuss care of individual patients<br />
Expansion of LTC programme<br />
Canterbury Health pathways adapted<br />
for local situation and implemented<br />
Dual staff appointments<br />
Core general practice<br />
redesign<br />
Long term conditions<br />
Health pathways<br />
Business case EoI V38 AC 25Feb10 Page 67
Goal 5. <strong>Better</strong>: Improving co-ordination of care between general practices, hospitals and<br />
community providers<br />
Objectives Key activities Associated projects<br />
<strong>More</strong> co-ordinated care<br />
from the wider<br />
multidisciplinary team<br />
Co-ordinated support for<br />
high needs patients with<br />
LTCs<br />
Integrated mental health<br />
<strong>Better</strong> access to the range<br />
of services for frail older<br />
people<br />
Closer links with Māori<br />
providers<br />
Closer links with NGOs<br />
Closer links with pharmacy<br />
Shared information<br />
MDT clinically focused meetings in<br />
each IFHC and satellite clinic<br />
Lay navigators<br />
Clinical nurse specialists based in or<br />
linked with IFHC<br />
Allied health providers based in or<br />
linked with IFHC<br />
One entry point to primary and<br />
secondary care<br />
Establishment of co-ordinator roles<br />
<strong>Primary</strong> care involvement in discharge<br />
planning, shared care arrangements<br />
Community mental health workers and<br />
psychiatrists see patients in IFHCs<br />
Free primary care checkups and flu<br />
vaccinations<br />
<strong>Care</strong> link in IFHCs<br />
Pathways of care<br />
Case management with key clinical<br />
workers and heath navigators<br />
Processes for referrals to and from<br />
Shared approach to LTC – CVD<br />
screening<br />
Regular monthly forum at each IFHC<br />
<strong>New</strong>sletters<br />
Locum prescribing guide<br />
Medication reviews<br />
Written My Shared Health Record<br />
for patients with LTCs<br />
Web based patient record, eg.<br />
MedTech Manage My Health portal<br />
ED access to general practice notes<br />
General practice access to Health<br />
Views<br />
Improved referral and discharge<br />
information<br />
Shared electronic clinical notes across<br />
all providers based in IFHCs<br />
Integration: DHB<br />
community based<br />
services<br />
Integration: DHB<br />
community based<br />
services<br />
Mental health<br />
Frail older people<br />
Long term conditions<br />
Long term conditions<br />
Integration: DHB<br />
community based<br />
services<br />
IFHC facilities<br />
Goal 6. <strong>More</strong> convenient: community based care in integrated family health care<br />
Objectives Key activities Associated projects<br />
IFHC established<br />
All community based services located<br />
in 3 integrated family health centres,<br />
IFHCs facilities<br />
Business case EoI V38 AC 25Feb10 Page 68
Devolved community based<br />
services<br />
with satellite clinics for more remote<br />
areas<br />
Community nursing, allied health, <strong>Care</strong><br />
Link devolved to primary care<br />
Integration: DHB<br />
community based<br />
services<br />
Devolved specialist<br />
services<br />
Direct access to secondary<br />
services<br />
Move some First Specialist<br />
Assessments (FSAs) follow-ups to<br />
IFHC when workforce issues solved<br />
Expand direct access to radiological<br />
investigations<br />
Health pathways<br />
Improved access to<br />
diagnostics<br />
Remote clinical support Telemedicine Acute care<br />
Goal 7: Greater clinical leadership<br />
Objectives Key activities Associated projects<br />
Clinical engagement in<br />
leading change<br />
Shared training<br />
Ensuring staff spread<br />
across IFHCs maintain<br />
professional relationships<br />
Clinical leaders planning workshops<br />
Enhanced practice Quality<br />
Improvement (QI) teams<br />
Training centre for rural excellence<br />
providing multidisciplinary education<br />
Peer support and development for<br />
each professional group<br />
Core general practice<br />
redesign<br />
Integration: DHB<br />
community based<br />
services<br />
Workforce<br />
Integration: DHB<br />
community based<br />
services<br />
Goal 8: Living within available funding<br />
Objectives Key activities Associated projects<br />
Return DHB owned and<br />
operated practices to<br />
profitability<br />
Return other DHB owned &<br />
operated services to<br />
profitability<br />
Engage clinicians within practices in<br />
identifying the problems & owning the<br />
solutions<br />
Reduce unnecessary and/or duplicated<br />
management layers<br />
Transfer practices to NGO (PHO)<br />
ownership(?), and apply private sector<br />
disciplines<br />
Engage clinicians within services in<br />
owning the problem and identifying<br />
the solutions<br />
Reduce unnecessary and/or duplicated<br />
management layers<br />
Transfer services to NGO (PHO)<br />
ownership(?), and apply private sector<br />
disciplines<br />
Governance, ownership,<br />
management<br />
Governance, ownership,<br />
management<br />
Cost effective prescribing Analyse current spend for laboratory Referred services<br />
Business case EoI V38 AC 25Feb10 Page 69
and laboratory testing<br />
and pharmacies<br />
Identify potential areas of saving<br />
Implement programmes to align<br />
clinical and financial drivers<br />
10.6 Work in progress items<br />
While this entire business case is a work in progress, we note that the following, in particular<br />
require further work and consideration:<br />
The linkages between Reefton and Buller /Greymouth based services.<br />
<br />
<br />
<br />
<br />
<br />
The linkages between South Westland and Hokitika / Greymouth based services.<br />
The nature of the future assessment and care co-ordination role/function at each IFHC<br />
relative to LTC management, frail elderly service co-ordination and mental health.<br />
The size and timing of service related savings.<br />
The organisational structure and governance arrangements.<br />
The activity based FTE model.<br />
10.7 Risks and Mitigations<br />
The following risks and mitigations strategies have been identified.<br />
Risk description<br />
Mitigation<br />
Service continuity<br />
If clinical staff do not support the proposed<br />
changes then they may move elsewhere,<br />
jeopardizing service continuity.<br />
Keep staff informed and apply best practice<br />
change management techniques. Programme<br />
adequate funding and time to achieve shifts in<br />
models of care.<br />
Workforce<br />
Workforce may be unprepared to take on new<br />
clinical tasks or to work in new ways.<br />
Invest in workforce competency development.<br />
Decreased integration between<br />
primary/community and secondary care<br />
Devolution of community services to a primary<br />
care organisation may result in decreased<br />
integration with secondary care.<br />
DHB Financial impact<br />
DHB may retain fixed costs in the form of<br />
overheads and facilities and corporate<br />
services, but with reducing revenue.<br />
PHO Financial impact<br />
PHO may inherit services that run at large<br />
deficit, without ability to manage costs down.<br />
Invest in purposeful development of clinical<br />
pathways across primary and secondary care<br />
using an engagement approach. Contract<br />
SMOs to visit IFHCs and to deliver outpatient<br />
services from IFHCs.<br />
Allocate overhead costs to community services<br />
and require PHO to purchase back from the<br />
DHB those services for the initial 3 year<br />
period.<br />
Ensure change programme agreed prior to<br />
transfer. Agree transitional funds to cover<br />
deficit for the first 3 years.<br />
Business case EoI V38 AC 25Feb10 Page 70
Appendices<br />
Appendix One: Health Equity Assessment Tool - Integrated Family Health Centres ....................... 2<br />
Appendix Two: Core general practice redesign ............................................................................................... 6<br />
Appendix Three: Acute care................................................................................................................................ 18<br />
Appendix Four: Keeping people healthy ......................................................................................................... 26<br />
Appendix Five: Long term conditions ............................................................................................................... 38<br />
Appendix Six: Integration - DHB community based services .................................................................. 52<br />
Appendix Seven: Integration - HealthPathways .......................................................................................... 63<br />
Appendix Eight: Improved access to diagnostics ......................................................................................... 71<br />
Appendix Nine: Referred services.................................................................................................................... 79<br />
Appendix Ten: Mental health.............................................................................................................................. 88<br />
Appendix Eleven: Frail older people ................................................................................................................ 101<br />
Appendix Twelve: Workforce ............................................................................................................................ 110<br />
Appendix Thirteen: IFHCs - Facilities ........................................................................................................... 119<br />
Appendix Fourteen: IFHCs – Information technology.............................................................................. 130<br />
Appendix Fifteen: Project advisory and reference groups..................................................................... 139<br />
Business case appendices V12 AC 25Feb2010 Page 1
Appendix One: Health Equity Assessment Tool -<br />
Integrated Family Health Centres<br />
1. What health issue is the programme addressing?<br />
<br />
<br />
Access to better sooner more convenient primary health services.<br />
Quality of service/care pathways through primary – community - secondary health<br />
services.<br />
2. What inequalities exist in this health area?<br />
<br />
<br />
<br />
<br />
<br />
Despite year on year increases in PHO enrolments occurring at faster rate for Māori,<br />
enrolment in primary care remains lower than for non Māori.<br />
Māori enrolment in primary care is lowest in the Grey District.<br />
Māori enrolled in primary care access GP/nurse appointments at a lower rate than<br />
non Māori.<br />
Māori are under enrolled and have lower utilization rates in some primary care<br />
programs (eg. care plus, CVD annual reviews, immunisation) but not all (cancer<br />
navigation services, diabetes annual review, youth sexual health, primary mental health,<br />
green prescription).<br />
Māori have poorer health outcomes in the majority of health outcomes monitored.<br />
3. Who is the most advantaged and how?<br />
Data would indicate that non Māori are the most advantaged, with higher enrolments and<br />
higher access rates than Māori, they receive the benefits associated with primary<br />
practice enrolment including:<br />
<br />
<br />
<br />
<br />
VLCA fees<br />
lower after hours fees<br />
recall for screening, annual reviews and immunisations<br />
access to programs including, smoking cessation, green prescriptions, brief intervention<br />
counselling and self management education programs.<br />
4. How did the inequality occur? (What are the mechanisms, by which this inequality was<br />
created, is maintained or increased?)<br />
The inequality was created, and is maintained through a variety of mechanisms including:<br />
long term impact of colonization and the resulting education and economic disparities<br />
lower enrolments in primary care<br />
mainstream service effectiveness<br />
Business case appendices V12 AC 25Feb2010 Page 2
ongoing GP shortage creating an environment where:<br />
- it can take up to 20 days for a routine appointment, disadvantaging those with<br />
more difficulty using the system<br />
- a number of medical practices have had closed books, including at one stage all<br />
practices in Greymouth (now only one of three), meaning those who were<br />
unregistered could not register, compounding the inequalities as Māori are<br />
disproportionately represented in the unregistered population<br />
- consults can be rushed, which is not conducive for providing holistic whanau ora<br />
services.<br />
5. What are the determinants of this inequality?<br />
Socio-economic, culture, living conditions, geographic location, social and community<br />
influences and behavioural determinants all impact on the development and maintenance of<br />
inequalities in primary care access, utilization and health outcomes.<br />
6. How has the Treaty of Waitangi in the context of the <strong>New</strong> <strong>Zealand</strong> Public Health and<br />
Disability Act 2000 been addressed?<br />
Māori are entitled to the same health status as other West Coasters, and addressing the<br />
existence of inequalities in enrolments, access and outcomes for Māori, requires a specific<br />
and dedicated focus.<br />
The Integrated Family Health Centre (IFHC) Model is a more holistic model of service<br />
delivery, utilizing a greater range of health practitioners, including kaiawhina/navigators<br />
within multi-disciplinary teams that are in turn more integrated with community and<br />
secondary health services.<br />
Ensuring Māori benefit more than non Māori, from the implementation of Integrated<br />
Family Health Centres will contribute to reducing the existing inequalities in enrolments<br />
and access to services and health outcomes. Employing specific Māori nursing positions<br />
within each integrated family health centre, employing a kaiawhina to focus on improving<br />
enrolments, developing Māori workforce, and increasing mainstream service effectiveness<br />
by increasing cultural competencies among non-Māori staff are identified as the dedicated<br />
focus to achieve.<br />
7. Where/how will you intervene to tackle this issue? (use the Ministry of Health<br />
Intervention Framework to guide your thinking).<br />
The proposal intervenes at the Health and Disability Services level of the Intervention<br />
Framework to improve health and reduce inequalities. Specifically:<br />
Business case appendices V12 AC 25Feb2010 Page 3
Improving Access:<br />
increasing co-location of a range of primary, community and secondary services<br />
increasing multi-disciplinary working<br />
implementing navigator/Kaiawhina positions to provide practical assistance to access<br />
services<br />
implementing Māori nursing positions within each integrated family health centre<br />
increasing mainstream service effectiveness by increasing cultural competencies among<br />
non-Māori staff<br />
changing models of care to increasing nurse/allied health led services, including<br />
advancing development of nurse practitioners and working understanding orders.<br />
Improving pathways through care:<br />
reviewing pathways across through primary, community, secondary services across a<br />
number of disease states<br />
navigator/kaiawhina positions implemented to „navigate‟ patients through care.<br />
Take a population health approach:<br />
matching services to identified health needs, including Māori health needs<br />
increasing self-management education.<br />
8. How will the intervention affect health inequalities?<br />
Inequalities in enrolments and utilization of services will reduce with the interventions,<br />
particularly with the focus on enrolment and access of the kaiawhina position, and the<br />
increasing responsiveness of mainstream services with specific Māori nursing positions<br />
within each Integrated Family Health Centre, and increasing cultural competencies among<br />
non Māori staff.<br />
Implementation of these initiatives will also reduce inequalities in health outcomes over<br />
time.<br />
9. Who will benefit the most?<br />
Those enrolled in primary practice and utilizing primary health services will benefit the<br />
most from access to better sooner more convenient primary health services and improved<br />
quality of service and care pathways through primary-community-secondary health<br />
services<br />
Business case appendices V12 AC 25Feb2010 Page 4
10. What are the unintended consequences?<br />
There is the potential that improving access to better sooner more convenient primary<br />
health services and improved care pathways through primary, community and secondary<br />
health services will increase inequalities if Māori continue to have lower enrolments, and<br />
lower access rates to primary services.<br />
11. What will you do to make sure it does reduce/eliminate inequalities?<br />
To ensure that implementation of Integrated Family Health Services reduce inequalities in<br />
enrolment, access and health outcomes for Māori, the following initiatives are included in<br />
the business case:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Māori nursing positions will be established within each IFHC<br />
a kaiawhina with a focus on increasing Māori enrollments and access to primary<br />
services, including by providing practical assistance will be appointed in Greymouth<br />
Māori workforce development<br />
increasing cultural competencies among non Māori staff to improve mainstream service<br />
effectiveness<br />
increasing integration with kaupapa Māori health services<br />
matching services to identified Māori health needs<br />
increasing provision of culturally based self-management education<br />
continuing to measure access to services and health outcomes with ethnic comparisons<br />
so as to monitor improvements and make further changes as required.<br />
The Steering Committee overseeing the development of the business case has included the<br />
West Coast DHB (WCDHB) GM Māori Health and the CEO of Rata Te Awhina Trust,<br />
kaupapa Māori health service. A review of the work of all 15 work-streams has been<br />
undertaken by the WCDHB Māori health service staff.<br />
12. How will you know if inequalities been reduced/eliminated?<br />
The following measures will be monitored to measure if inequalities have been reduced or<br />
eliminated:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Māori enrolment in West Coast PHO (WCPHO)<br />
% of Māori not enrolled in the PHO<br />
utilization of GP/nurse appointments<br />
immunisation coverage rates: childhood and flu<br />
cancer screening: breast and cervix<br />
mental health assessments and brief intervention counselling<br />
Long Term Conditions Programme enrollments and outcome indicators for<br />
cardiovascular, respiratory and diabetes.<br />
Business case appendices V12 AC 25Feb2010 Page 5
Appendix Two: Core general practice redesign<br />
1 Aspirational statement<br />
West Coasters will be able to access appropriate primary health care in a timely manner.<br />
2 Project overview<br />
This project addresses the important issue of access to core general practice care by<br />
redesigning general practitioner, nurse and health assistant roles and medical centre delivery<br />
systems, including appointment systems. The IHI Breakthrough Series PDSA quality<br />
improvement model will be used as the change management tool.<br />
This project also includes improving access to appropriate primary health care for Māori<br />
through developing roles for Māori nurses and kaiawhina.<br />
An expanded first contact role for community pharmacists is proposed.<br />
This project does not include integration of general practice with other community based<br />
nursing, allied health or NGOs, after hours care or recruitment and retention since these<br />
aspects are covered in other plans.<br />
3 Problem definition<br />
In every consultation meeting with health providers from primary or secondary care, and with<br />
community representatives, the following two problems were seen as the most important to<br />
solve as part of this EoI process:<br />
long waiting times to be seen<br />
difficult for new arrivals to the West Coast to enrol in a health centre.<br />
Other related issues commonly raised were:<br />
lack of extended hours clinics to improve access for those with full time jobs<br />
lack of continuity of care, ie. seeing a different GP or nurse each time<br />
limited co-ordination/communication between GPs and nurses, sometimes resulting in<br />
inconsistency of care<br />
lack of community understanding of nursing roles and abilities.<br />
Business case appendices V12 AC 25Feb2010 Page 6
It is common for people with an acute health problem wanting an appointment to be seen by a<br />
GP, to wait three weeks to get an appointment in either Buller or in Greymouth (very urgent<br />
adult presentations and sick children are seen sooner).<br />
The perceived reasons for difficulties in accessing appointments are:<br />
lack of permanent GPs on the Coast<br />
heavy dependence on locums and difficulties at times attracting locums<br />
GPs in DHB owned health centres are on MECA contracts and so have three half days<br />
each week as non contact time<br />
variable development of nursing roles.<br />
General practice team roles<br />
To counter the GP shortage a number of initiatives have already been implemented:<br />
staffing remoter rural clinics with rural nurses as first line carers<br />
increased role for nurses in providing long term condition management, carrying out<br />
reviews and assessments and providing repeat prescriptions signed by the GP<br />
nurses seeing acute patients and then slotting in to see a GP or asking GP to sign a script<br />
as required<br />
nurses seeing patients and providing medications under standing orders<br />
GPs and nurses doing quick retrospective case note reviews of patients managed by<br />
nurses<br />
dividing the health centre enrolled population into subgroups with teams of one to two<br />
GPs (one permanent, one locum) and two nurses per subgroup<br />
phone triage of appointments to nurse or GP by either receptionist or by a nurse.<br />
Currently in many places on the West Coast nurses are providing a significant proportion of the<br />
kind of consultations that would elsewhere be done by GPs. While in some practices nurses with<br />
advanced qualifications have been employed, there has been extensive nurse training and/or<br />
standing orders have been implemented according to Ministry of Health guidelines, in others<br />
practices nurses are taking on an expanded role in order to meet patient needs, without<br />
adequate training, support or supervision.<br />
Currently while there are no nurse practitioners with prescribing rights on the West Coast,<br />
some nurses are working towards this qualification.<br />
Community Pharmacy<br />
The West Coast is well served by four community pharmacies who have assisted when GPs are<br />
not available by:<br />
managing minor ailments with over the counter (OTC) preparations<br />
providing up to two weeks medication as a pharmacy-generated interim prescription<br />
when a prescription for long term medications is required but the patient cannot get an<br />
appointment<br />
Business case appendices V12 AC 25Feb2010 Page 7
dispensing nurse generated, unsigned scripts with a formal agreement that a GP will take<br />
full responsibility and sign within one week.<br />
Māori access<br />
Māori access to care, as shown by the percentage of the census population enrolled in a health<br />
centre, has also been an issue, previously in the Buller region and now in Greymouth. For two<br />
years a kaiawhina was employed by the PHO in the Buller region to enhance relationships<br />
between the health centres and the Māori community.<br />
4 Objectives:<br />
The objectives of this plan are:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
to improve access to first contact core general practice team care (access to long term<br />
condition management is addressed in the Long Term Conditions project)<br />
to reduce waiting times for general practice appointments<br />
to improve continuity of care<br />
to improve co-ordination of care<br />
to develop a team approach with patients seen by GP or nurse according to health need<br />
to implement the above through providing a facilitated learning environment for health<br />
centres in each region to redesign their delivery systems to improve access and<br />
continuity of care<br />
to improve access to care through expansion of the role of community pharmacist<br />
to improve access for Māori through health centres working closely with local kaiawhina.<br />
5 Benefits and gains<br />
Output measures<br />
Indicator Baseline Target – Year 2 Year 3<br />
Yr 1<br />
Facilitated regional planning sessions 0 6 4 2<br />
% of health centres with extended<br />
0% 25% 50% 60%<br />
hours clinics<br />
% of health centres with drop in nurse 37% 50% 50% 50%<br />
clinics for acute problems<br />
% of health centres with weekly clinical 88% 100% 100% 100%<br />
review meetings between GPs and<br />
nurses<br />
Number pharmacists dispensing using 0 0 4 6<br />
„standing orders‟<br />
Number of Māori nurses employed 4 5 6 7<br />
Number of Kaiawhina employed 1 1 2 2<br />
Business case appendices V12 AC 25Feb2010 Page 8
Outcome measures<br />
Indicator Baseline Target –<br />
Yr 1<br />
Year 2 Year 3<br />
Nurse:GP consultation ratio 0.78:1 1:1 1.2:1 1.5:1<br />
Waiting time for adult with acute Same day Same day Same day Same day<br />
problem, eg. short of breath, to be<br />
seen<br />
Average waiting time for adult needing<br />
3 monthly check and script<br />
Winter<br />
10 days 7 days 4 days 2 days<br />
Summer<br />
5 days 4 days 3 days 2 days<br />
% of health centres enrolling new<br />
patients<br />
88% 100% 100% 100%<br />
Measure of continuity of care – to be<br />
developed<br />
% of Māori enrolled in PHO Buller: 95%<br />
Gymth: 76%<br />
Wstlnd: 95%<br />
Number of triage 5 seen at Greymouth<br />
ED 07.00-15.30hrs Mon - Fri<br />
TBC TBC TBC TBC<br />
Buller: 95%<br />
Gymth: 85%<br />
Wstlnd: 95%<br />
Buller: 95%<br />
Gymth: 95%<br />
Wstlnd: 95%<br />
43/week 40 35 30<br />
Community satisfaction survey results TBC TBC TBC TBC<br />
6 Deliverables / activities<br />
The business case modeling around the financial sustainability of general practice assumes a<br />
move to a strategy whereby experienced practice and rural nurses see most general patients<br />
(including dispensing under standing orders), and GPs provide back-up support, supervision and<br />
are available to see complex patients whose diagnosis and care plan is less clear. Currently a<br />
version of this model of care is in place at some practices, but often in an unplanned way – as an<br />
ad hoc response to a shortage of GPs. This model of care accepts that the West Coast<br />
generally has ratios of 1 GP to 2000 patients, and provides the necessary supports in the form<br />
of additional practice nurses and consistent policies and processes to make this model safe and<br />
rewarding for patients and staff. However this model is not yet set in stone and if alternatives<br />
are proposed that have as good or better outcomes in terms of access, safety of care and<br />
financial viability, they will be considered.<br />
This plan uses the IHI Breakthrough Series PDSA methodology to develop and implement plans<br />
within each health centre, with sharing of ideas, progress and outcomes between health centres.<br />
This methodology harnesses clinical leadership to develop and trial new initiatives using PDSA<br />
cycles to Plan (a potential solution), Do (implement), Study (review the effectiveness of the<br />
solution) and Act on the outcome (either try a new solution or imbed the trialed one so that it<br />
Business case appendices V12 AC 25Feb2010 Page 9
ecomes business-as-usual). Input is also provided by expert speakers and reports of<br />
successful initiatives in other places.<br />
Implementation plan: to June 30<br />
A. IHI PDSA cycles methodology to improve health centre delivery systems:<br />
identify team(s) in each health centre to work on this project with at least one nurse,<br />
one GP and the practice manager in each team<br />
facilitate one workshop for health centre teams in both Greymouth and Westport<br />
facilitate two team workshops with each health centre<br />
identify the current patient pathway for common types of presentation to general<br />
practice as per the Stratified Levels of <strong>Care</strong> model in the <strong>Primary</strong> Health <strong>Care</strong> Advisory<br />
Council report 20 (see Appendix A)<br />
reach consensus on the desired patient pathways (see Appendix B for potential change in<br />
patient pathway for acutely unwell adult)<br />
implementation of at least two PDSA cycles in each health centre that may include the<br />
following initiatives to improve the patient pathway:<br />
- increased role for nurses as first contact;<br />
- triage systems for deciding who patient needs to see and length of appointment;<br />
- GPs providing back up for a nurse team (patients make appointments with nurses,<br />
GP provides input and advice at the end of nurse consultations);<br />
- implementation of standing orders (see Acute <strong>Care</strong> plan);<br />
- longer booked consultations with GPs for complex patients;<br />
- GP and nurses divided into smaller teams within the health centre, each with its<br />
own designated population;<br />
- development of the nurse practitioner role within practice teams;<br />
- regular clinical meetings of GP and nurse teams;<br />
- shared review of clinical notes for high needs patients;<br />
- e-mail and phone consultations;<br />
- extended hours clinics during the week;<br />
- drop in nurse clinics;<br />
- development of a health assistant role;<br />
- using Dr Info for recall letters;<br />
- provide focused education for frequent flyers<br />
development of data definitions and collection mechanisms for measuring continuity of<br />
care and community satisfaction with services<br />
identification of training needs of nurses and arrange for Nursing Post Graduate<br />
Certificate Health Assessment paper to be delivered on the Coast in 2010 (see Acute<br />
<strong>Care</strong> paper)<br />
<br />
20 <strong>Primary</strong> Health <strong>Care</strong> Advisory Council. Progress Report of the Council‟s work to provide advice to the<br />
Ministry of Health and District Health Boards on <strong>Primary</strong> Health <strong>Care</strong> Service Models. Nov 2009<br />
Business case appendices V12 AC 25Feb2010 Page 10
determine ratio of nurses and GPs to patient population (see Workforce project)<br />
address recruitment and retention issues (see Workforce Project).<br />
B. Improving access and outcomes for Māori:<br />
implement a time-limited Greymouth based version of the kaiawhina project that was<br />
successful in engaging Māori in Buller with the medical centre there:<br />
- ascertain roles of various players (health centres, Māori health provider, PHO);<br />
- implement kaiawhina role to address Grey district enrolment of Māori;<br />
- provide appropriate training and support<br />
identify/recruit one Māori nurse in each practice. Develop part of her/his role to focus<br />
on improving access and health outcomes for meeting the needs of Māori patients,<br />
providing a whanau ora approach and improving Māori engagement in services and clinical<br />
programmes<br />
link health navigators in each health centre with Māori nurses so that they can provide<br />
community based support for hard to reach patients.<br />
C. Extended role for pharmacists<br />
Formalise arrangements between practices and pharmacies for pharmacists to provide<br />
interim prescriptions when GPs not available to sign prescriptions.<br />
Year one:<br />
A. IHI PDSA cycle to improve health centre delivery systems<br />
Task<br />
Four facilitated workshops in each health centre to review PDSA cycles<br />
and implement new ones<br />
Review progress on outcome measures and feed back into quarterly<br />
planning sessions<br />
Monthly meetings with health centre delivery systems redesign teams<br />
to provide support<br />
Three regional workshops to share ideas across health centres<br />
Health centre newsletters to explain new systems<br />
Develop community education programmes about care of common minor<br />
ailments<br />
By when<br />
Quarterly<br />
Quarterly<br />
Monthly<br />
August, Nov, Feb<br />
August<br />
April<br />
B. Māori access<br />
Task<br />
Roles of Māori nurses defined<br />
Kaiawhina commences<br />
Review level of Māori enrolment<br />
By when<br />
July<br />
July<br />
Quarterly<br />
Business case appendices V12 AC 25Feb2010 Page 11
C. Extended role for pharmacists<br />
Task<br />
Investigate pharmacy access to MedTech<br />
Extend the Standing Orders aspect of the Improving Access to Acute<br />
<strong>Care</strong> project to include pharmacists as follows:<br />
In consultation with GPs select two conditions from the current<br />
Westland Medical Centre Standing Orders documentation that<br />
are appropriate for pharmacists.<br />
Formalise process for pharmacists to assess patients, document<br />
consultation, send copy of consultation note (formal GP referral<br />
forms are currently in use at some pharmacies) and<br />
prescription for retrospective signing to GP, review by GP and<br />
further education provided as required.<br />
Formalise a process for pharmacists to be remunerated.<br />
Provide half day training session for first two conditions.<br />
By when<br />
March<br />
May<br />
Year two<br />
A. IHI PDSA cycle to improve health centre delivery systems:<br />
evaluate success of this project to date<br />
identify remaining problem areas<br />
continue facilitated health centre workshops where outcome targets are not being met.<br />
B. Māori access:<br />
continue to monitor increases in Māori enrolments each quarter<br />
refine roles of Māori nurses, kaiawhina and health navigators.<br />
C. Extended role for pharmacists:<br />
evaluate success of standing orders pilot<br />
identify whether more conditions should be added<br />
provide further training as required.<br />
Year three<br />
A. IHI PDSA cycle to improve health centre delivery systems:<br />
continue to report on outcomes<br />
address any problem areas with more workshops.<br />
B. Māori access:<br />
<br />
evaluate impact; review & revise role/project as necessary.<br />
Business case appendices V12 AC 25Feb2010 Page 12
C. Extended role for pharmacists:<br />
identify whether more conditions should be added<br />
provide further training as required.<br />
7 Capability and capacity<br />
This project will require dedicated time from health centre staff, particularly their Quality<br />
Improvement (QI) teams. Currently they have limited time to engage so where possible their<br />
time on this project will be back filled with locum cover. A skilled facilitator will be contracted<br />
to assist with this project.<br />
Capacity issues and desired numbers of GPs and nurses are addressed in the Workforce project.<br />
Support and training will be provided for the kaiawhina.<br />
Dedicated time from pharmacists will be required in order to provide greater first contact care.<br />
8 Effect on inequalities<br />
The development of Māori nurse and kaiawhina positions will improve access for Māori to<br />
primary health care (see section on addressing inequalities).<br />
9 Evidence for this initiative<br />
The IHI Breakthrough Series is an evidence based quality improvement approach 21 . It has been<br />
used in a number of settings with good results 22 and was successfully used on the West Coast in<br />
2009 to implement the PHO Long Term Conditions Framework 23 .<br />
Different models of nursing care and enhanced roles for nurses have been implemented<br />
successfully internationally 24 , and in <strong>New</strong> <strong>Zealand</strong> 25 .<br />
21 Wagner - find Wagner E, Austin B, Davis C, Bonomi A., Provost L, McCulloch D, Carver P, Sixta C. Quality Improvement<br />
in Chronic Illness care: a Collaborative approach. J Q Improvement 2001; 27(2):63-80.<br />
22 Daniel D. Norman J. Davis C. Lee H. Hindmarsh M. McCulloch D. Wagner E. Sugarman J. A state-level application of<br />
the chronic illness breakthrough series. Joint Commission Journal on Quality and Safety. 2004; 30(2):69-79.<br />
23 North D, Tracey J. Evaluation of the IHI Breakthrough Series Project for West Coast PHO. Jan 2010.<br />
24 Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can<br />
provide equivalent care to doctors. BMJ 2002; 324: 819-23.<br />
Business case appendices V12 AC 25Feb2010 Page 13
Pharmacist minor ailments services have operated successfully in the UK (Scotland) for a<br />
number of years.<br />
The effectiveness of the kaiawhina role in improving Māori enrolments has already been proven<br />
in the Buller region 26 .<br />
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Staff do not have<br />
time to engage<br />
Medium High Arrange workshops in locations and at<br />
times that suit practices.<br />
Health centres<br />
unable to implement<br />
new systems<br />
Medium High Health centre teams take lead in<br />
developing plans.<br />
Project manager visits each health<br />
centre monthly to provide support and<br />
identify early barriers.<br />
Changes made do not<br />
improve access<br />
Low High Monitor results of PDSA cycles<br />
quarterly and adapt plans as required.<br />
Insufficient training<br />
and support provided<br />
to nurses<br />
Medium High Provision of training in Health<br />
Assessment and Standing Orders (see<br />
Acute <strong>Care</strong> project).<br />
Ongoing general professional<br />
development provided (see Workforce<br />
project).<br />
At least weekly shared clinical<br />
meetings.<br />
Monitoring by clinical nurse leader.<br />
Difficult to attract<br />
Māori nurses<br />
Low High Develop a whanau ora, holistic model of<br />
care in health centres.<br />
Provide Tiriti o Waitangi workshops to<br />
other staff.<br />
Pharmacists do not<br />
have time to expand<br />
their role<br />
Medium Medium Assist pharmacists with recruitment<br />
and retention.<br />
25 McKinlay E. Thinking beyond <strong>Care</strong> Plus: The work primary health care nurses in chronic conditions programmes NZ Fam<br />
Phys 2007;34(5):322- 7.<br />
26 Cooke A. Evaluation: Improving Māori Access in Kawatiri. Jul 2009.<br />
Business case appendices V12 AC 25Feb2010 Page 14
11 Engagement<br />
Working group who developed this plan: Dr Greville Wood, Dr Anna Dyzel, Nigel Ogilvie RN, Dr<br />
JD Naidoo, Hecta Williams, Marie West, Dr Paul Cooper, Pauline Ansley, Helen Reriti, Karyn<br />
Kelly, Julie Kilkelly, and Kerri Miedema.<br />
Other clinicians involved: Workshops were initially held in Greymouth and Westport, with all<br />
nurses, GPs and practice managers invited. Follow-up meetings were held in each health centre<br />
to refine the content of this proposal.<br />
12 Organisational accountabilities<br />
The change management process will be managed by the PHO in consultation with health centre<br />
owners of all health centres; private and DHB.<br />
13 Budget considerations<br />
Costs from this plan include:<br />
practice, district and regional change management support and facilitation<br />
modeling and analysis of changes in model of care on practice viability<br />
development/ adaptation and annual administration of community survey<br />
kaiawhina employment (SIA).<br />
Year one Year Two Year Three<br />
Change management facilitation and<br />
$74,000 $50,000 $40,000<br />
support<br />
Analysis of effects of changes on<br />
$10,000 $10,000 $10,000<br />
practice viability<br />
Community survey $10,000 $10,000 $10,000<br />
Kaiawhina ($60,000 from SIA Budget)<br />
Total $94,000 $70,000 $60,000<br />
These costs are included in the Investing in Change budget, Section 11.1 in the business case.<br />
Estimated savings to health centres from changing the model of care are included in Section 9.2<br />
of the business case.<br />
Business case appendices V12 AC 25Feb2010 Page 15
Appendix A: Models of care from <strong>Primary</strong> Health <strong>Care</strong> Advisory Council report<br />
Business case appendices V12 AC 25Feb2010 Page 16
Appendix B: Acutely unwell adult patient journey<br />
Unwell adult: current situation<br />
Makes appt<br />
to see<br />
nurse<br />
• May wait several days for<br />
appt<br />
•Nurse may manage<br />
consult<br />
•May also need review by<br />
GP – then or later<br />
Unwell adult rings<br />
for appointment –<br />
3+ week wait for GP<br />
Given<br />
phone<br />
advice by<br />
nurse<br />
Goes to<br />
ED<br />
•May be managed with<br />
phone advice<br />
•May need rptd ph calls<br />
•May need to make appt<br />
or end up at ED<br />
•Seen at ED<br />
•May be for problem<br />
better managed in GP<br />
•May have LTC and ED<br />
may not know current<br />
Rx<br />
Waits 3<br />
weeks for<br />
GP<br />
•My deteriorate while<br />
waiting and be admitted<br />
•May suffer from delayed<br />
treatment<br />
•May get better and not<br />
need appt<br />
Unwell adult: future scenario<br />
Given appt<br />
to see<br />
nurse<br />
within 24<br />
hours<br />
•Seen within 2 days<br />
•Nurse may manage<br />
consult under SO<br />
•May also need review by<br />
GP at the time<br />
Unwell adult rings<br />
for appointment –<br />
triaged over phone<br />
Given<br />
phone<br />
advice by<br />
nurse<br />
Advised to<br />
see<br />
pharmacist<br />
•May be managed with<br />
phone advice<br />
•IF not improving within<br />
24 hours seen by nurse or<br />
GP<br />
•Seen by pharmacist and<br />
treated under ‘SO’ with GP<br />
reviewing consult note<br />
and signing script later<br />
Given appt<br />
to see GP<br />
within 48<br />
hrs<br />
•Different appt lengths<br />
available according to<br />
nature of problem – 10 /<br />
15/ 20 / 30 min (e.g.<br />
exacerbation of complex<br />
LTC)<br />
Business case appendices V12 AC 25Feb2010 Page 17
Appendix Three: Acute care<br />
1. Aspirational statement<br />
All West Coasters will know how to appropriately access acute and after hours care and will be<br />
satisfied with the service received.<br />
2 Project overview<br />
This project has three main aspects: introducing HML nurse phone triage after hours, increasing<br />
community knowledge of how to access after hours care appropriately, and upskilling nurses to<br />
provide more acute care after hours and within office hours.<br />
It builds on the West Coast After Hours Plan which is available for review.<br />
If patients who are acutely unwell are unable to be seen during the day by their usual GP/nurse<br />
team, then this increases the demand for after hours care and inappropriate use of emergency<br />
departments. The project on the redesign of core general practice care addresses this issue.<br />
3 Problem definition<br />
Key problems in the provision of both after hours care and acute care within office hours are:<br />
the burden of after hours call<br />
lack of community understanding of how to access after hours services<br />
high rates of triage 5 attendances at Greymouth ED, both during office hours and after<br />
hours<br />
variation in training and skills of nurses providing after hours and acute care.<br />
For greater detail on the current situation see Appendix One.<br />
Recruitment and retention and decreasing the waiting time to be seen in general practice are<br />
important contributors to after hours issues; they are covered in other project plans.<br />
Business case appendices V12 AC 25Feb2010 Page 18
4 Objectives<br />
<br />
<br />
<br />
<br />
<br />
<br />
to implement nurse phone triage throughout the West Coast after hours<br />
to provide advanced training for nurses doing after hours call<br />
to implement the use of standing orders in all practices<br />
to increase community understanding of how to use after hours services<br />
to decrease inappropriate attendances at ED<br />
to increase coordination of care between practices and ED.<br />
5 Benefits and gains<br />
Output measures<br />
Indicator Baseline Target – Yr<br />
1<br />
HML triage in place By June 10<br />
Community education campaign<br />
implemented<br />
Number of nurses with PG Cert in<br />
Assessment and Pharmacology or<br />
equivalent<br />
ED and hospital pharmacy able to<br />
access patient MedTech notes<br />
Year 2 Year 3<br />
By August Rptd in April Rptd in April<br />
2010<br />
11 20 25 30<br />
No<br />
In place<br />
Outcome measures<br />
Indicator<br />
Number of triage 5 seen at<br />
Greymouth ED 07.00-15.30 Mon -<br />
Fri<br />
Number of triage 5 seen at<br />
Greymouth ED 15.30-22.40 Mon -<br />
Fri<br />
Number of triage 5 seen 22.40-<br />
08.00 Mon - Sun<br />
Numbers of triage 5 seen at<br />
weekends 08.00-22.40<br />
Numbers triaged and<br />
redirected/wk<br />
Baseline<br />
YTD to<br />
Dec 09<br />
Target – Yr 1 Year 2 Year 3<br />
43/week 40 35 30<br />
11/week 9 8 7<br />
1.75/week 1.7 1.6 1.5<br />
15/week 13 12 11<br />
0 7 14 21<br />
Business case appendices V12 AC 25Feb2010 Page 19
% pts discharged of transferred<br />
from ED within 6 hours<br />
% ringing HML who need local<br />
GP/nurse assessment<br />
100% >95% >95% >95%<br />
TBC<br />
6 Deliverables / activities<br />
Implementation plan: to June 30<br />
HML Triage:<br />
<br />
<br />
<br />
<br />
Draw up contract with HML Triage to provide after hours nurse phone triage for every<br />
practice.<br />
HML visits every practice and Greymouth ED to gather information on local systems and<br />
capability.<br />
Ensure practices have good systems in place to care for patients who need follow-up<br />
care the next day, eg. phone consultations, acute appointment slots, walk in clinics.<br />
Ensure all practices receive regular reports from HML and all systems are working<br />
appropriately.<br />
Community education campaign – four to six weeks later:<br />
<br />
<br />
<br />
<br />
<br />
Content: if you are unwell after hours ring your general practice and you will receive<br />
advice from an experienced nurse regarding what you should do. Do not go straight to<br />
the emergency department unless it is an emergency.<br />
Involve St John in campaign.<br />
Design campaign methodology: newspaper articles, pamphlets, radio messages, practice<br />
newsletters.<br />
Campaign also tailored towards Māori and Pacific Island communities.<br />
Implement campaign.<br />
Redesign Greymouth after hours arrangements:<br />
<br />
<br />
<br />
<br />
<br />
Practices will see their own urgent patients during the day instead of these patients<br />
being seen at the duty practice. There will be a duty practice but it will see only urgent<br />
out of town or non-enrolled patients (often re-directed from ED).<br />
The newly established academic practice will be on-call in the evenings (Mon, Tues, Wed)<br />
with GP registrars seeing patients under the supervision of Dr Willet or Dr Wood.<br />
Town practices will roster Thursday evening call.<br />
Weekends will be covered by all practices allocated on the basis of capitation population.<br />
This should result in a more equitable allocation of on-call and reduce the number of GP<br />
patients presenting at ED because urgent appointments will be available at each<br />
practice.<br />
Business case appendices V12 AC 25Feb2010 Page 20
Review Buller after hours arrangements:<br />
The practice closes at 5 pm and any urgent presentations from about 4:30 to 5:00 are<br />
directed to Buller Health ED.<br />
Buller Health ED is staffed by a GP until 5:30 and may stay on duty until 10:00 pm if<br />
required.<br />
An after hours co-ordinator supervises a mix of RNs and ENs who staff ED.<br />
GPs are on call for Triage 1 and Triage 2 patients. The decision to call the GP for other<br />
triage levels is made by the team leader on duty.<br />
Weekend emergency clinics operate on Saturday, Sunday and Public Holidays from 10:00<br />
to 11:00 am and again at 5:00 to 6:00 pm.<br />
x-ray services are provided 24/7 on an on call basis between 4:30 pm and 8:30 am.<br />
Nurse education:<br />
Identification of training needs of the nurses providing after hours and acute primary<br />
care (24 practice nurses and 12 rural nurses).<br />
Arrange for Nursing Post Graduate Certificate Health Assessment paper to be<br />
delivered on West Coast in 2010, with funding from after hours budget if required.<br />
Arrange access to further PRIME training for new staff on PRIME call out roster as<br />
required, with support for travel and accommodation costs.<br />
Standing orders:<br />
Develop standard processes for the use of standing orders in practices.<br />
Adopt content of the Westland Medical Centre standing orders for Coast-wide use.<br />
Select which standing orders.<br />
Establish subcommittee to oversee development of standing orders training.<br />
Develop a curriculum to provide training on each standing orders over 2010/11.<br />
Develop the lesson plan for the first training session.<br />
Run the first two training sessions for 6-8 standing orders in both Westport and<br />
Greymouth.<br />
Fund nurses to attend training sessions.<br />
Visit each practice to discuss the use of standing orders and obtain written agreement<br />
to use the standard processes and content from all GPs.<br />
Plan and run second training session in both regions.<br />
Co-ordination with ED:<br />
Install a copy of MedTech in a computer in ED.<br />
Change patient registration form/casualty sheet on arrival to include consent for access<br />
to their MedTech notes for that hospital visit.<br />
Ensure privacy considerations are met.<br />
Obtain agreement from practices.<br />
Create link into DHB practice server.<br />
Evaluate community cellulitis management project and extend to all practices.<br />
Business case appendices V12 AC 25Feb2010 Page 21
Year one:<br />
HML triage:<br />
review use and acceptability – Dec.<br />
Community education:<br />
agree on processes to be used by ED to redirect patients who would be better seen by<br />
general practice (triage 5) – by August<br />
implement processes, along with voucher system for those in financial hardship – by<br />
September<br />
repeat community education campaign in April.<br />
Nurse education:<br />
providing funding for more nurses to do PG Cert papers and PRIME.<br />
Standing orders:<br />
provide 5 more day long training sessions in Greymouth and Westport<br />
review and update content of standing orders - May<br />
review use in each practice and adapt standard processes as required – October.<br />
Co-ordination with ED:<br />
create link into other MedTech practices<br />
enable hospital pharmacy to link into MedTech.<br />
Review after hours arrangements in South Westland:<br />
include St John – enhancing conditions for volunteers, including ability to sleep over.<br />
Telemedicine:<br />
implement proof of concept plan for telemedicine links from IFHCs.<br />
Year two<br />
Community education campaign:<br />
repeat in April.<br />
Nurse education:<br />
providing funding for more nurses to do post graduate certificate papers and PRIME.<br />
Standing orders:<br />
provide 4 more day long training sessions in each of Greymouth and Westport<br />
review and update content of standing orders - May<br />
review use in each practice and adapt standard processes as required – October.<br />
Evaluate and update after hours plan and develop other initiatives as required.<br />
Business case appendices V12 AC 25Feb2010 Page 22
Year three<br />
Community education campaign<br />
repeat in April.<br />
Nurse education<br />
<br />
providing funding for more nurses to do PG Cert papers and PRIME.<br />
Standing orders<br />
provide 4 more day long training sessions in each of Greymouth and Westport<br />
review and update content of standing orders - May<br />
review use in each practice and adapt standard processes as required – October.<br />
7 Capability and capacity<br />
This project is about increasing capacity by using HML to triage all after hours phone calls, with<br />
an expected drop in GP/nurse call outs of 50%.<br />
It also builds on the models of care developments in that it promotes an increased role for<br />
nurses, and so provides extra postgraduate training and training in standing orders to increase<br />
nurse capability.<br />
The plan also provides extra capability through use of new technology, ie. Cisco in Buller.<br />
8 Effect on inequalities<br />
It is well documented that the inequalities in health exist between Māori and non Māori on the<br />
West Coast.<br />
The after hours primary health care services proposed in this plan will ensure that all West<br />
Coast residents, and particularly those with the greatest need, will have access to free and<br />
consistent telephone triage services, through the diversion of phone calls from general practice<br />
to HML triage. For those who have no phone and go directly to an emergency department there<br />
will be vouchers available if they are referred to afterhours services and cannot pay the fee.<br />
Business case appendices V12 AC 25Feb2010 Page 23
9 Evidence for this initiative<br />
HML Triage has been successfully implemented throughout <strong>New</strong> <strong>Zealand</strong>, now covering over one<br />
million people each night.<br />
Standing orders have been successfully implemented in Westland Medical Centre resulting in<br />
the majority of acute care and after hours care being provided by skilled nurses.<br />
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Practices select not to Low Moderate Fund out of After Hours funding<br />
use HML triage<br />
Nurses unable to take<br />
time off to do standing<br />
Moderate High Provide courses at weekends and pay<br />
for attendance<br />
orders training<br />
Nurses unable to take Moderate Moderate Deliver papers on the West Coast<br />
time off to do PG Cert<br />
papers<br />
Triage 5 patients still go<br />
to ED<br />
Redirection to IFHCs<br />
Use vouchers for low socioeconomic<br />
Adapt community education campaign<br />
11 Engagement<br />
Working group who developed this plan: Hecta Williams, Dr JD Naidoo, Nigel Ogilvie RN,<br />
Dr Martin Smith, Julie Lucas RN, Dr Rodger Mills, Karyn Kelly RN, Wayne Turp, Shona McLeod,<br />
Dr Vicki Robertson, Barbara Smith RN, Dr Greville Wood, Dr Carol Atmore, Dr Jocelyn Tracey.<br />
Other clinicians involved: Copy sent to every general practice for input by nurses and GPs.<br />
12 Organisational accountabilities<br />
Shared DHB and PHO accountability in the after hours steering group.<br />
Business case appendices V12 AC 25Feb2010 Page 24
13 Costs<br />
Budget considerations:<br />
<br />
<br />
<br />
The DHB received $80,000 for implementing the after hours plan in 2009/10. It is<br />
expected that the same amount will be received in 2010/11.<br />
Postgraduate university fees for advanced nursing papers are covered by Clinical<br />
Training Agency funding.<br />
Note that separate funding is available from MoH for proof of concept of the benefit<br />
of telemedicine in remote sites.<br />
To June 10<br />
Year one<br />
Income<br />
MoH after hours fund 80,000 80,000<br />
Expenditure<br />
HML 18,000 36,000<br />
Standing orders training sessions 24,400 30,500<br />
PRIME support 2,000 3,000<br />
Communication 10,000 5,000<br />
ED vouchers 500 1000<br />
Project management 25,000 4500<br />
Total expenditure 79,900 80,000<br />
Profit $100 $0<br />
Business case appendices V12 AC 25Feb2010 Page 25
Appendix Four: Keeping people healthy<br />
1. Aspirational statement:<br />
All West Coasters will live healthy lives.<br />
2 Project overview<br />
Many of the public health and health promotion activities delivered on the West Coast by the<br />
West Coast DHB (WCDHB), West Coast PHO (WCPHO) and Community & Public Health (CPH)<br />
address the same health outcomes. Some degree of joint planning and implementation of health<br />
promotion activities take place at present however there is a need to shift the focus from the<br />
sharing of information and co-operation to effective and meaningful „collaboration‟. It has been<br />
determined that each of the three organisations focuses on the following areas that will serve<br />
as the basis of joint planning and collaboration for „keeping West Coast people healthy‟:<br />
tobacco control/smokefree<br />
improving immunisation coverage<br />
increasing physical activity and nutrition.<br />
This initiative is designed to further enhance public health and health promotional activities in<br />
the above three areas through the production of a joint health promotion plan and<br />
implementation strategy that will be shared between the organisations. The first year of this<br />
plan describes common areas of delivery in detail and indicates the breadth of activity that will<br />
be planned jointly at the end of three years.<br />
There are other areas of health promotion delivery that do not cross over between<br />
organisations and are not incorporated as part of this plan. The details of PHO specific<br />
activities are however detailed in the deliverables section.<br />
3 Problem definition<br />
For the last three years the West Coast District Health Board (DHB), West Coast <strong>Primary</strong><br />
Health Organisation (PHO) and Community & Public Health (CPH) have carried out some degree<br />
of joint planning around health promotion activities. This joint planning was designed to bring<br />
the three organisations together and to identify areas of commonality where each could<br />
complement others work. This often focused on the sharing of information and the<br />
implementation of joint initiatives where all three organisations contributed to a project. To<br />
enhance this joint planning and initiate more effective collaboration the Healthy West Coast<br />
Governance Group, with management level membership across the three organisations was<br />
Business case appendices V12 AC 25Feb2010 Page 26
established. This group now oversees health promotion projects/activities developed by each<br />
organisation.<br />
Up until recently each of the three organisations continued to develop their own public health<br />
and health promotion plans, and there was the potential for a large amount of cross over and<br />
duplication of effort and resourcing. The imperative to reduce this duplication was augmented<br />
by the limited health promotion funding and qualified public health workforce on the West<br />
Coast. By carrying out joint planning and avoiding potential cross over means that any funding<br />
and workforce we do have is maximized to it best potential.<br />
Keeping people healthy and reducing the burden of chronic disease through public health and<br />
health promotion initiatives is integral to the primary care business case. The emphasis of<br />
keeping people healthy is on preventing West Coasters from becoming unwell and improving the<br />
health of those with existing chronic conditions. The three key priorities, tobacco<br />
control/smokefree, increasing immunisation and physical activity and nutrition coverage have<br />
been selected due to the impact that these interventions areas have on preventing or minimizing<br />
chronic disease and infirmity.<br />
Tobacco Control/Smokefree<br />
Smoking is one of the leading causes or mortality and morbidity for the West Coast population,<br />
with 25.7% of all West Coasters reporting they are regular smokers compared to 20.7% of the<br />
national population 27 . Māori smoking rates are considerably higher on the West Coast (by<br />
comparison with non Māori), particularly for Māori girls at Year 10 28 . Of concern is the high<br />
rate of smoking amongst 20-24 year olds, with 40.9% of West Coast youth compared with<br />
29.8% nationally smoking on a regular basis. Lifestyle changes such as not smoking will have a<br />
positive impact on the health status of West Coasters and lead to a reduction in chronic illness,<br />
notably respiratory, cardiac and vascular conditions, cancer rates and diabetes.<br />
Increasing Immunisation Coverage<br />
Increasing immunisation coverage at 24 months of age continues as a focus for improving child<br />
health on the West Coast. In 2008/09 80% of children were immunised at 24 months of age,<br />
below the national target of 85%. <strong>More</strong> recently the Immunisation Advisory Group has<br />
extended its brief to focus on seasonal influenza and HPV vaccinations. In 2008/09 55% of<br />
the total West Coast population and 60% of the high needs West Coast population were<br />
vaccinated for seasonal influenza.<br />
Physical Activity & Nutrition<br />
Sedentary lifestyles, poor nutrition and overweight and obesity are a major and increasing cause<br />
of preventable disease, disability and death in <strong>New</strong> <strong>Zealand</strong> 29 . The <strong>New</strong> <strong>Zealand</strong> Health Survey<br />
2002/03 indicates that West Coasters have particularly high levels of excess adiposity, with<br />
27 Statistics <strong>New</strong> <strong>Zealand</strong>. (2006). Census of Population and Dwellings. Wellington: Statistics <strong>New</strong> <strong>Zealand</strong>.<br />
28 Beg A. West Coast Tai Poutini Maori Health Profile, August 2008.<br />
29 Ministry of Health. (2000). The <strong>New</strong> <strong>Zealand</strong> Health Strategy. Wellington: Ministry of Health.<br />
Business case appendices V12 AC 25Feb2010 Page 27
61% of residents identifying as overweight or obese. Of particular concern are the high levels<br />
of obesity among West Coast Māori (32%) 30 . Furthermore, over half of West Coasters do not<br />
consume at least two pieces of fruit per day.<br />
4 Objectives<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
To enhance the health and well being of West Coasters and reducing the burden of<br />
chronic disease through a reduction in smoking initiation and increase in cessation;<br />
increasing immunisation coverage; increased physical activity, improved nutrition and<br />
reduced rates of obesity throughout the district.<br />
To improve immunisation coverage for West Coast residents, particularly relating to<br />
childhood immunisations, HPV vaccination and seasonal influenza vaccine.<br />
To improve the health and wellbeing of West Coast residents through the creation of<br />
environments that support physical activity, healthy eating (including breastfeeding) and<br />
weight reduction.<br />
To reduce harm caused by tobacco with the overall objective of reducing the number of<br />
West Coasters who smoke on a regular basis to be no greater than the national average.<br />
To create and maintain social and physical environments that support smokefree.<br />
To empower West Coast communities to take action around „keeping people healthy‟.<br />
Establish a virtual single entity where the WCPHO, WCDHB and CPH plan and implement<br />
the health promotion strategy collaborative to „keep West Coasters healthy‟.<br />
To maximize resources (funding and personal) available to the West Coast by ensuring<br />
that projects are provided efficiently and are designed to meet the needs of the<br />
community and are evidence based.<br />
5 Benefits and gains<br />
Increased immunisation:<br />
85 percent of two year olds will be fully immunised by July 2010; 90 percent by July 2011; and<br />
95 percent by July 2012.<br />
<strong>Better</strong> help for smokers to quit:<br />
80 percent of hospitalised smokers will be provided with advice and help to quit by July 2010;<br />
90 percent by July 2011; and 95 percent by July 2012. The measures for primary care that will<br />
be introduced from July 2010, through the PHO Performance Programme are the percentage of<br />
the enrolled population for whom smoking status has been recorded and the percentage of the<br />
enrolled population who are current smokers.<br />
30 Ministry of Health. (2004). A portrait of health: Key results of the 2002/03 <strong>New</strong> <strong>Zealand</strong> Health Survey. Wellington:<br />
Ministry of Health<br />
Business case appendices V12 AC 25Feb2010 Page 28
Output measures<br />
Tobacco control / smokefree<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
% total population who have ever<br />
had a smoking status recorded –<br />
Total (PPP)<br />
% total population who have ever<br />
had a smoking status recorded –<br />
High needs (PPP)<br />
% of current smokers who been<br />
given brief advice in the last 12<br />
months July 2011. (PPP)<br />
% of current smokers who been<br />
given or referred to cessation<br />
support services in the last 12<br />
months July 2011. (PPP)<br />
% of hospitalised smokers will be<br />
provided with advice and help to<br />
quit by July 2010<br />
Total West Coast-wide population<br />
accessing smoking cessation<br />
services (AKP, Coast Quit, Quitline,<br />
WCDHB)<br />
33% 36% 40% 44%<br />
35% 38% 42% 46%<br />
TBC TBC TBC TBC<br />
TBC TBC TBC TBC<br />
19% 80% 90% 95%<br />
969 979 989 1000<br />
Outcome measures<br />
Tobacco control / smokefree<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
Year 10 students who smoke on a 3.2% 3% 2.8% 2.6%<br />
daily basis (ASH)<br />
Year 10 students living in a<br />
smokefree home (ASH)<br />
55% 60% 65% 70%<br />
Immunisation<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
% Childhood Immunisation<br />
Coverage at 24 months – Māori<br />
(NIR*)<br />
70% 75% 80% 85%<br />
% Childhood Immunisation<br />
Coverage at 24 months – Total<br />
(NIR*)<br />
% seasonal influenza coverage –<br />
Total (PPP)<br />
% seasonal influenza coverage –<br />
High needs (PPP)<br />
80% 83% 86% 89%<br />
55% 56% 57% 58%<br />
60% 61% 62% 63%<br />
Business case appendices V12 AC 25Feb2010 Page 29
Physical Activity and Nutrition<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
Full and exclusive breastfeeding at 75% 75% 76% 77%<br />
6 weeks – total (Plunket)<br />
Full and exclusive breastfeeding at 66% 68% 70% 72%<br />
6 weeks – Māori (Plunket)<br />
Full and exclusive breastfeeding at<br />
6 months – total (Plunket)<br />
35% 35% 36% 37%<br />
Full and exclusive breastfeeding at<br />
6 months – Māori (Plunket)<br />
25% 27% 29% 31%<br />
* figures are adjusted for WCDHB „eligible‟ population as Gloriavale Christian Community does not immunise.<br />
6 Deliverables / activities<br />
Implementation phase<br />
<br />
Alignment of the three organisations planning processes and joint planning in three<br />
priority areas (tobacco control/smokefree, immunisation, physical activity and nutrition).<br />
Year one<br />
Tobacco control/Smokefree:<br />
Implementing the ABC strategy –joint implementation of the ABC strategy to ensure<br />
<br />
<br />
<br />
<br />
<br />
patients across community, primary and secondary care are provided with advice and<br />
support to quit.<br />
Smoking cessation services – including training of primary and secondary staff on brief<br />
advice (additional training will be provided to mental health workers, Māori providers,<br />
midwives and those working with youth), utilization of NRT and referrals onto specialist<br />
cessation services, a media campaign to promote smokefree lifestyles and cessation<br />
services and provision of a range of cessation services (including Coast Quit, ABC & NRT<br />
dispensing, Aukati kai Paipa, WCDHB Specialist Smoking Cessation Services, Quitline).<br />
Smokefree pregnancy – smoking cessation training will be provided to midwives<br />
throughout the district. A joint plan will be established to provide services specifically<br />
for this key target group (including a key focus on Aukati kai Paipa for Māori women).<br />
Māori Smokefree Initiatives – implementation of smokefree initiatives and health<br />
promotion through Aukati kai Paipa and Rata Te Awhina Trust. This will include other<br />
health promotion activities. Māori smokefree health promotion roopu continues to work<br />
together to reduce unacceptable Māori smoking rates on Tai Poutini.<br />
Reducing smoking initiation – joint health promotion initiatives will focus on increasing<br />
the percentage of year 10 students living in a smokefree home. The HPS programme will<br />
continue to support smokefree environments and strategies in West Coast schools.<br />
Smokefree Policies - training and support will be offered to WCDHB providers and<br />
selected workplaces.<br />
Business case appendices V12 AC 25Feb2010 Page 30
Improving immunisation coverage – health promotion strategies:<br />
Co-ordination of the Immunisation Advisory Group - continue to co-ordinate an<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Immunisation Advisory Group (includes Māori representation) to work strategically to<br />
increase immunisation coverage and work collaboratively to achieve this outcome.<br />
Seasonal Influenza – facilitation of a range of seasonal influenza health promotion<br />
activities such as primary care clinics, promotions in practices, promotional campaigns<br />
targeting the chronically ill and those aged 65 years and over, supermarket promotions<br />
and linking into the national campaign through radio advertisement, aquatic centre<br />
promotion and pharmacy flu bug themed promotions.<br />
Staff Seasonal Influenza Vaccination Programme – facilitation of the WCDHB and<br />
WCPHO staff seasonal influenza promotion (encouraging and educating staff on getting<br />
immunised). Supporting workplace staff to become immunised throughout the West<br />
Coast (for larger organisations such as Pike River Coal).<br />
Childhood Immunisations (including HPV):<br />
Improvement of the practice process for immunisation, particularly relating to providing<br />
timely recall information (using the long term conditions model of engagement and<br />
collaboration) and offering flexibility around clinic times.<br />
Ongoing promotion and implementation of the HPV programme in schools throughout the<br />
West Coast with a focus on promotion and uptake for Māori girls.<br />
Provision of immunisation education in antenatal classes.<br />
Health promoting schools framework used to promote immunisation services.<br />
Outreach Immunisation Services – continued provision of Outreach Immunisation<br />
Services with a focus on reducing inequalities in coverage for tamariki Māori and<br />
children in NZ Dep 9 and 10 areas (including by use of Māori staff).<br />
Training & Education – the ongoing provision of practice nurse training by the<br />
Immunisation Co-ordinator.<br />
Increase physical activity and improve nutrition:<br />
Breastfeeding Action - implement the Breastfeeding Action Plan (focus on<br />
<br />
<br />
<br />
implementation of the Mum4Mum Peer Support programme, education of primary care<br />
and social service providers, antenatal education, creating and maintaining environments<br />
that support breastfeeding and professional development for maternity and well child<br />
staff).<br />
Māori Community Action - implement the Māori Community Action Plan that focuses on<br />
Māori communities being supported and assisted to devise and implement programmes<br />
that improve nutrition, increase physical activity and reduce chronic disease.<br />
Healthy Ageing Programme - this programme targets adults aged 65 years and over (and<br />
Māori aged 55 years and over) and focuses on improving nutrition, increasing physical<br />
activity and decreasing falls.<br />
Building Community Capability – implement programmes such as the Cooking Skills to Life<br />
Skills, Senior Chef, workplace wellness interventions and relevant physical activity<br />
programmes that use a skill-based model to build capability of community volunteers and<br />
at risk populations.<br />
Business case appendices V12 AC 25Feb2010 Page 31
Prevention & Early Intervention – co-ordination and facilitation of early intervention<br />
programmes (such as Green Prescription, Cooking Skills to Life Skills), information<br />
dissemination and education, creating social environments that support healthy eating<br />
and physical activity and provision of the Health Promoting Schools programme in West<br />
Coast schools.<br />
PHO specific deliverables – health promotion<br />
Men‟s health forums - focused on men‟s health issues including cardiovascular, mental<br />
health and urology issues. Men‟s engagement with the practices to reach „hard-to-reach‟<br />
males is a key focus of this campaign.<br />
<br />
<br />
<br />
Whanau Ora Pai /Living Well Hui - targeted for West Coast Māori and focused on all<br />
aspects of healthy living in a culturally appropriate environment.<br />
Awareness week promotions - targeted on cervical screening, diabetes, mental health,<br />
breastfeeding, prostate cancer and men‟s health, cancer.<br />
Breastfeeding support - peer support programme, community promotions, breastfeeding<br />
friendly workplaces and cafés.<br />
As well as working on the above priority areas we also intend to:<br />
work together to reduce health inequalities<br />
<br />
<br />
<br />
<br />
<br />
<br />
operate as a virtual single entity for the three key priority areas<br />
work under a common banner for health promotion 'Healthy West Coast'<br />
produce a common community health needs assessment<br />
have transparent funding streams for public health for the three key priority areas<br />
work to develop a common approach to evaluation and review the effectiveness of<br />
different types of programme<br />
share training across all workers within the three organisations.<br />
Year two:<br />
<br />
<br />
<br />
<br />
One joint plan covering all health promotion services that each organisation implements<br />
in addition to tobacco control, immunisation coverage, physical activity and nutrition.<br />
This will further enhance the virtual single entity and ensure the needs of the West<br />
Coast community are met.<br />
Review and revise outputs and outcomes for the tobacco control/smokefree,<br />
immunisation coverage and physical activity and nutrition plans.<br />
Re-allocate funding to programmes/activities which have been shown to be more<br />
effective by appropriate evaluation.<br />
Transfer responsibility for programmes/activities to those organisation best placed to<br />
deliver them.<br />
Business case appendices V12 AC 25Feb2010 Page 32
Year three<br />
<br />
<br />
<br />
<br />
Continued joint planning by each organisation with one plan covering all health promotion<br />
services.<br />
Enhanced collaboration between the three organisations.<br />
Fully functional virtual single operating entity where each organisation WCPHO, WCDHB<br />
and CPH work together to create a “Healthy West Coast”.<br />
7 Capability and capacity<br />
Between the three organisations, the West Coast has a small but strong health promotion<br />
workforce. This workforce is strongly supported by a range of clinicians including general<br />
practice teams, pharmacies, rural nurse specialists, practice nurses and so on. General practices<br />
and pharmacies are actively engaged in health promotion campaigns and provision of health<br />
promotion resources.<br />
West Coast PHO<br />
The West Coast PHO has a small but strong health promotion workforce with 0.5 Full Time<br />
Equivalent (FTE) Health Promoter and 1 FTE Active Communities Co-ordinator that are<br />
supported by the Clinical Manager. The Coast Quit programme is implemented by GP‟s, practice<br />
nurses, rural nurse specialists and three pharmacies.<br />
West Coast DHB<br />
Tobacco Control/Smokefree - the 1 FTE Regional Smokefree Co-ordinator is based within the<br />
Planning & Funding team and smoking cessation services and clinical training a delivered within<br />
the hospital setting by the Smoking Cessation practitioners (1 FTE total).<br />
Physical Activity and Nutrition - the Healthy Eating Healthy Action (HEHA) team is based<br />
within Planning & Funding and consists of 2.5 FTE of HEHA co-ordinators that work across the<br />
nutrition and physical activity areas and 1 FTE HEHA manager that works across the West<br />
Coast and Canterbury DHBs.<br />
Immunuisation - Outreach Immunisation co-ordinators (1 FTE total – 0.4 clinical, 0.6 Māori coordination),<br />
HPV co-ordinator (0.4 FTE), Public Health Nurses, Immunisation co-ordinator (0.6<br />
FTE).<br />
Community & Public Health<br />
Tobacco Control/Smokefree - Aukati Kai Paipa 1.0 FTE, Māori Smoking Health Promoter 0.4<br />
FTE, Smokefree Health Promoter 0.5 FTE, Smokefree Environment Compliance 0.2 FTE.<br />
Immunuisation - Youth Health Promoter 0.2 FTE, Health Protection Officer 0.2 FTE, Public<br />
Health Specialist 0.1 FTE.<br />
Business case appendices V12 AC 25Feb2010 Page 33
Physical Activity and Nutrition - Community Dietician 0.5 FTE, Health Promoting Schools 0.2<br />
FTE, Health Promoter Physical Activity 0.3 FTE.<br />
This team is managed and supported by the Medical Officer of Health, Regional Manager and<br />
Team Leader. Support is also provided through Canterbury-based staff particularly around<br />
research and evaluation<br />
8 Effect on inequalities<br />
All projects implemented by the three organisations are based around the Ministry of Health<br />
key target areas, as well as areas identified in a West Coast Health Needs Assessment and<br />
Māori Health Needs Profile 2008, which identified areas of concern. At the core of this work<br />
is our belief that health inequity is unacceptable and all West Coasters are entitled to be as<br />
healthy as they can be regardless of ethnicity or socio-economic status.<br />
Projects worked on are evidenced based to show their effectiveness, or developed with a strong<br />
evaluative component to measure effectiveness. They are also designed with community input<br />
taking into account the principles of the Treaty of Waitangi and the requirements of involving<br />
Māori in all aspects of planning and implementation processes. West Coast Māori experience<br />
inequalities in their health status and as such each of the three components of this initiative<br />
has a key focus on improving the health of Māori and „keeping whanau well‟. The General<br />
Manager of Māori Health is a key member of the Healthy West Coast Governance Group. In<br />
addition it is anticipated that the Healthy West Coast Governance group will receive advice<br />
from Māori involved in the health sector regarding appropriate ways to engage Māori with<br />
health education and health promotion messages<br />
9 Evidence for this initiative<br />
The three organisations have been working closely in planning and delivery for the last three<br />
years. It is our understanding that this joint planning and sharing of information does not take<br />
place in other areas and in fact there is often competition and conflict between District Health<br />
Boards, <strong>Primary</strong> Health Organisations and Public Health Units. This initiative is unique in its<br />
approach to collaborative planning and implementation of strategies between the three<br />
organisations and provides value for money.<br />
We consider this project to be a pilot and evidence of its effectiveness will be gathered over<br />
the course of the implementation.<br />
The following PHO programmes have been evaluated over the last three years (evaluations have<br />
all been positive and suggested continuation or expansions of the programmes with suggestions<br />
for improvement 31 ): and full version are available on request:<br />
31 Copies of the full evaluation reports are available on request<br />
Business case appendices V12 AC 25Feb2010 Page 34
extending health promotion activities into medical centres and pharmacies<br />
smoking cessation<br />
Mum4Mum breastfeeding peer support programme<br />
men‟s health events.<br />
An evaluation into the effectiveness of school-based edible gardens in achieving HEHA<br />
outcomes is currently underway. The final results of this evaluation will be available in May<br />
2011.<br />
An evaluation of the Appetite for Life programme was also completed in 2008 which<br />
demonstrated positive outcomes for participants (copy available on request).<br />
An evaluation of the Rata Ahuahi Kore project is also underway and evaluation of the<br />
implementation of the first phase will be completed in March 2010. A further report on<br />
progress and impacts of the second phase will be available by the end of 2010.<br />
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Further reduction in<br />
public health and<br />
health promotion<br />
funding<br />
Workforce –<br />
recruitment and<br />
retention of<br />
appropriately<br />
qualified staff<br />
Shifting government<br />
priorities<br />
Mainstream<br />
approaches are<br />
ineffective in<br />
reaching Māori<br />
Medium High Review of health promotion focus<br />
areas (potential reduction in key<br />
priorities and areas of<br />
implementation).<br />
High High Refer to the recruitment and<br />
retention workstream of this business<br />
case.<br />
Medium High As above, the health promotion focus<br />
areas will be reviewed and potentially<br />
reduced depending on government<br />
priorities.<br />
Low to<br />
medium<br />
High<br />
Ensure Māori are involved from the<br />
beginning and that Māori health<br />
inequalities are addressed through a<br />
strong cooperative commitment to<br />
improving Māori health .<br />
11 Engagement<br />
Working group who developed this plan: Healthy West Coast Governance Group (comprised of<br />
representatives from the West Coast PHO, West Coast DHB and Community & Public Health).<br />
Other clinicians involved: The West Coast Medical Officer of Health is a member of the<br />
Healthy West Coast Governance Group.<br />
Business case appendices V12 AC 25Feb2010 Page 35
Networks/Groups: Active West Coast Network (Network of health promotion staff from a<br />
range of government departments and NGOs), Immunisation Advisory Group.<br />
12 Organisational accountabilities<br />
The accountability for this initiative is with the members of the Healthy West Coast<br />
Governance Group that includes:<br />
• Wayne Turp, General Manager - Planning & Funding, West Coast DHB<br />
• Gary Coghlan, General Manager - Māori Health, West Coast DHB<br />
• Cheryl Brunton, Medical Officer of Health/Public Health Specialist<br />
• Jocelyn Tracey, Acting CEO, West Coast PHO<br />
• Helen Reriti, Clinical Manager, West Coast PHO<br />
• Kim Sinclair, HEHA Manager, West Coast DHB<br />
• Derek Benfield, Regional Manager, Community & Public Health<br />
• Jem Pupich, Team Leader, Community & Public Health<br />
• Heather Muir, Regional Smokefree Co-ordinator<br />
This Governance Group will continue to oversee and retain the accountabilities for this project<br />
in the short and long term. As specified in the Terms of Reference for the Healthy West Coast<br />
Governance Group will act in a joint advisory capacity to the organisations represented, but will<br />
not have final decision making capacity except when mutually agreed by all of the agencies<br />
represented.<br />
13 Costs<br />
The following tables indicate the funders and providers of health promotion services in the<br />
tobacco control/smokefree, immunisation and physical activity and nutrition areas.<br />
Tobacco Control / Smokefree<br />
Funder<br />
Provider<br />
Activity<br />
WCDHB MOH (via CDHB) WCDHB WCPHO CPH<br />
Smokefree DHB regional co-ordination $85,000 $85,000<br />
Smoking cessation $89,500 $81,000 $8,500<br />
NRT $100,197 $100,197<br />
Aukati Kai Paipa $65,000 $65,000<br />
Māori Smokefree $25,000 $25,000<br />
Smokefree Compliance $11,000 $11,000<br />
Smokefree Projects $6,000 $6,000<br />
Business case appendices V12 AC 25Feb2010 Page 36
Immunisation Coverage<br />
Funder<br />
Provider<br />
Activity<br />
WCDHB MOH (via CDHB) WCDHB WCPHO CPH<br />
Immunisation Co-ordination $78,666 $78,666<br />
HPV $169,527 $169,527<br />
NIR Administration $65,780 $65,780<br />
Health Protection $13,000 $13,000<br />
Public Health Specialist $18,000 $18,000<br />
Youth Health Promotion $12,000 $12,000<br />
Health Promotion Infrastructure $10,000 $10,000<br />
Physical Activity & Nutrition<br />
Funder<br />
Provider<br />
Activity<br />
WCDHB MOH (via CDHB) WCDHB WCPHO CPH NGO<br />
HEHA Leadership and<br />
$142,160 $142,160<br />
Co-ordination<br />
HEHA Breastfeeding $113,174 $26,674 $86,500<br />
Māori Community Action $128,000 $45,000 $83,000<br />
HEHA Information<br />
$12,000 $5,000 $5,000<br />
dissemination<br />
Older Persons HEHA & Falls $85,000 $85,000<br />
Prevention<br />
Cooking Skills to Life Skills $10,000 $10,000<br />
Green Prescription $16,728 $16,728 *<br />
Health Promotion<br />
$41,000 $41,000<br />
Infrastructure<br />
Community Dietetics $36,000 $36,000<br />
Health Promoting Schools $12,000 $12,000<br />
Health Promoter – Physical<br />
$18,000 $18,000<br />
Activity<br />
Project Funding $5,000 $5,000<br />
*Plus an additional SPARC contract of $14,440.<br />
Business case appendices V12 AC 25Feb2010 Page 37
Appendix Five: Long term conditions<br />
1. Aspirational statement:<br />
Every patient with a long term condition will have the clinical care and support they need to<br />
achieve good health outcomes.<br />
2 Project overview<br />
The West Coast Long Term Conditions (LTC) Management Strategy was developed in 2006 by<br />
the West Coast District Health Board i(WCDHB) in collaboration with the West Coast <strong>Primary</strong><br />
Health Organisation (WCPHO), Community & Public Health (CPH) (the local public health<br />
provider), NGOs and Māori and consumer representation. This strategy is underpinned by<br />
Wagner‟s Chronic <strong>Care</strong> Model 32 and the Continuum of <strong>Care</strong> approach. The LTC Steering Group<br />
continues to meet regularly and oversees the implementation of the various aspects of the<br />
framework by each of the contributing organisations.<br />
As part of that strategy the PHO redesigned all its LTC programmes (<strong>Care</strong> Plus, Diabetes<br />
Annual Review, Cardiovascular Annual Reviews, Diabetes Self Management Education groups,<br />
Coast Quit smoking cessation) into one overall LTC management programme in 2008.<br />
Implementation of this programme began in 2009, assisted by Ministry of Health funding to use<br />
the Institute for Healthcare Improvement (IHI) Breakthrough Series 33 approach to quality<br />
improvement.<br />
This project builds on the work already done, particularly in regards to enhancing the<br />
integration of care for those with high complexity LTCs and to providing extra health navigation<br />
support services.<br />
3 Background and Problem definition<br />
DHB wide strategy<br />
The DHB strategy contains a framework that incorporates all DHB, primary care and NGO<br />
activity around LTCs and is updated on an annual basis to ensure that all groups are working<br />
32 Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical<br />
Practice. 1998;1:2-4<br />
33 Wagner - find Wagner E, Austin B, Davis C, Bonomi A., Provost L, McCulloch D, Carver P, Sixta C. Quality<br />
Improvement in Chronic Illness care: a Collaborative approach. J Q Improvement 2001; 27(2):63-80. 33<br />
Business case appendices V12 AC 25Feb2010 Page 38
The<br />
Community<br />
Health<br />
System<br />
Delivery System<br />
Design<br />
Clinical<br />
Information<br />
Systems<br />
Equity in<br />
Health<br />
together to meet the health needs of the population. While full version of this runs to many<br />
pages, the key aspects are summarises in the following diagram:<br />
Chronic conditions management – the WCDHB<br />
framework,<br />
The Patient’s Journey<br />
Environment<br />
Healthy<br />
At Risk<br />
Acute<br />
Event<br />
Initial<br />
management<br />
Long term<br />
clinical and<br />
Self<br />
management<br />
End of Life<br />
<strong>Care</strong><br />
Healthy public<br />
policy and<br />
creation of<br />
supportive<br />
environments<br />
Non-italics=<br />
existing service<br />
Italics= proposed<br />
service<br />
Healthy<br />
Schools;<br />
Smoke free;<br />
HEHA:<br />
Community<br />
events;<br />
Breast feeding;<br />
Men‟s health;<br />
Green Rx;<br />
Health<br />
promoting<br />
practices<br />
CVD and<br />
diabetes<br />
screening,<br />
follow up<br />
for those at<br />
highest risk<br />
Smoking<br />
cessation<br />
Diagnosis,<br />
hospital<br />
admission<br />
Pre-hospital<br />
fibrinolysis<br />
Diabetes<br />
Pulmonary<br />
rehabilitation,<br />
Cardiac<br />
rehabilitation,<br />
Arthritis and<br />
diabetes<br />
education/<br />
support<br />
groups<br />
PHO LTC: Focus on,<br />
CVD, diabetes ,<br />
COPD: clinical and self<br />
management support<br />
<strong>Care</strong>Link and AT&R<br />
assessments and MDT<br />
review for more<br />
complex<br />
Cancer<br />
navigators<br />
Palliative<br />
care<br />
funding in<br />
primary<br />
care<br />
UNDERPINNED BY THE WEST COAST‟S 7 PILLARS OF CHRONIC CONDITIONS MANAGEMENT<br />
The PHO Long Term Conditions programme (as it is now)<br />
The programme is both based on the Wagner Chronic <strong>Care</strong> model 1 (self-management support,<br />
community support, delivery system redesign, clinical information systems and decision support)<br />
and the Kaiser Triangle stratified care approach 34 . The programme meets the National Health<br />
Committee‟s objectives 35 of providing effective chronic care management and co-ordination<br />
through using a population health approach to care delivery, based on level of need, both clinical<br />
need and need for self management support. There is a focus on those with conditions that are<br />
frequent or severe, and these are addressed by national evidence based clinical guidelines and<br />
are responsive to enhanced primary care management, and have outcomes that can be tracked<br />
over time to measure improvement (Cardiovascular Disease (CVD), Diabetes, and Chronic<br />
Obstructive Pulmonary Disease (COPD)).<br />
34 World Health Organisation Innovative <strong>Care</strong> for Chronic Conditions: Building Blocks for Action: Global Report 2002<br />
WHO document no. WHO/NMC/CCH/02.01.<br />
35 National Health Committee People with Long Term Conditions A Discussion Paper National Health Committee<br />
Wellington May 2005<br />
Business case appendices V12 AC 25Feb2010 Page 39
The DHB and the Ministry of Health both approved the content of the LTC management<br />
programme in late 2008, including giving permission to allocate all LTC funds (Diabetes Annual<br />
Review, <strong>Care</strong> Plus, some Section J contract lines and some SIA funding) into a global budget for<br />
this programme.<br />
The programme is based on all patients with diabetes, CVD or COPD having an annual review<br />
from the time of diagnosis, and then based on their clinical condition and ability to self manage,<br />
a decision is made as to the level of care they require for the following year as shown in the<br />
diagram below:<br />
Patient enters system<br />
Package of care<br />
discussed<br />
with patient,<br />
package provided<br />
for following year<br />
Annual assessment<br />
carried out of<br />
patient's clinical<br />
condition & ability<br />
to self manage<br />
Decision made as to<br />
which level of<br />
care is most<br />
suitable for patient<br />
Patient may<br />
exit following<br />
annual<br />
assessment of<br />
care<br />
There are three packages of care, with increasing intensity and support as shown in the<br />
following three tables:<br />
Level One <strong>Care</strong>: Annual Reviews<br />
Patient LTC Diabetes ±<br />
Cardiovascular Disease<br />
(CVD)<br />
Target group<br />
Only CVD or<br />
Diabetes or<br />
COPD patients:<br />
Meets diagnostic<br />
criteria for diabetes.<br />
Assessed to be self<br />
managing well –<br />
informally or formally<br />
Cardiovascular<br />
Disease<br />
(If risk only, use CV<br />
Screening<br />
programme)<br />
Established<br />
cardiovascular<br />
disease<br />
Assessed to be self<br />
managing well<br />
Chronic Obstructive<br />
Pulmonary Disease<br />
(COPD)<br />
Confirmed diagnosis of<br />
COPD: Spirometry<br />
showing FEV 1 /FVC
Clinical care<br />
Practice self<br />
management<br />
support<br />
PHO/Community<br />
self care support<br />
Electronic clinical<br />
decision support<br />
Targets<br />
Annual review of clinical management by GP team according to national<br />
guidelines<br />
Recall for annual review and annual flu vaccination<br />
Plus ongoing usual clinical care<br />
Refer to CNSs and allied health as required<br />
My Shared Health Record 36 provided or updated at annual review, used<br />
at all consultations, smoking cessation (Coast Quit programme) if<br />
required<br />
Referral to Diabetes self management group, cooking skills for life,<br />
Living a Healthy Life, Kaiawhina, community support groups, green<br />
prescription, pharmacist support<br />
Diabetes advanced EDGE CVD form COPD Advanced form<br />
form (this includes<br />
CVD)<br />
National Practice Performance Programme (PMP) targets for Diabetes<br />
and CVD<br />
15% current smokers and 85% flu recall for COPD<br />
Numbers Enroll all COPD, CV Disease and Diabetes pts – estimated number 2000<br />
Level Two <strong>Care</strong>: Annual reviews and quarterly follow-up to support self management<br />
LTC Diabetes CVD COPD Other<br />
Patient will benefit from extra level of care<br />
Patient gives consent<br />
Capped numbers for each practice<br />
Target group<br />
<strong>New</strong> diagnosis of<br />
diabetes OR<br />
HbA1c> 8<br />
AND/ OR<br />
Flinders PIH<br />
assessment shows<br />
person is not self<br />
managing well<br />
<strong>New</strong> diagnosis of<br />
CVD OR<br />
BP>150/90<br />
TC >6mmol/l<br />
Worsening<br />
symptoms<br />
AND/OR<br />
high Flinders<br />
Score<br />
<strong>New</strong> diagnosis OR<br />
FVC 1 < 60%<br />
(moderate –<br />
severe COPD)<br />
Smoker<br />
AND/OR high<br />
Flinders score<br />
Two or more<br />
long term<br />
conditions<br />
(but not<br />
COPD, CVD or<br />
Diabetes)<br />
AND<br />
High Flinders<br />
score<br />
Clinical care<br />
Practice Self<br />
Management<br />
Support<br />
Quarterly half hour reviews by GP Team of clinical management according<br />
to national guidelines<br />
Recall for quarterly appointments and annual influenza vaccination<br />
Timing to coincide with need for regular script<br />
Focus on continuity of care – same provider for regular visits<br />
Other care as required<br />
Refer to clinical nurse specialist and allied health as required<br />
My Shared Health Record developed at annual review, used at all<br />
consultations, Full Flinders assessment, smoking cessation (Coast Quit<br />
programme),<br />
referral as required to PHO Mental Health Programme<br />
36 This includes goal setting, medication card, list of health problems, educational material<br />
Business case appendices V12 AC 25Feb2010 Page 41
PHO/Community<br />
self care<br />
support<br />
Electronic<br />
clinical decision<br />
support<br />
Targets<br />
Referral to Diabetes SME group, cooking skills for life, Living a Health<br />
Life, Kaiawhina, community support groups, green prescription, pulmonary<br />
or cardiac rehabilitation, pharmacist support<br />
Diabetes form<br />
Flinders<br />
Questionnaire<br />
National PMP<br />
targets<br />
EDGE CVD form<br />
Flinders<br />
Questionnaire<br />
National PMP<br />
targets<br />
COPD Advanced<br />
form<br />
Flinders<br />
Questionnaire<br />
15 % smokers<br />
85% flu<br />
vaccination<br />
Flinders<br />
Questionnaire<br />
Decrease in<br />
Flinders<br />
score<br />
Capped numbers Capped at 950 across whole PHO Cap of 25%<br />
of 950<br />
Level Three <strong>Care</strong>: Integration (level two care, plus the following)<br />
Patient with long term conditions – not managing, clinical Patient with long term<br />
problems (+/- social problems)<br />
conditions – not managing<br />
well due to social problems<br />
Assessed by GP: Needs level 3 Long Term Conditions <strong>Care</strong><br />
Refer for inpatient AT&R<br />
assessment<br />
Referred to <strong>Care</strong> link<br />
asking for AT&R<br />
assessment<br />
Referred to <strong>Care</strong> link asking<br />
for NASC assessment<br />
Has AT&R assessment – inpatient or outpatient<br />
Has NASC assessment by<br />
needs assessor<br />
Plan written<br />
Referrals to allied health, mental health, secondary care (physicians, nurse specialists),<br />
pharmacy medication utilization reviews, home care, community support groups, as required<br />
Copy of plan to GP<br />
Followed up by AT&R nurse in community<br />
Followed by <strong>Care</strong> Link<br />
service co-ordinator<br />
3 monthly reports to GP, until discharge from ongoing co-ordination<br />
Practice puts patient onto level 3 LTC care<br />
Receives funding for extra hour of GP time and extra hour of nurse time for either<br />
quarterly 30 minute GP assessments or quarterly 15 minute assessments plus home visit<br />
Full Flinders assessment with quarterly follow up by nurse and My Shared Health Record<br />
Funding available for GP or nurse to participate in case conference with AT&R nurse or <strong>Care</strong><br />
Link service coordinator or clinical nurse specialist<br />
At one year GP reassesses and decides whether :<br />
- Goes back to Level 2 care<br />
- Or continues on Level 3 with ongoing service integration/AT&R nurse<br />
- Or continues on Level 3 and referred for another AT&R or NASC assessment<br />
Capped at 190 patients each year for the whole PHO<br />
Implementation of the programme has gone well in 2009 using the IHI Breakthrough Series<br />
methodology. A recent evaluation 37 of the implementation showed high acceptance by practices<br />
37 North D, Tracey J. Evaluation of the IHI Breakthrough Series Project for West Coast PHO. Jan 2010.<br />
Business case appendices V12 AC 25Feb2010 Page 42
and increases in the numbers of patients with LTCs managed in a proactive and planned manner<br />
as shown in the following table:<br />
Enrolment Comparisons<br />
December 2008 December 2009<br />
<strong>Care</strong> Plus enrolments 51% 80%<br />
Level 1 enrolments 0 1061<br />
Level 2 enrolments 0 300<br />
Level 3 enrolments 0 27<br />
COPD enrolments 0 74<br />
CVD annual reviews 558 675<br />
Diabetes annual reviews 55 Māori reviewed<br />
35% Māori smoking<br />
61 Māori reviewed<br />
26% Māori smoking<br />
Cardiovascular risk and diabetes screening<br />
Active screening is in place for both cardiovascular risk and for diabetes, with follow-up<br />
management and support. The programme can profile and monitor cardiovascular risk<br />
assessments where people have a greater than 15% risk of having a cardiovascular event within<br />
the next 5 years. These identified patients are closely followed up with interventions to reduce<br />
their risk, and provide patients with the individual supports they require for self management<br />
and risk reduction.<br />
Cancer navigators<br />
The PHO has had pilot funding from the Ministry of Health to provide a Cancer Lay Navigator<br />
service for three years, finishing in June 2010. Programme evaluation reports have shown that<br />
the navigators have developed excellent skills in supporting predominantly low socio-economic<br />
and Māori people to access the health care and social support systems they need in order for<br />
their condition to be appropriately managed. There is growing international support for the use<br />
of lay navigators to support patients with LTCs 38 and opportunity to expand the role of this<br />
workforce to include LTCM.<br />
Clinical nurse specialists and allied health<br />
The clinical nurse specialist‟s are experienced clinicians in their respective fields of cardiac,<br />
respiratory, diabetes, oncology, urology, palliative care and AT&R. This specialised group of<br />
nurses provide clinical management to people with sometimes very complex needs. Some nurses<br />
work across two specialty areas like cardiac and respiratory which proves as a great advantage<br />
to continuity of care and management of these patients.<br />
38 Improving access to cardiac care report: http://www.libin.ucalgary.ca/documents/news/Libin-2008-07-23.pdf . accessed 14<br />
Jan 2010<br />
Business case appendices V12 AC 25Feb2010 Page 43
Each provides support and education to clinicians within primary and secondary settings, as well<br />
as education and self management support to patients within the hospital and home settings,<br />
some examples are:<br />
Breathe easy groups have been happening sporadically according to staff resourcing cardiac<br />
rehabilitation have two formal programmes:<br />
phase 2 cardiac rehabilitation, a six week outpatient programme based at the DHB<br />
physio gym in Greymouth and a modified programme at Buller hospitals<br />
Heart Guide Aotearoa, a home based programme designed to improve access to<br />
rehabilitation for West Coasters.<br />
Allied health comprises physiotherapy, occupational therapy, social work, dietician, speech<br />
language therapy, all with work components crossing secondary and primary care. These<br />
services are utilized within all levels of care as required, preferably sooner than later within the<br />
patient journey, this will ensure patient and family supports are put in place earlier before crisis<br />
point is hit.<br />
Pharmacist support<br />
This is related to levels of care, people would tend to move to more „intensive‟ care over time.<br />
Patients managing well – prescription dispensing, brief counseling/education as medicines<br />
added or adjusted, eg. take with food, side effects to watch for, inhaler/spacer<br />
technique, self care cards, adherence support, referral onto other team members as<br />
required.<br />
Supporting self management – as above but likely to be seen more often as receiving<br />
more medicines and more presentations to pharmacy, increased likelihood of<br />
medicines-related problems, medication reviews, compliance aid provision as necessary.<br />
Integration – as above, likely weekly compliance packaging – picked up or delivered to<br />
home or sometimes district nursing, reminders to visit GP for 3 monthly prescription,<br />
liaison with hospital and GP practice at discharge, follow-up if (blister-packed)<br />
medications not collected. Scope for comprehensive medication review at this level.<br />
General support – pharmacists are involved with various support groups, eg. cardiac and<br />
respiratory as speakers and are accessible to those with questions, presenting for Over<br />
The Counter (OTC) products or wanting their weight or blood pressure measured.<br />
Smoking cessation services are offered. People are referred as necessary, eg. to<br />
diabetes nurse specialist or general practice team.<br />
Ambulatory sensitive hospitalisations for those aged 45–64 are helpful in indicating whether<br />
LTC management is keeping people out of hospital. 39<br />
39 Included are angina, MI, CHF, pneumonia, asthma, diabetes, stroke, epilepsy<br />
Business case appendices V12 AC 25Feb2010 Page 44
Ambulatory Sensitive Hospitalisation ISDR - ages 45 to 64 years (12 months to 30 Sep 2009)<br />
Indirectly Standardised Discharge Rate per 1,000<br />
Māori Pacific peoples Other<br />
West Coast Actual ASH rate 8 n/a 152<br />
ISDR value for Year to Date 35.1 n/a 90.4<br />
West Coast DHB overall total discharge rates per 1000 for ambulatory sensitive<br />
hospitalisations, while below the average of 100, does not vary significantly from the overall<br />
national rates at the 99% confidence interval.<br />
Current issues<br />
Areas where there is still room for improvement include:<br />
total numbers of patients enrolled in LTC<br />
percentage of patients meeting clinical KPIs, e.. target lipid, BP, HbA1c levels<br />
closing of inequality gaps, eg. smoking levels<br />
integration of care for Level 3 patients (who have high hospitalisation rates), with a<br />
focus on preventing acute exacerbations and avoiding hospital admissions<br />
more support for those Level 3 patients who have difficulty accessing the health and<br />
social systems and would benefit from kaiawhina and/or health navigator assistance<br />
closer co-ordination and greater consistency of care between clinical nurse specialists<br />
(CNS) and medical centres and allied health and medical centres<br />
more support for patients self care is required .<br />
4 Objectives<br />
<br />
<br />
<br />
<br />
<br />
To increase implementation of the programme so that over 70% of all patients with<br />
COPD, CVD and/or diabetes have an annual review followed by a timely package of care<br />
appropriate for their level of need.<br />
Development of a Māori team within each Integrated Family Health Centre (IFHC) who<br />
will focus on improving access and health outcomes for Māori.<br />
To review the management of Level 3 patients and enhance the integration between<br />
general practice care and AT&R, <strong>Care</strong> Link and nurse specialist care and allied heath.<br />
To enable and empower people in the community to obtain process and understand health<br />
information and services needed to make appropriate decisions about their health.<br />
To develop health navigator support services for Level 3 patients who have difficulty<br />
accessing health care and social services.<br />
Business case appendices V12 AC 25Feb2010 Page 45
To better integrate the support provided to patients by CNSs, allied health and medical<br />
centres, eg. through better communication and information sharing.<br />
To link with the activities described in the health promotion workstream.<br />
5 Benefits and gains<br />
Output measures<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
% <strong>Care</strong> Plus enrolments 80% 83% 85% 88%<br />
Numbers in level 1, 2, 3<br />
All<br />
Māori<br />
1061/300/27<br />
35/24/2<br />
% estimated CVD coded* All 21.5%<br />
Māori 25%<br />
% estimated diabetes coded* All 69%<br />
Māori 72%<br />
1410/500/80<br />
75/45/6<br />
70%<br />
70%<br />
73%<br />
74%<br />
1880/750/120<br />
100/65/12<br />
80%<br />
80%<br />
77%<br />
77%<br />
2000/950/190<br />
150/75/15<br />
90%<br />
90%<br />
80%<br />
80%<br />
% diabetes (coded) annual reviews* All 57% 65% 75% 80%<br />
% of diabetes reviews with retinal All 73% >85% >85% >85%<br />
screening<br />
Māori 67%<br />
Number CVD annual reviews YTD All 577<br />
Māori 28<br />
Number COPD annual reviews All 75<br />
Māori 4<br />
% eligible popn screened for CV<br />
risk/diabetes*<br />
All 33%<br />
Māori 31%<br />
627<br />
35<br />
200<br />
30<br />
51%<br />
51%<br />
677<br />
40<br />
300<br />
45<br />
65%<br />
65%<br />
720<br />
45<br />
400<br />
60<br />
80%<br />
80%<br />
No. pharmacy medication reviews 0 100 200 300<br />
% of those hospitalised with angina 49% 55% 62% 70%<br />
or MI receiving cardiac<br />
rehabilitation 79 YTD to Sept 09<br />
% of those hospitalised with COPD 0 20% 30% 40%<br />
receiving pulmonary rehabilitation<br />
% patients admitted who are<br />
offered smoking cessation<br />
support*<br />
70% 75% 80% 85%<br />
Outcome measures – for all and for Māori<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
% diabetes HbA1c80%<br />
80%<br />
70%<br />
70%<br />
% CVD LDL
% CVD on lipid lowering drugs,<br />
beta blockers<br />
ACE<br />
aspirin*<br />
% diabetes with microalbuminuria<br />
on ACE*<br />
Māori 67% 70% 75% 80%<br />
73%<br />
49%<br />
49%<br />
73%<br />
All 84%<br />
Māori 89%<br />
80%<br />
55%<br />
55%<br />
80%<br />
86%<br />
89%<br />
85%<br />
65%<br />
65%<br />
85%<br />
88%<br />
90%<br />
90%<br />
70%<br />
70%<br />
90%<br />
90%<br />
90%<br />
% COPD on flu recall All 84% 86% 88% 90%<br />
% COPD not smoking All 73% 77% 81% 85%<br />
Average number exacerbations in 2.6 2.4 2.2 2<br />
last year/patient<br />
% decrease in Flinders score TBC<br />
LTC ASH rates: ISDR (aged 45-<br />
64yrs) includes: Diabetes, MI/angina,<br />
Pneumonia, CHF, Stroke<br />
90.4 89 87.5 85<br />
*Current or proposed PHO Performance Programme indicators and National Health targets<br />
6 Deliverables / activities<br />
Implementation plan: to June 30<br />
Increase participation:<br />
<br />
<br />
continue to employ a practice nurse facilitator to support practices to identify and enrol<br />
new patients into LTCM<br />
assist practices to adopt texting or use of Dr Info IT package for recalls.<br />
Level 3:<br />
<br />
<br />
<br />
review the implementation of level 3 care to date<br />
work with AT&R and <strong>Care</strong> Link, specialist nurses and allied health to develop processes<br />
to increase co-ordination and integration with primary care in a case management style<br />
approach within the IFHC environment, (overlap with workstream on community based<br />
nursing and allied health integration)<br />
implementation of regular meetings with cardiac, respiratory, diabetes nurse specialists<br />
within practice teams to plan level 3 patient care/management.<br />
Discharge planning:<br />
This is a stand-alone project being managed by the DHB Patient Journey Improvement<br />
Co-ordinator that aims to provide advice around service changes and identify opportunities to<br />
enhance discharge planning processes at WCDHB. It will be completed by June 2010 and<br />
encompasses the following objectives:<br />
<br />
Provide advice on clinical service and business process changes related to discharge<br />
planning to enhance outcomes and efficiencies.<br />
Business case appendices V12 AC 25Feb2010 Page 47
Participate in the development and review of change proposals to improve discharge<br />
planning across the continuum of care, including examination of models of good practice<br />
which exist elsewhere, and support implementation of changes.<br />
Undertake consultation with staff groups being represented by members to ensure that<br />
all those involved in the discharge planning process are adequately engaged in the<br />
development and implementation of service changes.<br />
Promote internal and external multi disciplinary team working and communication.<br />
Promote continuous improvement of discharge planning activities to all staff.<br />
Self management/health literacy support:<br />
group diabetes self management programme: 4 sessions per year<br />
continue support for and referrals to Arthritis Foundation group self management<br />
support programme<br />
develop data analysis and reporting systems for measuring changes in Flinders self<br />
management score, produce first reports<br />
training session for health providers on health literacy<br />
publicise health navigator patient self management website – for providers and<br />
community, eg. pamphlet in prescription bags<br />
create link to Community & Public Health website on PHO website<br />
restart pulmonary rehabilitation programme, and create referral pathways from Green<br />
prescription<br />
increase referrals to other NGOs providing educational support<br />
support pharmacist to complete accreditation for medication utilization reviews<br />
develop a whanau focused approach to health literacy and self management.<br />
Year one<br />
Link PHO LTCM programme in with relevant HealthPathways<br />
Implement IT support for integration:<br />
create health views link from all practice and outpatients, wards and hospital pharmacy<br />
link into MedTech<br />
investigate use of shared electronic record.<br />
Medication reviews:<br />
develop funding stream for medications utilization reviews done by hospital and<br />
community pharmacies.<br />
Māori health team:<br />
develop a dedicated team that includes a Māori nurse and kaiawhina to build and<br />
strengthen relationships across the health care sector and with a key focus on the<br />
disengaged and hard to reach Māori within the West Coast community.<br />
Business case appendices V12 AC 25Feb2010 Page 48
Health navigators/ kaiawhina:<br />
change cancer navigator processes and criteria to include helping those with LTCs<br />
provide training in LTCs for health navigators and kaiawhina<br />
health literacy training for kaiawhina/navigators<br />
align health navigators and kaiawhina with IFHCs<br />
refine patient pathways between navigators/kaiawhina, in close relationship with Māori<br />
nurses within the IFHCs<br />
develop and implement pathway to follow-up frequent LTC emergency department (ED)<br />
attendees/admissions so that they understand how to access and navigate the primary<br />
care system.<br />
Self management/health literacy support:<br />
scope MedTech Manage my Health portal as a tool to improve self management<br />
review transport issues and develop plan to address these.<br />
Integrated community nursing and allied health in IFHCs:<br />
regular multidisciplinary meetings with clinical nurse specialist and allied health<br />
placing of CNS and allied health in IFHCs<br />
investigate use of shared electronic record.<br />
Decreasing repeat attendances at ED for LTC patients:<br />
work with ED to create a pathway to refer these people to either CNSs, health<br />
navigators or core general practice team.<br />
<strong>Care</strong> Link integration (see Appendix Eleven: Frail older people for more information)<br />
InterRAI assessments done in IFHCs/practices<br />
include <strong>Care</strong> Link in MDT meetings in IFHCs<br />
align LTC and frail elderly pathways.<br />
Data and reporting:<br />
review prevalence estimates and Read coding for West Coast, particularly for COPD<br />
review appropriateness of reports provided to IFHCs<br />
Year two<br />
more integrated community nursing and allied health working in IFHCs, (see EOI<br />
community and allied workstream plan)<br />
packages of care for patients with deteriorating medical condition/social situation,<br />
enabling faster access to a greater range of home/community support services.<br />
Year three<br />
review outputs, outcomes and the implementation of this plan, revise this plan as<br />
required.<br />
Business case appendices V12 AC 25Feb2010 Page 49
7 Capability and capacity<br />
The PHO currently has strong capability to design and implement LTC programmes: the clinical<br />
advisor teaches the LTC Management Postgraduate Certificate at the University of Otago, the<br />
Nurse Clinical Manager has a strong focus on LTCs and the LTCM practice facilitator is an<br />
experienced practice nurse.<br />
The current cancer navigators have highly developed skills in their role, and as of late 2010 will<br />
broaden their focus from cancer alone to cancer and LTCs. This will require both extra training<br />
and a stronger focus on the high needs population of the West Coast.<br />
Hospital based community nurses key focus is care of people within the community, with closer<br />
integration and co-ordination with practice teams this can only improve services and care to<br />
patients and families.<br />
8 Effect on inequalities<br />
Already the focus on LTCM has made considerable difference to inequalities in management and<br />
health outcomes for diabetes (see 2008 Diabetes Annual Review report).<br />
By reporting on differences by ethnicity at the practice level there is encouragement to work<br />
towards further reduction in inequalities.<br />
A dedicated Māori health team, addressing inequalities through better links and communication<br />
with all health care providers whilst helping Māori people on their health care journey. This is<br />
about engagement (face to face) at the right time from the right people, fostering relationships<br />
and promoting trust.<br />
The PHO is working with Rata Te Awhina in regards to support a whanau ora approach that will<br />
co-ordinate screening for cardiovascular risk and ensure patients with high CV risk, CVD,<br />
Diabetes or COPD are given free vouchers for annual reviews with their GP.<br />
9 Evidence for this initiative<br />
The programme is both based on the Wagner Chronic <strong>Care</strong> Model 1 (self management support,<br />
community support, delivery system redesign, clinical information systems and decision support)<br />
and the Kaiser Triangle stratified care approach 40 . The Programme meets the National Health<br />
40 World Health Organisation Innovative <strong>Care</strong> for Chronic Conditions: Building Blocks for Action: Global Report 2002<br />
WHO document no. WHO/NMC/CCH/02.01.<br />
Business case appendices V12 AC 25Feb2010 Page 50
Committee‟s objectives 41 of providing effective chronic care management and co-ordination<br />
through using a population health approach to care delivery, based on level of need, both clinical<br />
need and need for self-management support.<br />
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Potential reduction in funding<br />
for LTC programme<br />
Medium High Clear communication with key<br />
stakeholders regarding necessity<br />
for ongoing funding<br />
Enrolments in LTC do not<br />
increase as expected<br />
Medium High Address workforce issues; see<br />
plans for Core General Practice<br />
Redesign and Workforce<br />
When community services<br />
move into IFHCs demand is<br />
too great<br />
Develop patient pathways and<br />
target criteria<br />
11 Engagement<br />
Working group who developed this plan: WCDHB LTC steering group: Helen Reriti RN, Peter<br />
McIntosh (Funding and Planning, DHB), Jem Pupich (Community and Public Health), Dr Cheryl<br />
Brunton, Lisa Smith CNS, Maureen Frankpitt RN, Kim Sinclair (HEHA), Barbara Beckford<br />
(Consumer rep), Gary Coghlan (GM Māori), Dr Jocelyn Tracey<br />
Plus Robyn McLachlan (<strong>Care</strong> Link), Danielle Smith (Cancer navigator), Janette Anderson (DHB<br />
Physio), Dr Carol Atmore, Community pharmacists.<br />
This plan has been reviewed and amended by PHO Clinical Governance Group and DHB <strong>Primary</strong><br />
secondary liaison group.<br />
12 Organisational accountabilities<br />
The DHB LTC steering group will continue to oversee the implementation of this plan. Changes<br />
in organisational accountability are covered in the Service Delivery design aspect of the<br />
business case.<br />
13 Budget considerations<br />
The PHO LTC budget has been modified to include cancer navigators.<br />
Secondary care budgets are assumed unchanged at this stage.<br />
41 National Health Committee People with Long Term Conditions A Discussion Paper National Health Committee<br />
Wellington May 2005<br />
Business case appendices V12 AC 25Feb2010 Page 51
Appendix Six: Integration - DHB community based services<br />
1. Aspirational statement:<br />
West Coasters with complex health needs will receive co-ordinated and consistent care from<br />
their health providers working together as an integrated health team.<br />
2 Project overview<br />
This project establishes integrated health teams inclusive of general practice based primary<br />
health practitioners and non general practice based community health nurses 42 and allied health<br />
staff, to ensure the provision of integrated and co-ordinated multi disciplinary care and a<br />
holistic approach to meeting the populations' needs.<br />
3 Problem definition<br />
Traditional medical centres, or general practices, care for their enrolled populations. Some of<br />
those same patients are cared for by district nurses, and other community based nursing and<br />
allied health professionals, both as hospital inpatients and post discharge, sometime for an<br />
extended time period. But the two systems of care are not routinely or systematically well<br />
connected together. They operate to a large extent as parallel systems of care. When the two<br />
systems do intersect, it may be purposeful, eg. a GP refers a patient to district nursing, or it<br />
may occur by accident, eg. one individual is employed as both a practice nurse and a clinical nurse<br />
specialist, or a district nurse and a GP happen to know each other and have a working<br />
relationship. This work stream aims to better connect these two significant health care<br />
workforces, and to do so systematically and fundamentally, to ensure patients will benefit from<br />
co-ordinated and consistent care.<br />
Key issues identified as a result are:<br />
Lack of co-ordination of care across the different systems of care and difficulties for<br />
the patient navigating through the system:<br />
- communication gaps between primary and secondary health providers (referral,<br />
discharge, treatment)<br />
- duplication of care, and consequent unnecessary costs<br />
42 "community health nurses" is defined broadly; it is taken to include: district nurses, public health nurses, rural nurse<br />
specialists, neighbourhood nurses, immunisation coordination & outreach nurses, Well Child & Plunket nurses and clinical<br />
nurse specialists (cardiology, respiratory, oncology, palliative, diabetes etc)<br />
Business case appendices V12 AC 25Feb2010 Page 52
- lack of consistency of care between providers; inconsistent information given to<br />
patients by different providers<br />
Inequalities in health outcomes:<br />
- poorer health status for Māori and deprived populations through lower access<br />
rates to services<br />
Lack of continuity of care:<br />
- seeing a different health provider each visit<br />
- lack of a single patient record system across health care providers<br />
- providers working in silos and not „joining up‟ episodes of care.<br />
Problems in accessing services:<br />
- services not co-located in some areas, making it particularly difficult for the<br />
frail elderly or those without transport who need to see several health care<br />
providers<br />
- referral system for care outside core primary health team inefficient and<br />
unwieldy.<br />
Workforce shortages.<br />
The patient numbers and, in particular, the patient demand on the health system, relevant to<br />
the possible intersection of these two workforces, are significant.<br />
An analysis of West Coast PHO enrolled patients and visit numbers for 2009 shows the<br />
following:<br />
Business case appendices V12 AC 25Feb2010 Page 53
It is significant that the 9% of the 30,000+ enrolled population who attended medical centres<br />
most frequently, accounted for 35% of the 120,000+ visits to medical centres, ie. those sickest<br />
9% patients attended their medical centre an average 16 times during 2009.<br />
In addition, district and rural health nurses received 2,351 referrals in 2009 and saw patients<br />
on average 12 times, clinical nurse specialists received 782 referrals and saw patients on<br />
average 6 times, while allied health received 4,613 referrals and saw patients on average 4<br />
times. All in all, the community nursing and allied health workforces conducted some 50,000<br />
patient contacts, in addition to the 120,000+ visits to medical centres.<br />
4 Objectives<br />
The overarching aim is to provide better co-ordinated care for patients across medical centres,<br />
community nursing and allied health services, by including the community nursing and allied<br />
health workforces as members of Integrated Family Health Centres (IFHC)teams. This is likely<br />
to be of particular benefit for high complexity patients with Long Term Conditions (LTCs) and<br />
high numbers of admissions (see also LTC Project plan).<br />
A multi disciplinary team (MDT) approach to care (for that subset of patients who will benefit<br />
from it), including MDT clinical review, will be developed. Patient pathways for common and<br />
complex conditions, which integrate home based and clinic based care, and that align the<br />
activities of health professionals providing that care will be developed (see also the LTC Project<br />
plan and the Health Pathways Project plan).<br />
We will therefore work towards achieving a unified management and clinical leadership<br />
structure which respects and promotes the professional contribution of all staff within the<br />
IFHC, and makes the most efficient use of the nursing and allied health resources available on<br />
the West Coast. This structure will recognise the particular ownership characteristics and<br />
needs of participating health providers in the integrated setting.<br />
Where particular roles or professions need to contribute to more than one IFHC, we will define<br />
how such specialist roles can best be organised across the region. It will be important to<br />
maintain linkages between professional groups, who are working in a variety of settings, and to<br />
review and develop professional roles so that they contain both generalist and special interest<br />
components. Health professionals will retain their professional identity and have access to<br />
robust professional development processes to ensure the delivery of evidence based best<br />
practice, especially in the context of delivery of rural/remote services with practitioners often<br />
working in isolation.<br />
We intend to develop health assistant roles within the IFHCs and so ensure health professionals<br />
are working to their maximum capacity in delivering care to patients commensurate with their<br />
Business case appendices V12 AC 25Feb2010 Page 54
qualifications and skills. Where care can be delegated to a health assistant, this should happen,<br />
provided the health assistant receives adequate support, supervision and training. This will then<br />
free the health professional to provide the more complex care.<br />
We will also design and implement common infrastructure systems and service specifications to<br />
support a more integrated way of working.<br />
Patients will benefit from GPs and practice/rural nurses being made aware immediately when one<br />
of their patients is admitted to hospital (for example), and the district nurse and allied health<br />
professionals can work with the GP & practice nurse on the plan for the patient's discharge<br />
from the time of their admission to hospital. Patients will benefit when these two workforces<br />
are utilizing the same clinical information system to record their interactions with, and care for,<br />
the patient, and when all the health professionals involved in their care are giving them<br />
consistent advice.<br />
Patients will benefit when clinical nurse specialists and allied health professionals are available<br />
to intervene earlier with patients with long term conditions, rather than being called in to<br />
address the patient's needs only after a patient has been admitted to hospital.<br />
Currently well child service provision is fragmented between Plunket, primary care, Māori health<br />
NGO providers, midwives and community nursing services. The advent of IFHCs creates the<br />
opportunity to bring these carers together, so that care is streamlined, information is shared<br />
and families get the right level of follow-up. Initial discussions with NGO service providers<br />
indicate a willingness to collaborate in order to achieve better health outcomes and better use<br />
of resources. <strong>More</strong> detailed discussions and project planning will occur in year one of the<br />
implementation phase.<br />
Objectives:<br />
to improve the care of patients with the greatest need on the health system<br />
to make the most efficient use of the nursing and allied health resources available on<br />
the Coast<br />
to design and implement common infrastructure systems and service specifications to<br />
support a more integrated way of working<br />
provide leadership that is able to respond to the flexing/changing needs, and provides all<br />
staff with feedback on performance<br />
include staff in planning the delivery of services, complete a gap analysis asking staff<br />
what is working/not working and implement these ideas in to working smarter/better use<br />
of resources<br />
review and develop nursing roles into a more holistic primary health nurse role aimed at<br />
blurring existing boundaries between specific nurse functions, but one that contains<br />
both generalist and special interest components.<br />
Business case appendices V12 AC 25Feb2010 Page 55
5 Benefits and gains<br />
Output measures<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
Percentage of health centres with<br />
monthly (or more frequent) regular<br />
clinical full MDT meetings<br />
25% 67% 100% 100%<br />
Development of single health<br />
assessment<br />
Shared electronic health record<br />
Patient timeframe to move through<br />
system - average time from new<br />
routine service request to patient<br />
being seen:<br />
- district nurses<br />
- rural health nurses<br />
- clinical nurse specialists<br />
- allied health<br />
Not in<br />
place<br />
Not in<br />
place<br />
TBC<br />
In place<br />
Partially in<br />
place<br />
In place<br />
Outcome measures<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
ASH rates<br />
See LTC<br />
paper<br />
% people with LTCs meeting<br />
clinical targets, eg. HbA1c, lipids<br />
and BP<br />
See LTC<br />
paper<br />
Annual No. re-admissions per year 8.21%<br />
(2009)<br />
No. patients with more than 6 ED TBC<br />
attendances per year<br />
No. patients with more 2 or more 199<br />
admissions for 5 or more bed days (2009)<br />
per year 43<br />
8% 7% 6%<br />
190 180 170<br />
43 Definition borrowed from the Counties Manukau project: Roseman, P. (2003). "Frequent Adult Medical Admissions<br />
Final Report." Retrieved 15 December 2008, 2008, from http://www.cmdhb.org.nz/Funded-<br />
Services/CCM/documents.htm.<br />
Business case appendices V12 AC 25Feb2010 Page 56
6 Deliverables / activities<br />
Implementation plan: to June 30<br />
<br />
<br />
<br />
<br />
<br />
<br />
Establish MDT meetings: allied health, district nursing and clinical nurse specialists will<br />
meet with core health centre staff in each health centre to plan the care of specific<br />
high complexity patients. <strong>More</strong> sharing of information about patient needs for care will<br />
ensure more effective management of these patients. Guidelines for conducting these<br />
meetings will be developed.<br />
Identify extent and nature of overlap between medical centre frequent attenders<br />
cohort and community nursing/allied health clients; conduct review of care provided to<br />
patients common to both cohorts; examine systems and/or performance issues<br />
identified by this review and rectify/optimize.<br />
Review nature and type of home based nurse assessments with a view to developing<br />
standardised assessment procedure.<br />
Plan for assignment of community nursing and allied health clinicians to practice<br />
populations.<br />
Identify a professional grouping/team(s) and locations to be the first centre for<br />
implementation of the integrated model. Pilot, refine, spread.<br />
Develop common, integrated service specifications (break down barriers created by the<br />
existing specs). Consolidate and reduce reporting requirements where possible. To<br />
achieve this outcome, communication with the Ministry of Health needs to commence<br />
this year.<br />
Year one:<br />
Develop and implement a pathway for nurse care for different patients groupings, eg.<br />
post surgery, long term condition, frail elderly, palliative (covering the various nursing<br />
groups/specialties) and for wound care, across clinic and home settings.<br />
Examine better linking of home based care with district nursing.<br />
Develop IT and administration systems that enable closer integration, including those<br />
that enable data capture in the home/at the bedside.<br />
Review current referral systems, considering potential role of <strong>Care</strong> Link, and change to<br />
'within-system-request-for-assistance/booking'. Monitor workload and waiting times<br />
and develop new priority and entry criteria as required.<br />
Identify the requirements for sharing clinical notes on MedTech in a single clinical file<br />
used by all health providers in the IFHC. Develop specifications for new system and<br />
fund implementation. Work with the current health centre that does not currently use<br />
MedTech to determine the barriers and facilitators for change.<br />
Develop a plan for better integration of well child services.<br />
Business case appendices V12 AC 25Feb2010 Page 57
Year two:<br />
Maintain deliverable/activities from year one. Monitor & audit progress & changes.<br />
Extend MedTech across all health centres and for all community nursing and allied<br />
health.<br />
Develop a client load aligned with practice populations, eg. each physiotherapist, social<br />
worker or specialist nurse relates to one (or more) health centres and may see patients<br />
there. They will be members of the multi disciplinary team.<br />
Review the location of sexual health services, with a view to them being located in IFHCs<br />
Year three<br />
<br />
Build on and maintain previous years work.<br />
7 Capability and capacity<br />
Capability and capacity are core aspects of this plan and are therefore covered in the above<br />
sections.<br />
8 Effect on inequalities<br />
This work stream focuses on those who are current frequent users of the health system,<br />
including the frail elderly, and aims to improve their care. While focusing on optimizing care for<br />
those who do frequently interact with the health system, it will be important to ensure that<br />
those who typically don't benefit, and are disconnected, from the health system (but who could<br />
benefit from better care) are not forgotten. It is intended that achieving better (as distinct<br />
from more) care for those patients currently utilizing the health system frequently, will free<br />
resources that can then be focused onto meeting the needs of Māori and Pacific peoples.<br />
9 Evidence for this initiative<br />
The need for new models of integrated care for the aging population and those with long term<br />
conditions has been well described by Rosen and Ham 44 :<br />
44 Rosen R, Ham C. Integrated <strong>Care</strong>: lessons from evidence and experience. Report of the 2008 Sir Roger Bannister<br />
Annual Health Seminar by R Rosen, Nuffield Trust , C Ham, University of Birmingham<br />
Business case appendices V12 AC 25Feb2010 Page 58
“With an aging population and an increasing prevalence of chronic disease, ever more<br />
people require care and support services from organisations that cross the boundaries<br />
of health, social care, housing and voluntary organisations. A wealth of studies report<br />
that people with chronic, complex health problems – particularly older people – are often<br />
confused by the array of services they are faced with, receive duplicate interventions,<br />
and find it hard to understand where to turn with specific problems. They value<br />
initiatives to coordinate care and simplify their journey through the health and social<br />
care systems.<br />
Equally, with pressure to deliver elective care in community settings and prevent<br />
avoidable ill health, integration and collaboration between generalists and specialists –<br />
GPs, consultants, specialist nurses and other clinicians – is increasingly important.”<br />
They advise that any project involving integration of services:<br />
makes improved patient care the main objective of every proposal<br />
develops clearly articulated and shares goals<br />
involves local primary care networks and clinicians in developing the strategy<br />
takes time and effort to build the relationships, trust and clinical leadership required in<br />
integrated teams<br />
measures clinical and social outcomes so that the effect of changes can be reviewed and<br />
programmes modified<br />
is careful to unbundle the true costs of any services before devolution occurs<br />
develops robust governance arrangements from the start<br />
establishes the right incentives for services and clinicians to want to be involved.<br />
Similarly Glendenning 45 observes that integration is more likely when the following are present:<br />
joint goals<br />
tight knit highly connected professional networks<br />
high degree of mutual trust<br />
joint arrangements which are part of „core business‟ rather than marginal integration at<br />
the edges<br />
joint arrangements covering operational and strategic issues and shared or single<br />
management arrangements,<br />
Nick Goodwin, Kings Fund 46 , in his recent presentation to the Ministry of Health concluded from<br />
the international literature that:<br />
“There is a lack of rigorous evaluations of polyclinics in other countries. Contextual<br />
differences are important.<br />
Co-location of professionals is not sufficient to guarantee integrated care - in the<br />
same polyclinic, and between polyclinics and hospitals.<br />
45 Glendenning, C (2002) „Breaking down barriers: integrating health and care services for older people in England‟,<br />
Health Policy 65: 139–151.<br />
46 Nick Goodwin. Powerpoint presentation to Ministry of Health, Wellington. 15 March 2010<br />
Business case appendices V12 AC 25Feb2010 Page 59
Risks to professional development and motivation.<br />
Issues of patient choice and continuity of care, and how these are to be<br />
safeguarded within a polyclinic-based system<br />
Caution needs to be exercised in basing policy on international experience. “<br />
His advice for successful integration was:<br />
“Strong clinical leadership – quality focus<br />
Team working<br />
Cluster services & diagnostics around patient needs<br />
Investment in change management & process redesign<br />
Maximise benefit of new technologies and IT”<br />
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Co-location of community<br />
nursing and allied health<br />
with medical centres is<br />
achieved, but does not lead<br />
to better integration<br />
Re-orientation and<br />
re-focusing of community<br />
nursing/allied health<br />
workforces towards<br />
primary end leads to<br />
overload for staff<br />
("something added, but<br />
nothing dropped")<br />
Re-orientation and<br />
re-focusing of community<br />
nursing/allied health<br />
workforces towards<br />
primary care, worsens<br />
connection with secondary<br />
care<br />
High High Recognise this key risk (as identified from<br />
overseas experience/published literature).<br />
Understand the limitations of co-location<br />
back-up co-location with electronic<br />
records integration<br />
back up co-location with common<br />
organisational/management structures<br />
where possible<br />
back up co-location with development and<br />
implementation of an Integration Charter<br />
that is linked to lease/tenancy<br />
arrangements.<br />
High High Identify early opportunities for improving<br />
outcomes (rather than just responding to<br />
service demands) for patients with high<br />
demands on the system with view to reducing<br />
the current level of demand/service utilization.<br />
Target services to those most in need/most<br />
able to benefit; refine entry/exit &<br />
prioritisation criteria.<br />
Medium High Recognise this key possibility and address from<br />
the outset.<br />
Ensure inpatient workload is fully understood<br />
and necessary availability to the wards etc is<br />
protected.<br />
Business case appendices V12 AC 25Feb2010 Page 60
Differences between<br />
revenue generating<br />
imperatives faced by<br />
medical centres and free<br />
service ethos of<br />
community nursing/allied<br />
health causes professional<br />
disconnects and/or<br />
confusion for the public<br />
Management of change<br />
process handled<br />
ineffectively.<br />
Physical co-location of<br />
community nursing and<br />
allied health with medical<br />
centres cannot be achieved<br />
Community nursing/allied<br />
health workforce being<br />
allocated to medical<br />
centres leads to<br />
fragmentation and loss of<br />
support within the<br />
professional groupings<br />
Sub-specialisation becomes<br />
impossible and/or is not<br />
supported (in any move to<br />
generalist roles)<br />
High Medium <strong>Care</strong>fully examine & understand public policy<br />
implications & possibilities; engage with MoH<br />
early.<br />
Ensure all workforces are aware of financial<br />
imperatives & requirements.<br />
Ensure clear boundaries, entry/exit criteria<br />
etc.<br />
Ensure clear communication with<br />
patients/public.<br />
Medium High Have a transition pathway.<br />
Introduce a change manager to lead this.<br />
Ensure patients/family/whanau and the<br />
Community walk alongside the developments/<br />
Consumer input and involvement.<br />
Have clear guidelines and timeframes.<br />
Have plan for management of staff resistance<br />
and monitor.<br />
Medium Medium Ensure clinical notes integration.<br />
Implement common organisational/management<br />
links.<br />
Medium Medium Recognise this key possibility and address from<br />
the outset.<br />
Ensure professional support and communication<br />
needs are understood and addressed in<br />
implementation plan.<br />
Ensure new business/organisational model<br />
contains necessary support, mentoring,<br />
professional development infrastructure for all<br />
professional groups.<br />
Low Medium Recognise this possibility and address from the<br />
outset.<br />
Identify and plan out the skills required, set<br />
education around this plan and review.<br />
11 Engagement<br />
Working group who developed this plan: Hecta Williams, Raewyn McKnight, Maureen Frankpitt,<br />
Janette Anderson, Hecta Williams, Helen Reriti, Pauline Ansley, Barbara Smith, Jenny<br />
Robertson, Jane O‟Malley, Cheryl Hutchison, Jenny Woods, Dr Jocelyn Tracey, Anthony Cooke.<br />
Other clinicians involved: Dee Dolby, Dr Carol Atmore, PHO Clinical Governance Committee.<br />
Business case appendices V12 AC 25Feb2010 Page 61
12 Organisational accountabilities<br />
There are two levels of change proposed.<br />
Within each IFHC, co-located services will sign up to an Integration Charter that sits alongside<br />
their tenancy/lease agreement. This Charter will commit those services that co-locate to the<br />
service integration objectives of the IFHC and to involvement in the 'service integration<br />
management team' that is likely to operate in each facility.<br />
Subject to decisions made in relation to the overall ownership and operation of various services<br />
(see the Ownership, Governance & Management work stream) it may be that services currently<br />
operated by the DHB will come under the auspices of the PHO. The PHO, suitably revised or<br />
replaced, would then become the operator of a larger proportion of the community and primary<br />
health care service infrastructure, with service integration, management and development of<br />
the whole primary and community health service, its core role and responsibility.<br />
13 Costs<br />
No change to ownership of services is proposed initially. Each service owner will continue to be<br />
responsible for their services own revenue & costs.<br />
Achieving the early goal of change to, and integration of, clinical services will, however, require<br />
dedicated project & change management resource as described in the Business Case.<br />
Business case appendices V12 AC 25Feb2010 Page 62
Appendix Seven: Integration - HealthPathways<br />
1. Aspirational statement:<br />
Patients will receive care that is consistent, co-ordinated and in accordance with best practice<br />
guidelines across their health care journey.<br />
2 Project overview<br />
HealthPathways is a web-based information system developed by Canterbury DHB Planning and<br />
Funding in conjunction with local clinicians. GPs and hospital clinicians identified the importance<br />
of current information in securing the best care for patients within existing constraints<br />
(workforce and fiscal) and developed HealthPathways to provide this information, with a primary<br />
focus on general practice care, as part of the Canterbury Initiative (see www.canterbury<br />
initiative.org.nz.).<br />
This project describes the adaptation and implementation of HealthPathways for the West<br />
Coast.<br />
3 Problem definition<br />
Description of HealthPathways<br />
HealthPathways:<br />
Uses the skills of other clinicians including nursing, allied health, and health scientists.<br />
Provides local information about local services.<br />
Is based on and referenced to Best Practice NZ guidelines if available, or international<br />
guidelines.<br />
Provides information on assessment, management, hospital departments, and referral;<br />
and also patient information, reference material, and educational resources.<br />
Covers the most frequent reasons for referral to a hospital department, acute and<br />
non acute.<br />
Is complementary to the planned electronic referral management system.<br />
Keeps clinicians up-to-date with which services are available, which are funded, and how<br />
to access them.<br />
Business case appendices V12 AC 25Feb2010 Page 63
HealthPathways is not:<br />
decision support software (no patient information is entered)<br />
evidence-based guidelines<br />
designed for patients<br />
comprehensive – many departments and clinical areas have not been started.<br />
Development of pathways:<br />
Pathways are initiated by the clinical work groups within the Canterbury Initiative and<br />
then progressed by clinical editors. T he relationships developed in the work groups<br />
provide the foundation to develop the pathways. Additional pathways are continually<br />
being added to HealthPathways as additional work groups are created.<br />
While one of the key drivers in Canterbury for the development of HealthPathways was to<br />
decrease waiting times for first specialist appointments (FSAs), the drivers for the West Coast<br />
are somewhat different. Currently, the primary care system on the West Coast is not in a good<br />
position to take on clinical tasks currently performed in secondary care settings. Similarly, Grey<br />
Base Hospital services are generally staffed on a capacity model – in which staff costs do not<br />
vary with reductions in activity. However, in the medium term, with the strengthening of the<br />
primary care sector, and the development of more activity based staffing for some services,<br />
associated with a closer working relationship with Canterbury DHB 47 , there may be an<br />
opportunity to move some clinical work from the hospital setting into Integrated Family Health<br />
Centres (IFHCs).<br />
West Coast issues to be addressed by this programme:<br />
The care provided is not always consistent across primary and secondary providers.<br />
There is a heavy dependence on locums, often from overseas, to provide GP care and<br />
they do not always know what can be done in general practice, and when to refer to<br />
secondary care.<br />
Nurses are taking an increasing role in first line care in general practice and will find<br />
locally adapted HealthPathways valuable to guide the care they provide.<br />
While waiting times for FSAs are not a major issue currently given the relative high<br />
specialist:population ratio, as the Sustainability Project effects the numbers and types<br />
of secondary care clinicians on the West Coast it will become important to have<br />
pathways that describe what is expected to take place in primary care prior to referral<br />
for an FSA.<br />
An increasingly amount of secondary care is provided by clinicians jointly employed by<br />
Canterbury and West Coast DHBs; it is therefore important that care and access to<br />
FSAs is consistent across the regions.<br />
47 See LECG report: Analysis of options: models of care for West Coast DHB. Nov 2009<br />
Business case appendices V12 AC 25Feb2010 Page 64
It is expected that HealthPathways will provide:<br />
<strong>Better</strong> care – in line with Best Practice guidelines, and consistent between providers,<br />
including primary, secondary and Māori providers.<br />
<strong>Sooner</strong> care – patients will be able to access some investigations and treatment options<br />
earlier directly from their general practice, and waiting times for FSAs may decrease.<br />
<strong>More</strong> convenient care –more care will be provided at IFHCs rather than hospital based.<br />
Nurses and doctors working in general practice have expressed interest and support for this<br />
development, as have those in community nursing, allied health and secondary care.<br />
4 Objectives<br />
<br />
<br />
<br />
To enhance the patient journey for patients presenting with common health problems,<br />
including the incorporation of a whanau ora approach.<br />
To increase the consistency and co-ordination of care between primary and secondary<br />
care.<br />
To increase the appropriateness of FSAs.<br />
5 Benefits and gains<br />
Output measures<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
Number of topic areas<br />
HealthPathways sections adapted<br />
for the WC<br />
0 8 6 6<br />
Referral quality audit TBC 20%<br />
improvement<br />
Number of hits on West Coast HP<br />
web site per month<br />
Further 10%<br />
improvement<br />
Further 10%<br />
improvement<br />
0 500 1000 2000<br />
Outcome measures<br />
Indicator<br />
FSA rates (numbers actually seen)<br />
Paediatrics<br />
Gynaecology<br />
Baseline<br />
2009 year<br />
177<br />
371<br />
Target – Yr 1 Year 2 Year 3<br />
No change 10%<br />
decrease<br />
Further 10%<br />
decrease<br />
Business case appendices V12 AC 25Feb2010 Page 65
6 Deliverables / activities<br />
Implementation plan: to June 30<br />
Trial a process for adapting the HealthPathways:<br />
Decide on the first two areas – areas where HealthPathways have already been<br />
developed in Canterbury, where there are keen local clinicians, and where there are no<br />
major barriers to progress.<br />
Identify local hospital specialists, GPs, hospital and community based nurses who are<br />
willing to participate.<br />
Set up two workshops with local clinicians, plus experienced clinicians and IT support<br />
from Canterbury for the first two pathways.<br />
At the workshops begin with copies of the Canterbury pathways and work through each,<br />
identifying what changes need to be made and where there are access or resource<br />
issues that will need to be solved outside the workshops.<br />
Write up the results of the workshops and circulate back to members.<br />
Work with management to resolve access and resource issues as possible.<br />
Meet in person (or e-mail) to finalise the West Coast adaptation.<br />
Hold professional development meetings with primary and secondary care to educate<br />
regarding the HealthPathways.<br />
Evaluation:<br />
Review how well the above process went, adapt and refine.<br />
Develop a process to adapt future pathways locally without requiring facilitation from<br />
Canterbury.<br />
Select next areas for developing the West Coast adaptation.<br />
Referral quality audit:<br />
develop audit tool<br />
use to gather baseline data.<br />
Year one:<br />
implement the process to adapt another 8 groups of Health Pathways groupings<br />
refine processes<br />
provide further educational sessions<br />
review results of<br />
develop referral quality audit and work on addition of Health Pathways (will depend on<br />
cost and available resources).<br />
Business case appendices V12 AC 25Feb2010 Page 66
Year two<br />
implement the process to adapt another 6 groups of Health Pathways groupings<br />
refine processes<br />
provide further educational sessions<br />
evaluate usage and progress, adapt plan as required.<br />
Year three<br />
implement the process to adapt another 6 groups of Health Pathways groupings<br />
refine processes<br />
provide further educational sessions.<br />
7 Capability and capacity<br />
Capability: This project is an adaptation of the successful Canterbury Initiative project and will<br />
be supported by Canterbury and hence benefit from their expertise.<br />
The project is supported by key West Coast clinicians (Chief Medical Officer, Director of<br />
Nursing and Midwifery, <strong>Primary</strong> Secondary GP Liaison) and the Patient Journey Improvement<br />
Co-ordinator. They will manage the implementation of the project.<br />
The project depends on the involvement of other local clinicians in working groups. Given the<br />
demands on local clinicians the project has been adapted so as to use their time as efficiently as<br />
possible.<br />
8 Effect on inequalities<br />
It is important that the patient journeys take into account a whanau ora approach and provide a<br />
holistic approach to care. Māori will be included in developmental working groups.<br />
9 Evidence for this initiative<br />
The following evidence from the Canterbury initiative suggests that this programme is likely to<br />
be successful:<br />
Proven implementation team from Canterbury to work with WCDHB.<br />
Proven track record in Canterbury - over 180 pathways in just over a year many<br />
adaptable for the West Coast.<br />
Business case appendices V12 AC 25Feb2010 Page 67
Rapid rise in figures on use of the website containing the HealthPathways. Statistics<br />
show average pages per day per month accessed for February 09, was 405 pages, June<br />
09, 647 pages and November 09, 1404 pages.<br />
Participation by hundreds of clinicians in Canterbury means the site is designed by the<br />
users for their needs. Regular and frequent feedback from participants in the<br />
Canterbury Initiative process has enhanced the content.<br />
A high participation rate by specialists and general practitioners was achieved in<br />
Canterbury in education sessions with positive feedback indicates the programme fulfills<br />
a need for information.<br />
Multiple changes in clinical service provision were achieved with gradually increasing<br />
uptake such as subsidised skin cancer surgery, gynaecology procedures and respiratory<br />
investigations.<br />
West Coast general practice is already accessing the Canterbury HealthPathways site<br />
for reference material and sees the value in customising it to fit the West Coast.<br />
Canterbury Initiative are evaluating effectiveness using a number of methods including an online<br />
questionnaire repeated over time to general practitioners and specialists, monitoring changes in<br />
service utilization with many sets of usually collected DHB data. As well, research programmes<br />
have been initiated for significant changes in service delivery including prioritisation of<br />
colorectal symptoms and the community management of post-menopausal bleeding.<br />
Canterbury clinicians have noted that the use of the pathways:<br />
Provide better outcomes for patients.<br />
Can provide alternatives to a referral from general practice to hospital for an FSA.<br />
Have improved the quality of information being provided by general practice enabling<br />
more effective and consistent triage.<br />
Allow hospital clinicians to discharge patients back to general practice for follow-up<br />
care.<br />
10 Risk analysis<br />
Risk Probability Impact Minimisation plan<br />
Low clinician<br />
engagement in<br />
High High Personal approach, pay for their time,<br />
share the load.<br />
workshops<br />
Relationship with<br />
CDHB deteriorates<br />
Low High Regular meetings and shared decision<br />
making.<br />
Business case appendices V12 AC 25Feb2010 Page 68
Low uptake by<br />
primary and<br />
secondary care<br />
clinicians<br />
Local adaptation<br />
process not<br />
effective<br />
Low -<br />
moderate<br />
High Educational sessions, assist clinicians<br />
to put in „favourites‟ in their web<br />
browser, multiple reminders about the<br />
pathways, link on PHO and DHB<br />
websites.<br />
Low High Will need to revert to joint workshops,<br />
if necessary.<br />
11 Engagement<br />
Working group who developed this plan:<br />
West Coast:<br />
Vicki Robertson, Chief Medical Officer<br />
Jane O‟Malley, Director of Nursing and Midwifery for West Coast District Health<br />
Dr Jocelyn Tracey, West Coast <strong>Primary</strong> Secondary Liaison Officer<br />
Alison McDougall, Patient Journey Improvement Coordinator<br />
Canterbury:<br />
Graham McGeoch – Canterbury Initiative Clinical Leader and Clinical Editor for HP<br />
Juanita Gibson – Technical Writer – Streamliners.<br />
Emma Harding Streamliners<br />
Ian Anderson – Streamliners, also working on CDHB EOI project.<br />
Bronwyn Petrie – Project Manager – Canterbury Initiative team.<br />
Other clinicians involved: Dr Greville Wood, Dr Carol Atmore, Dr John Garret, Alison Lobb (RN),<br />
Liz Burns (RN).<br />
12 Organisational accountabilities<br />
Canterbury will retain ownership of the Health Pathways.<br />
13 Costs<br />
The Canterbury Initiative is supporting and funding the West Coast adaption of the pathways as<br />
follows:<br />
access to HealthPathways web site<br />
Business case appendices V12 AC 25Feb2010 Page 69
time involvement of clinical editors will be funded in accordance with the package agreed<br />
with<br />
cost of technical support from Streamliners.<br />
Changes to HealthPathways that require input from WCDHB administration, clinician,<br />
management personnel will be provide from within current resources with the exception of<br />
general practitioner/nurse specialist input to workshops which will be remunerated at agreed<br />
Canterbury DHB rates. Reviewers and those who provide wider feedback are not remunerated.<br />
Given the small number of GPs and nurses on the West Coast, the burden of involvement may fall<br />
on a few individuals. The PHO will budget $5,000 each year in the workforce budget for extra<br />
payments for local primary care involvement.<br />
Business case appendices V12 AC 25Feb2010 Page 70
Appendix Eight: Improved access to diagnostics<br />
1. Aspirational statement:<br />
The people of the West Coast will be able to access radiological diagnostic investigations in a<br />
convenient and timely manner.<br />
2 Project overview<br />
Currently there is direct access from primary care to Grey Hospital for plain film x-ray and<br />
ultrasound (except musculoskeletal) in a timely manner.<br />
Direct access to selected CT imaging using referral guidelines will provide sooner and more<br />
convenient care for patients and will be implemented by July 2010.<br />
Direct access to musculoskeletal ultrasound will require capacity issues to be addressed;<br />
planning will commence in July 2010, with access using referral guidelines possible by January<br />
2011 if current barriers can be overcome.<br />
3 Problem definition<br />
A full range of plain x-ray, CT scans and ultrasounds is available at Grey Base Hospital. The<br />
digital PACS system is used and images sent digitally to Christchurch for reporting by<br />
Christchurch Radiology Group radiologists. Buller Hospital has plain x-ray.<br />
There is no private radiology service on the West Coast; to access private services patients<br />
travel to Christchurch or Nelson.<br />
Plain film radiology<br />
Currently there is open access from primary care to plain film radiology in Greymouth and<br />
Westport during office hours.<br />
For urgent x-rays in Greymouth the practice rings for an appointment and then faxes in the<br />
request form or sends it in with the patient; either same day, or within 24 hour access is<br />
available. For less urgent requests the form is posted and waiting times are a maximum of one<br />
week. This service is highly regarded by general practitioners.<br />
Business case appendices V12 AC 25Feb2010 Page 71
The service views the great majority of requests as being appropriate. There are times when<br />
locums and nurses (with GP sign off) appear to be quicker to x-ray rather than using time as a<br />
diagnostic tool to determine whether an x-ray is necessary.<br />
Current volumes of primary care ordered plain films and ultrasounds: 5000 per annum,<br />
increasing by about 200 per year. No national comparative data is available from the Ministry<br />
of Heath 48 .<br />
Ultrasound<br />
Open access is available from primary care for all ultrasound examinations except<br />
musculoskeletal. Current capacity is full and further sonographers and ultrasound machines<br />
would be required if access was made available for musculoskeletal investigations, which<br />
generally take longer, (eg. a shoulder ultrasound takes twice as long as an abdominal ultrasound).<br />
GP ordering of ultrasound is viewed by the service as being generally appropriate.<br />
There is no access to ultrasound in Westport currently, although this has been possible in the<br />
past.<br />
There are plans to introduce generalist medical ultrasound in ED in Greymouth, for use by<br />
clinicians in caring for patients acutely. This may have a small effect on the number of<br />
diagnostic ultrasounds ordered (generalist medical ultrasound is useful to aid doctors in ED<br />
management, however it lacks the sensitivity and specificity of a diagnostic ultrasound done by a<br />
trained sonographer, and is not reviewed and reported on by a radiologist).<br />
If a GP thinks a musculoskeletal ultrasound is required then a referral for an orthopaedic First<br />
Specialist Appointment (FSA) can be made, potentially adding to the cost of care if the<br />
ultrasound result proves the FSA unnecessary. Alternatively, a number of patients, either with<br />
injuries covered by ACC or with medical insurance, travel to Christchurch to access<br />
musculoskeletal ultrasound. On occasions this is linked in with private specialist appointments in<br />
Christchurch and subsequent procedures that might otherwise have been carried out at Grey<br />
Base Hospital and paid for by ACC.<br />
CT scans<br />
Currently the only access for primary care to CT scanning is for CT urogram for renal colic.<br />
However GPs can on occasions phone a Senior Medical Officer (SMO) and obtain verbal consent<br />
for the ordering of CT scans (this is more likely to happen if the GP knows the SMO, and is able<br />
48 Personal communication, Andrew Downes, Portfolio Manager, Elective Services<br />
Business case appendices V12 AC 25Feb2010 Page 72
to easily access by telephone). Otherwise the patient is referred for an FSA and may have the<br />
investigation done prior to, or after, their FSA.<br />
There is potentially spare capacity which does allow for increasing direct access for those<br />
conditions where:<br />
CT is the appropriate first line investigation,<br />
GPs are often able to provide the management indicated by the CT scan diagnosis<br />
without needing an FSA<br />
guidelines can be implemented that will manage demand.<br />
CTs currently seen by both general practitioners and the radiology department as being<br />
appropriate for direct access are:<br />
CT head for head injury<br />
CT scan for painless haematuria<br />
CT urogram for renal colic<br />
CT colonography instead of barium enemas.<br />
As the Health Pathways are adapted for West Coast, it may be that other kinds of CT scan are<br />
identified for development of direct access pathways.<br />
Remote access<br />
If patients are coming from remote rural areas, such as Fox Glacier, and are likely to need a<br />
FSA along with their radiological investigation, where possible the Central Booking Unit<br />
organises for both to happen on the same visit to Greymouth.<br />
There are difficulties for low socio-economic families in rural areas with the cost of transport<br />
to Greymouth for radiological procedures and the difficulty accessing travel assistance.<br />
Radiology in Integrated Family Health Centres (IFHC)<br />
The equipment and resources required for radiology services are expensive. Currently at 5000<br />
community ordered radiology investigations a year, this equates to approximately 1700 per year<br />
per IFHC, approximately 7 investigations per day per centre. While it would be desirable to<br />
have plain radiology and portable ultrasound in each IFHC, and this is achievable in Buller, in<br />
Hokitika/Westland (thirty minutes from Greymouth) this would not be cost effective. In<br />
Greymouth while it would be convenient to have the radiology department within the IFHC, use<br />
is greater by the hospital and having two radiology centres would not be cost effective;<br />
therefore the radiology department should remain close to ED, and medical and surgical wards.<br />
Proximity of the IFHC to the hospital could advantage those 7 patients a day who need<br />
radiology, but only if their investigation was able to be provided at the same visit.<br />
Business case appendices V12 AC 25Feb2010 Page 73
4 Objectives<br />
<br />
<br />
<br />
<br />
to continue with direct access from primary care to plain film radiology<br />
to develop direct access by primary care to CT scans for health problems that meet the<br />
criteria<br />
to develop access to musculoskeletal ultrasound without significantly increasing the<br />
waiting list for other types of ultrasound<br />
to enhance the skills of those requesting radiological investigations and interpreting the<br />
reports.<br />
5 Benefits and gains<br />
Output measures - track quarterly<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
Number of plain film and US 5000 pa 5200 5400 5700<br />
Total number of CT scans 3500 3750 4000 4250<br />
Numbers CTs ordered by GPs Est. 10 300 320 340<br />
Number of musculoskeletal 0 0 40 60<br />
ultrasounds<br />
Orthopaedic FSAs 873 870 830 810<br />
Number of educational sessions<br />
held per annum<br />
1 1 1 1<br />
6 Deliverables / activities<br />
Implementation phase: to June 30, 2010<br />
Develop guidelines for general practitioners to access:<br />
CT head for head injury<br />
CT scan for painless haematuria<br />
CT urogram for renal colic<br />
CT colonography instead of barium enemas.<br />
Task<br />
Gather copies of guidelines used in other regions<br />
Establish multidisciplinary groups to review guidelines and adapt for<br />
local use (include Māori participation)<br />
Develop referral template based<br />
Provide educational session for referrers in the use of the guidelines<br />
Establish system for tracking volumes<br />
By when<br />
March<br />
March – April<br />
May<br />
May<br />
Business case appendices V12 AC 25Feb2010 Page 74
Year One – July 2010 to June 2011<br />
Task<br />
Continue open access to plain x-rays<br />
Provide a generic Coast-wide educational session plus regular updates in<br />
newsletters and reminders of websites that provide guidance for both<br />
ordering and interpreting investigations, eg. CRG<br />
Review use of plain x-rays: audit use by practice according to size of<br />
enrolled population<br />
Put in place educational intervention for any practices that have<br />
significantly greater than average usage.<br />
If necessary develop notional budget holding<br />
Report on numbers of CTs requested<br />
Audit of CT requests against the guidelines<br />
Review existing CT referral templates, modify and develop an<br />
electronic version<br />
Review need for increased access to other radiology investigations as<br />
part of Health Pathways project<br />
Ensure HealthPathways contain helpful advice for those ordering<br />
investigations<br />
Review travel assistance arrangements and develop plan for Buller<br />
region (include Māori participation)<br />
By when<br />
July<br />
Annually<br />
August<br />
October<br />
June<br />
Quarterly<br />
April<br />
June<br />
Ongoing<br />
February<br />
Year Two – July 2011 to June 2012<br />
Investigate ability to provide direct access for musculoskeletal ultra sound (US)<br />
possibly increase capacity in Greymouth through starting regular fortnightly or monthly<br />
US service in Buller<br />
possibly establish notional budgeting for primary care US services and enable<br />
musculoskeletal US though tighter management of other US capacity.<br />
Expand direct access to other diagnostics as part of Health Pathways project.<br />
Annual educational session.<br />
Year three<br />
Consolidation and review.<br />
7 Capability and capacity<br />
Current capacity and capability exists to allow access to CT scans as along as volumes are<br />
controlled by the use and audit of referral guidelines.<br />
Business case appendices V12 AC 25Feb2010 Page 75
There is no current capacity to increase numbers of ultrasounds usage and therefore this is<br />
dependent wither on a decrease in current requests or the establishment of a service in Buller.<br />
There are concerns regarding the capability of some of those ordering and interpreting<br />
investigations. With an increase in primary care consultations managed by nurses there is a<br />
need for increasing educational support as described in the plan above.<br />
8 Effect on inequalities<br />
There is already very good direct access to radiology services which benefits low<br />
socio-economic families. Direct access to some CT investigations will remove the need for FSAs<br />
which will benefit those who have difficulty accessing extra appointments.<br />
The need for travel assistance for those living in Buller and travelling to Greymouth for<br />
diagnostic investigations is an important barrier for some and will be addressed as part of this<br />
plan.<br />
9 Evidence for this initiative<br />
A number of other regions in NZ have piloted direct access to CT and to musculoskeletal<br />
ultrasound as shown in the following table 49 :<br />
Location<br />
Details<br />
General ultrasound Northland<br />
Whanganui<br />
Range of US – developed referral guidelines (GL)<br />
Used Australian radiology GL – too many referred<br />
Abdomen, pelvic, renal<br />
US<br />
Auckland<br />
Canterbury<br />
Referral GL developed<br />
Also pelvic for 5 conditions<br />
Soft tissue US Canterbury Triage GL and education<br />
Shoulder US Canterbury <strong>New</strong> pathway and education<br />
CT abdomen, liver, Canterbury Triage GL and education<br />
pancreas<br />
CT for headache BoP<br />
Nelson<br />
GL and education<br />
GL developed<br />
CT colonoscopy<br />
Whanganui<br />
Nelson<br />
Developed referral GL<br />
For those where colonoscopy not so important<br />
CT and MRI Wairarapa For TIA, breathlessness and atrial fib<br />
CT renal colic Nelson Freed up ED time, decreased FSAs<br />
49<br />
Summarised from MoH report: A summary of improving patient pathways – diagnostic pilots. 2009<br />
Business case appendices V12 AC 25Feb2010 Page 76
LECG 50 evaluated whether “the improvement processes implemented in these pilots were cost<br />
effective and provided value for money”. They concluded that “redesign of pathways for<br />
patients referred by GPs for diagnostic tests do offer opportunities for cost effective<br />
improvements”. They also identified that “opportunities for improvement are location specific<br />
and need to be identified with care” and provided helpful guidance for the development and<br />
implementation of direct access pathways.<br />
LECG anlaysed in depth a number of pilots that have direct relevance to this project:<br />
Northland DHB musculoskeletal ultrasound, Nelson Marlborough CT urograms, Whanganui<br />
general ultrasound.<br />
The information from these analyses will be very useful in guiding the implementation of direct<br />
access on the West Coast.<br />
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Too many CTs ordered –<br />
(significant amount of<br />
radiation per CT)<br />
Low High Develop referral guidelines and audit<br />
regularly.<br />
Only general practitioners order CTs.<br />
Unable to free up<br />
capacity for<br />
Low High Work closely with all those involved<br />
using a variety of approaches.<br />
musculoskeletal US<br />
Increase in numbers of x-<br />
rays ordered resulting<br />
from changed primary<br />
care delivery models<br />
Medium Medium Educational sessions and audits as<br />
described above.<br />
11 Engagement<br />
Working group who developed this plan: Raewyn McKnight, Jason Lister, Wayne Champion,<br />
Jocelyn Tracey, Helen Reriti, Anthony Cooke.<br />
Other clinicians involved: Vicki Robertson, Martin Smith, Dr Martin London, Dr Andy Backhouse,<br />
Tony Young (Canterbury Radiology Group) .<br />
50 Moore D, Black M, van Essen E. Evaluation of 13 diagnostic pilots. Report from LECG for MoH, Nov 2009.<br />
Business case appendices V12 AC 25Feb2010 Page 77
12 Organisational accountabilities<br />
No change in current accountabilities until, and if, notional budget holding for investigations (in<br />
particular ultrasounds) is developed.<br />
13 Costs<br />
The changes in service delivery proposed for the implementation phase and year one, can be<br />
done within current budgets and resources. Currently $321,400 allocated for primary referred<br />
radiology. At approx 5000 investigations p.a., that is $64.28 per investigation.<br />
There will be some development costs (included in the „Implementing Service Strategies‟ aspect<br />
of the Investing in Change budget, Section 11.1 in the Business Case) as follows:<br />
Implementation Year one<br />
phase<br />
Project management, support for<br />
$10,000 $10,000<br />
guideline developments, education<br />
sessions, audits etc<br />
Multidisciplinary team members time to<br />
$1,600<br />
develop guidelines: locum cover<br />
Development of electronic referral<br />
$2,000<br />
templates<br />
Cost of educational activities $100 $100<br />
TOTAL $11,700 $12,100<br />
In years two and three the following costs will be calculated:<br />
cost savings due to decreased FSAs for CTs<br />
cost of any overall increase in CT volumes<br />
volumes and costs of current community ultrasounds, with a view to moving to devolved<br />
budget holding and opening access to shoulder ultrasounds<br />
any savings from decreased volumes in plain films resulting auditing practice volumes and<br />
providing educational initiatives.<br />
Business case appendices V12 AC 25Feb2010 Page 78
Appendix Nine: Referred services<br />
1. Aspirational statement:<br />
<strong>Better</strong> alignment of clinical and financial decision making for referred services within an<br />
integrated system will improve the effectiveness and efficiency of service provision both from<br />
a clinical and financial perspective.<br />
2 Project overview<br />
This project begins in year one with a detailed analysis of current laboratory and<br />
pharmaceutical expenditure so as to better understand current patterns of use and unexplained<br />
variation. Current expenditure on both laboratory investigations (labs) and pharmaceuticals<br />
(pharms) is below the national average. If the analysis shows potential for savings if financial<br />
and clinical incentives were better aligned, then a number of change management activities will<br />
be implemented.<br />
3 Problem definition<br />
General<br />
Poor access and/or delays in receiving appropriate treatment can result in increased utilization<br />
of emergency services and an increase in avoidable hospital admissions.<br />
Currently there is poor linkage and co-ordination between the different parties involved in the<br />
funding, commissioning, provision and monitoring of referred services.<br />
The general increase in demand for services is placing increasing pressure on scarce health<br />
resources. As both laboratory and pharmacy services are essentially demand-led services it<br />
would generally be inappropriate or counterproductive to cap or otherwise limit expenditure or<br />
funding. However it may be appropriate to establish better mechanisms and procedures to<br />
increase the effectiveness and efficiency of referred service utilization and the prescribing of<br />
pharmaceuticals to achieve better resource management and health outcome within an<br />
integrated model.<br />
Business case appendices V12 AC 25Feb2010 Page 79
Laboratory<br />
There is anecdotal evidence to suggest that GPs and primary care nurses are referring some<br />
patients that may be able to be safely managed within primary care without referral for<br />
investigations.<br />
While there has been relative stability in year on year cost for laboratory services, there is an<br />
overall (small) increase. Despite this, there is evidence to show that some laboratory<br />
procedures and tests are duplicated unnecessarily leading us to believe that further efficiency<br />
can be gained.<br />
.<br />
Annual variance in laboratory costs – total DHB<br />
Year Laboratory $ Increase<br />
(decrease) for year<br />
% increase<br />
(decrease) for year<br />
2005/2006 $1,148m - -<br />
2006/2007 $1.336m $218k 19%<br />
2007/2008 $1.186m ($150k) (11.2%)<br />
2008/2009 $1.193m $130k 10.9%<br />
Change over 3 yrs $45k 3.9%<br />
Annual variance in laboratory costs – PHO only (from PPP)<br />
Year Laboratory $ Increase<br />
(decrease) for year<br />
% increase<br />
(decrease) for year<br />
2005/2006 $678k<br />
2006/2007 $680k $2k 0.3%<br />
2007/2008 $732k $52k 7.7%<br />
2008/2009 $650k ($82k) (11.2%)<br />
On the basis of preliminary investigations it is believed that there are opportunities for process<br />
improvement through the streamlining of referral systems, achieving a reduction in the type and<br />
quality of referral procedures and avoiding unnecessary or wasted expenditure on repeat<br />
laboratory testing.<br />
PHO Performance programme data on the West Coast PHO share of the national expenditure<br />
using a needs-based population formula, based on the enrolled population, for the period ending<br />
30 September 2010, was significantly lower than the national average at 46.76 (performance<br />
target
them by technical errors or lack of detail in prescription details being brought to them by<br />
patients.<br />
PHO Performance programme data on the West Coast PHO share of the national expenditure<br />
using a needs-based population formula, based on the enrolled population, for the period ending<br />
30 September 2010, was 83.57 for pharms (performance target
5 Benefits and gains<br />
Output and outcome measures<br />
These will be developed on completion of the analysis phase.<br />
6 Deliverables / activities<br />
Implementation plan<br />
It is proposed to address the year one process in two phases as follows:<br />
Year one – phase one July 2010 to December 2010:<br />
Investigate the opportunities and benefits of implementing a comprehensive programme of<br />
process improvement for referred services (for labs and pharms).<br />
Subject to satisfactory conclusion and outcome of phase one, we will proceed to the next phase<br />
as follows:<br />
Year one – phase two January 2011 to June 2011:<br />
From this list of potential strategies those most likely to result in cost effective utilization of<br />
referred services will be implemented:<br />
Establish effective information sharing between clinicians, managers, funders and other<br />
staff who plan, fund, purchase, refer for and deliver diagnostic and pharmaceutical<br />
services.<br />
Use PHO Performance Programme cube tool to identify high cost medication usage and<br />
laboratory use, both generally across the region and also to identify outliers.<br />
Identify the greatest opportunities for cost saving without adversely effecting quality<br />
of care.<br />
Develop more detailed performance indicators for use of referred services and use as a<br />
process improvement motivator with providers.<br />
Develop better guidance on prescribing and test ordering as part of the HealthPathways<br />
initiative.<br />
Expansion of the pharmacy newsletter for GPs, to support the above.<br />
Establishment of a “pharmacist advisor” function to the GP practices to look at trends in<br />
pharmaceutical usage, provide updates on latest evidence and deliver clinical education<br />
sessions common to practice staff and pharmacists – community and hospital.<br />
Business case appendices V12 AC 25Feb2010 Page 82
Identify patients that would benefit from medication use reviews.<br />
Establish a test order mechanism (both at a GP level and within the Hospital) that will<br />
allow recommended repeat intervals to be applied to each type of test. (This would alert<br />
a requestor that a test has been performed and result available within the stated<br />
repeat interval).<br />
Improvement of diagnostic service quality, through reviews and improvements in<br />
administration, GP and nurse referral processes, and data management.<br />
Year two - July 2011 to June 2012<br />
Establish mechanisms that will better alignment of clinical and financial decision making<br />
processes for pharmaceuticals, laboratory services and radiology:<br />
Identify opportunities for delegated funding mechanism for some or all referred<br />
services.<br />
Audit and evaluate effectiveness of improved administration, GP and nurse referral<br />
processes.<br />
Improve the systems that lead to clinical decision making as other aspects of the<br />
integrated family health system come into play, such as greater delegation of clinical<br />
decision making to nurses.<br />
Year three - July 2012 to June 2013<br />
Potential delegation of funding and decision making in agreed areas of referred services:<br />
Conclude evaluation and monitoring of improvement in processes(s).<br />
Establishment of devolved funding and decisions making mechanism (refer alliance<br />
contracting model.<br />
7 Capability and capacity<br />
There are no changes in the staffing against current number overall but it is anticipated that<br />
role and function will change to incorporate combined decision making processes, the<br />
undertaking of medicine use reviews (MUR) and allow for the introduction of the “pharmacist<br />
advisor” function.<br />
The data analysis phase will require the identification of skilled resource who can be contracted<br />
to provide this support.<br />
Business case appendices V12 AC 25Feb2010 Page 83
8 Effect on inequalities<br />
It is anticipated that more effective and efficient clinical pathways in both laboratory referred<br />
services and pharmacy services will lead to a reduction in resource wastage (both time and<br />
money) enabling more attention and resources to identify and target those most in need in order<br />
meet their health needs in a better sooner more convenient way.<br />
9 Evidence for this initiative<br />
In 2009 West Coast <strong>Primary</strong> Health Organisation commissioned a report 51 to investigate ways in<br />
which the PHO could, and community pharmacies would, work together more closely to advance<br />
its goal of achieving better health for people on the West Coast. This report identified the<br />
following from evidence in the literature:<br />
“Medication has the ability to enhance the quality of life and reduce the manifestations<br />
of diseases that would normally lead to suffering and premature death. There is also a<br />
growing awareness of the potential for these same drugs to cause a significant amount<br />
of morbidity and mortality.<br />
Underpinning nearly all innovative, cognitive services that might be provided by<br />
pharmacists is the issue of drug-related morbidity and mortality. Drug-related<br />
morbidity and mortality represents a serious medical problem that requires expert<br />
interdisciplinary attention. Unrecognised and unresolved drug therapy problems may<br />
result in extra primary care visits, hospitalisations, long term care facility admissions<br />
and premature death. The literature suggests that a large proportion of drug-related<br />
morbidity is preventable. Potentially pharmacists have the skills to ameliorate this<br />
problem by identifying existing and potential drug therapy problems likely to cause<br />
harm, a reduction in the quality of life, or death. “<br />
It went on to say that:<br />
“Clinical advisory pharmacists are recognised as having the qualifications, skills and<br />
abilities to work in a variety of specialist roles. The services provided focus on<br />
optimising medicines-related health outcomes for individual patients and working to<br />
reduce existing and potential drug therapy problems from a population based health<br />
perspective,<br />
These roles may include:<br />
• Pharmacist facilitation<br />
• Comprehensive medication management (clinical medication reviews)<br />
• Medicines therapy assessment (eg. in rest homes, residential care)<br />
51 Linda Bryant and John Dunlop. Opening the Door on Community Pharmacy, , June 2009)<br />
Business case appendices V12 AC 25Feb2010 Page 84
• Provision of patient specific medicines information<br />
• Undertaking clinical audits at practice level<br />
• Working with community pharmacists<br />
• Review of medicines for high-risk people discharged from hospital<br />
• PHO Performance Management<br />
• Undertaking or assisting with research initiatives<br />
• Collaborative Prescribing”<br />
In 2007 DHBNZ published the “<strong>New</strong> <strong>Zealand</strong> National Pharmacists Framework” 52 . The<br />
executive summary of this document reads as follows:<br />
“Ministerial strategic documents highlight an opportunity for pharmacists to add value in the<br />
primary health care sector. The final framework describes existing dispensing services and five<br />
new services in two main themes:<br />
1. Information services comprised of:<br />
Health Education to patients.<br />
Medicines and Clinical Information Support to practitioners (this includes Clinical<br />
Advisory Pharmacist and Pharmacist Facilitation roles).<br />
2. Medicines review services.<br />
Medicines Use Review and Adherence Support (MUR), a four part review assessing<br />
the patient‟s use, understanding and adherence to their medication regimen. This<br />
service has been aligned with the NZ Pharmacy Council competency standards and<br />
titles.<br />
Medicines Therapy Assessment (MTA), a comprehensive clinical review of an<br />
individual patient‟s medication as part of a multidisciplinary team.<br />
Comprehensive Medicines Management (CMM), case based active management of<br />
changes and (future) pharmacist prescribing activities, as part of a multidisciplinary<br />
team.<br />
These new services aim to:<br />
Enable flexible implementation, eg. via District Health Boards (DHBs), or <strong>Primary</strong><br />
Health Organisations (PHOs), in line with available resources<br />
Promote optimal medicine related outcomes from medicines.<br />
Encourage multidisciplinary work practices, primary-primary and primary-secondary<br />
integration.<br />
Provide the prime tools in managing and ensuring value from pharmaceutical<br />
expenditure apart from PHARMAC supply and demand initiatives.<br />
Utilise the opportunity for enhanced access that community pharmacy offers for<br />
the promotion of public health and well-being and the encouragement of self-care.<br />
52 Elizabeth Plant & Ruth Rhodes. <strong>New</strong> <strong>Zealand</strong> National Pharmacist Services Framework, DHBNZ Pharmacy Advisory<br />
Group, 2007<br />
Business case appendices V12 AC 25Feb2010 Page 85
Enable the optimisation of health by evaluating and addressing where possible, the<br />
medication management needs of local populations and individual patients.<br />
Enable the development of medication management services that enhance patient<br />
choice, access and convenience and provide a positive experience for patients and<br />
other providers of healthcare.<br />
Enable the provision of a range of clinically effective and cost-effective medication<br />
management services that build on the strengths of community pharmacy teams and<br />
that are provided within a multidisciplinary environment.<br />
Enable the development of an integrated approach to planning and commissioning of<br />
innovative medication management services that contribute to the development of<br />
primary health care and the optimisation of health outcomes regionally and<br />
nationally.<br />
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Inability to “realise” savings<br />
made through more efficient<br />
and effective practice<br />
medium high Effective and ongoing monitoring and<br />
review to identify and attribute<br />
changes in volumes of referred<br />
services.<br />
Growth in patient need<br />
outstripping effectiveness<br />
and efficiency measures<br />
medium high See above.<br />
Linkages with other monitoring<br />
processes to determine improvement in<br />
wider health outcomes, (eg. avoidable<br />
hospital admissions).<br />
Increasing emphasis on long<br />
term condition management<br />
could lead to an increase in<br />
diagnostic testing and<br />
prescribing<br />
medium<br />
Close monitoring and evaluation of<br />
diagnostic testing and prescribing to<br />
determine the „desirability‟ of any<br />
specific increases or decreases in<br />
volumes.<br />
11 Engagement<br />
Working group who developed this plan:<br />
Dr. Tim Bolter (GP), Dr. Jocelyn Tracey (GP, <strong>Primary</strong>/Secondary Liaison), Phil Clark (Laboratory<br />
Manager), Nick Leach (Hospital Pharmacist), Wayne Champion (Corporate Services Manager,<br />
Acting Secondary Service Manager), Peter McIntosh (Senior Planning and Funding Analyst),<br />
Kerri Miedema, July Kilkelly and Lindy Mason (Community Pharmacists), Wayne Turp (GM<br />
Planning and Funding).<br />
Business case appendices V12 AC 25Feb2010 Page 86
12 Organisational accountabilities<br />
A shared DHB, PHO steering group will oversee the implementation of this plan.<br />
13 Costs<br />
A full cost analysis of the implementation of this workstream will be developed after phase one,<br />
year one. However $30,000 for further data analysis has been included in the Investing in<br />
Change budget, Section 11.1 in the Business Case.<br />
Business case appendices V12 AC 25Feb2010 Page 87
Appendix Ten: Mental health<br />
This plan was written on the basis of funding being available to employ a Mental Health<br />
Co-ordinator in each (Integrated Family health Centre) IFHC. It became apparent on 23<br />
February that this funding was not going to be available. While aspects of this plan may<br />
still be able to be implemented within existing resources and funding, this will require<br />
discussion with, and support from, clinicians from community mental health services,<br />
primary mental heath services and primary care. Given the time available a revision to this<br />
plan was therefore not attempted; this will done by June 30, 2010.<br />
1. Aspirational statement:<br />
Every West Coaster will be able to access the care and support they need to enjoy positive<br />
mental health and well being.<br />
2 Project overview<br />
This project aims to integrate mental health services and primary health care on the West<br />
Coast in a way that will result in better, sooner and more convenient services for patients,<br />
delivered from IFHCs.<br />
Changes in current service configurations include more seamless entry points for patients who<br />
require care and support for mental health issues, packages of care for those currently falling<br />
between primary and secondary services, shared care arrangements, improved discharge<br />
planning processes and delivery of secondary mental health and addiction service within IFHCs.<br />
A kaupapa Māori approach is incorporated into the plan. This will include enhanced information<br />
sharing and mental well being resources for both mental health professionals and service users.<br />
3 Current Situation and problem definition<br />
<br />
The <strong>Primary</strong> Mental Health Program, targeted at enrolled patients with mild to moderate<br />
mental health issues, has been operational on the West Coast for the past four years,<br />
with very good results and good integration with general practices. A strength of the<br />
program is that it does not purport to be a separate service but is an integral part of<br />
the general practice teams – „in the practice, of the practice, for the practice‟. Patients<br />
Business case appendices V12 AC 25Feb2010 Page 88
emain under the care and management of their general practices, thus allowing a more<br />
holistic approach to well being with no stigma attached.<br />
Secondary mental health services on the West Coast currently provide services to more<br />
than 3% of the population. Services are mainly community based and include adult,<br />
psychiatric emergency, child and adolescent, alcohol and drug, and Māori mental health<br />
teams, with a small inpatient unit and family and consumer advisory services. There are<br />
close linkages with Canterbury regional specialty services (youth inpatient, mother and<br />
baby, eating disorders, detoxification services) and service users are able to access a<br />
range of NGO provided residential and support services.<br />
The Māori mental health team work alongside mental health service case managers to<br />
provide cultural support to clients of mental health service and support clinical<br />
processes to ensure they are delivered in a culturally appropriate manner.<br />
“Recognising the integral relationship between cultural identity as Māori and Māori<br />
wellbeing is a core element of a kaupapa Māori model of care. The term “Kaupapa Māori”<br />
refers to the culturally derived philosophy that underlies and is woven into all aspects of<br />
service delivery, with wellness for tangata whaiora Māori as the desired outcome 53 .”<br />
To date there has been limited integration of primary and secondary care mental health<br />
services on the West Coast because of the following reasons:<br />
- they have been established, funded and operated in very different ways in order<br />
to adhere to two distinct sets of criteria;<br />
- shortages of psychiatrists to help develop shared care systems, shortages of<br />
GPs with consequent lack of resource to take on a greater role;<br />
- primary mental health co-ordinator role has focused on assessments and not had<br />
capacity to take on a wider role;<br />
- the current patient pathway is only established as a one way track i.e. primary<br />
mental health team to secondary, no pathway back to primary mental health for<br />
brief intervention counselling;<br />
- current primary/secondary contracts add to the fragmentation of services due<br />
to their distinction between mild and moderate/severe.<br />
In terms of volumes, currently the adult community mental health services carry out 736<br />
community adult assessments and admit to their service 636 new patients per year. This<br />
excludes TACT team (449 assessments), inpatient (63), Alcohol & Drug Services and Child &<br />
Adolescent Mental Health Services (382). The PHO Mental Health team assessed 414 patients<br />
(aged 14 and above: 37 Māori) in 08/09 of whom 180 received Brief Intervention Counselling<br />
(BIC) of up to six sessions per person.<br />
Issues of current concern that may be able to be addressed as part of an initiative to better<br />
integrate mental health services are:<br />
lack of seamless entry for patients into the most appropriate pathways via a stepped<br />
care approach<br />
53 Te Haererenga mo te Whakaoranga 1996-2006. The Journey of Recovery for the <strong>New</strong> <strong>Zealand</strong> Mental Health Sector.<br />
Mental Health Commission. Pg 157<br />
Business case appendices V12 AC 25Feb2010 Page 89
lack of clarity in regard to roles of <strong>Primary</strong> Mental Health Co-ordinator has led to<br />
duplicate assessment processes provided by both primary and secondary mental health<br />
services<br />
lack of assistance for patients who need ongoing psychosocial support for a period of<br />
time but neither qualify for secondary services, nor are suitable for brief intervention<br />
counselling<br />
Māori in primary care do not have access to Māori mental health support workers; Māori<br />
in secondary services do not receive the option of having a Māori Psychologist<br />
lack of primary care involvement in discharge planning<br />
lack of information for GPs from secondary mental care on the patient‟s mental health<br />
management plan and medications, eg. difficulties arise when GPs are asked to provide<br />
repeat prescriptions<br />
lack of information for GPs from secondary mental care on the patient‟s management<br />
plan and medications eg difficulties arise when GPs are asked to provide repeat scripts<br />
no processes in place for shared care between primary and secondary care prior to<br />
discharge from secondary care (except for methadone programme)<br />
limited promotion of self care activities, eg. web based support programmes.<br />
The recently released guidance paper, Towards optimal primary mental health care in the new<br />
primary care environment 54 , provides a helpful guide for the further development of primary<br />
mental health services. It makes a case for the importance of integrating mental health into<br />
primary care:<br />
“The World Health Organisation (WHO) and World Organisation of Family <strong>Doctor</strong>s (Wonca) list seven<br />
central reasons for integrating mental health into primary care (WHO and Wonca 2008). These<br />
include:<br />
1. Th e b urd en o f m en t al d isord ers is gr eat<br />
2. Men t al an d p h ysical h ealt h p r ob lem s are int er w o ven<br />
3. Th e t r eat m ent gap f o r m ent al d isord er s is en or m o us<br />
4. Pr im ar y care f or m ent al healt h en h an ces access<br />
5. Pr im ar y care f or m ent al healt h p r o m ot es resp ect of h um an r ight s<br />
6. Pr im ar y care f or m ent al healt h is af f o rd ab le and cost ef f ect ive<br />
7. Pr im ar y care f or m ent al healt h generat es good h ealt h o ut co m es”<br />
This paper describes an optimal service user pathway in primary care as follows:<br />
54 Ministry of Health. Towards optimal primary mental health care in the new primary care environment. MoH,<br />
Wellington, 2009.<br />
Business case appendices V12 AC 25Feb2010 Page 90
Service user pathways in an optimal primary mental health initiative (Dowell et al 2009)<br />
The role of the coordinator is further described:<br />
“Role of primary mental health coordinators<br />
The PMHC role involves a combination of service development, screening and assessment, referral,<br />
brief intervention, and mentoring existing primary care staff. Coordinators with clinical skills often<br />
carry a caseload and use a variety of psychological and other therapeutic techniques.<br />
An important role for PMHCs is care coordination for patients who have complex social needs and for<br />
whom multiple agencies might be involved. Related to the care coordination role, it is also important<br />
that PMHCs are good „connectors‟. They assess people referred from GPs or other primary care<br />
providers, identify clinical and social needs, and find appropriate services to meet those needs.<br />
Other key roles of PMHCs are:<br />
facilitating better working relationships and integration between primary and secondary mental<br />
health and AOD services<br />
visiting or liaising with key NGOs and social services to obtain up-to-date information on the<br />
services they offer and their referral criteria<br />
organising training for practice staff<br />
advocacy for service users with complex social needs – a key focus of intervention may be to<br />
assist patients with obtaining benefits and entitlements, or with obtaining transport services, or<br />
providing advice about the support available for victims of domestic violence<br />
project management – developing policies and procedures, designing referral and other forms,<br />
recruiting staff, etc.<br />
It is recommended that the primary health care sector move towards employing PMHCs with the<br />
clinical skills to conduct assessments, triaging, and brief mental health and/or substance use<br />
interventions. This is consistent with a stepped care approach because it enables the patient to<br />
Business case appendices V12 AC 25Feb2010 Page 91
eceive a brief intervention from the PMHC rather than (or prior to) a more expensive package of care.<br />
The clinical positions require some administrative support (eg., project management, paperwork<br />
involved in referring patients to different non-government organisations, scoring questionnaires,<br />
monitoring). Therefore there is also a need for non-clinical roles to provide this support.”<br />
This provides an appropriate blue print for the West Coast for further development and<br />
integration of mental health services.<br />
4 Objectives<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
To improve patient care by better integration between community mental health<br />
services and primary health care and more collaboration amongst primary mental health,<br />
secondary mental health, NGOs and social services.<br />
To continue to support general practice teams to provide screening, initial assessments,<br />
and extended consultations.<br />
To develop a common set of assessment processes.<br />
To develop a primary care based assessment service for all new adult patients (except<br />
those referred acutely to the TACT team) .<br />
To develop the primary mental health co-ordinator role.<br />
to develop stepped care pathways and packages of care for patients with different<br />
levels of severity and complexity, including shared care arrangements.<br />
To re-design discharge planning processes to include primary care.<br />
To extend the Kaupapa Māori mental health service to include tangata whai ora in both<br />
primary and secondary mental health care settings.<br />
To improve the patient pathway for Māori by establishing a whanau ora approach to the<br />
delivery of services.<br />
To develop a population health approach for all mental health services with service<br />
delivery focused on the enrolled population in each IFHC.<br />
to increase mental health promotional activities and support for self care.<br />
5 Benefits and gains<br />
Output measures<br />
Indicator<br />
Number of primary mental health<br />
co-ordinators appointed<br />
Single point of entry to mental<br />
health services<br />
Number of Multi Disciplinary Team<br />
meetings within practices / IFHCs<br />
Baseline<br />
09 year<br />
Target – End<br />
Yr 1<br />
Year 2 Year 3<br />
1 3 3 3<br />
Not in<br />
place<br />
Established<br />
Continued<br />
and revised<br />
Continued<br />
1/mth 3/mth 6/mth 6/mth<br />
Business case appendices V12 AC 25Feb2010 Page 92
Model for shared care pathways<br />
developed<br />
Shared discharge planning<br />
processes in place<br />
Number of adult community<br />
referrals processed<br />
Number of adult assessments done<br />
by MH co-ordinator<br />
Number of adult assessments done<br />
by Community MH<br />
Number of patients receiving BIC<br />
in primary care<br />
Number of patients receiving<br />
extended primary care consults<br />
Number of patients receiving<br />
other community based packages<br />
of care<br />
Number of patients admitted to<br />
specialist services<br />
Not in<br />
place<br />
Not in<br />
place<br />
Established<br />
Established<br />
Continued<br />
and revised<br />
Continued<br />
and revised<br />
Continued<br />
Continued<br />
1150 1150 1100 1050<br />
414<br />
814 950 1050<br />
Māori: 37<br />
736 436 150 0<br />
180<br />
180 150 150<br />
Māori: 10%<br />
79 100 120 140<br />
0 50<br />
Māori: 8<br />
636<br />
Māori:TBC<br />
Number of patients in shared care 10<br />
Māori: 2<br />
Numbers of tangata whai ora<br />
TBD<br />
accessing Kaupapa Māori mental<br />
health services<br />
100<br />
Māori: 15<br />
100<br />
Māori: 15<br />
610 580 540<br />
100<br />
Māori: 15<br />
150<br />
Māori:22<br />
300<br />
Māori:45<br />
Outcome measures<br />
Indicator<br />
% improvement in GHQ12 pre and<br />
post BIC<br />
HoNOS T10/12 scores %<br />
improvement entry to discharge<br />
Knowing the people planning (KPP)<br />
targets:<br />
Increase in the number of KPP<br />
clients in a shared care<br />
arrangement with mental health<br />
services and GP<br />
Increased number of KPP clients<br />
participating in metabolic<br />
monitoring<br />
Baseline<br />
at Dec 09<br />
Target – Yr 1 Year 2 Year 3<br />
78% >75% >75% >75%<br />
80% > 90% > 90% > 90%<br />
5%<br />
0%<br />
15%<br />
15%<br />
30%<br />
30%<br />
50 %<br />
50%<br />
Business case appendices V12 AC 25Feb2010 Page 93
6 Deliverables / activities<br />
Following the WHO model 55 , patients in primary health care with mental health problems will<br />
have their health needs identified and assessed and will be offered effective treatments,<br />
including referral to specialist services for further assessment, treatment and care, if they<br />
require it.<br />
To achieve this standard, each primary care group will need to work with the support of<br />
specialised mental health services to:<br />
develop the resources within each practice to assess mental health needs<br />
develop the resources to work with diverse groups in the population<br />
develop the skills and competencies to manage common mental health problems<br />
agree the arrangements for referral for assessment, advice or treatment and care<br />
have the skills and necessary organisational systems to provide the physical healthcare<br />
and other primary care support needed, as agreed in their care plan, for people with<br />
severe mental illness.<br />
This plan works towards a model of care that includes in the short term:<br />
single point of entry for those referred to mental health services 56<br />
primary mental health co-ordinators review all adult community referrals, and make the<br />
decision as to whether the initial assessment is best carried out by themselves or the<br />
specialist MH team<br />
an increase overtime in the assessments done in primary care until all are done by the<br />
coordinators<br />
provision of different packages of care available depending on need and ethnicity,<br />
ranging from community support to psychiatric assessment<br />
increased access by tangata whaiora to Kaupapa Māori mental health services<br />
development of processes for shared care<br />
review of discharge planning processes with the IFHC teams<br />
all mental health workers seeing patients within IFHCs.<br />
Integration of primary and secondary mental health services within IFHCs will be explored in<br />
year two.<br />
55 DoH (1999) „A National Service Framework for Mental Health: Modern Standards and Service Models‟. London<br />
accessed on 16/2/2010 at<br />
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4077209.pdf<br />
56 Patients assessed by General Practice Teams as needing only Brief Intervention Counselling (BIC), and meeting<br />
specified entry criteria, will go directly to BIC providers<br />
Business case appendices V12 AC 25Feb2010 Page 94
Implementation plan: to June 30<br />
Development of the Mental Health Co-ordinator role<br />
develop job descriptions and competencies required based on the role expectations<br />
outlined in the guidance paper<br />
identify FTEs required in Greymouth, Buller and Hokitika<br />
identify potential funding stream and transition of human resource<br />
develop assessment procedures: screening for anxiety and mood disorders, screening<br />
for substance use disorders, detailed comprehensive assessment when clinically<br />
indicated<br />
develop patient pathways for all new referrals to mental health services<br />
identify resource requirements for extending maupapa Māori Mental Health service to<br />
include tangata whai ora in primary settings<br />
develop a range of „packages of care‟, eg. brief intervention counselling provided by the<br />
co-ordinator, ongoing psychosocial support provided by the co-ordinator, client referred<br />
to community based support with or without ongoing review by co-ordinator, brief<br />
intervention counselling provided by primary mental health psychologist/ counsellor,<br />
client is referred for management to secondary mental health services, „shared care‟<br />
arrangements are supported by the co-ordinator.<br />
Enhance general practice team roles<br />
develop a pathway for selected patients who require only brief intervention counselling<br />
from psychologist/counsellor to be assessed by the general practice team and to access<br />
this counselling directly<br />
provide further training in screening and assessment to general practice teams<br />
up-skill nursing team in management of anxiety/panic/depression.<br />
Greater integration between secondary services and general practice teams<br />
enhance the psychiatric consultant liaison role to support GPs, providing phone support,<br />
educational sessions, medication reviews<br />
implement primary/secondary Multi Disciplinary Team meetings.<br />
Support for patient self care<br />
widely distribute PHO developed self help materials in a variety of formats<br />
promote approved mental well being resources supplied by CPH and available for patients<br />
and health professionals at IFHCs.<br />
create link to Community & Public Health website on PHO website<br />
enhance access to web based patient support programmes via publicity campaign eg.<br />
www.healthnavigator.org.nz, access to Monkey See DVDs<br />
develop links between primary mental health professionals and mental health promoters<br />
develop closer linkages with community agencies eg. PACT, Richmond Fellowship, Te Ara<br />
Mahi, Homebuilders and Focus Trust etc.<br />
Business case appendices V12 AC 25Feb2010 Page 95
Year one:<br />
Co-ordinator role:<br />
three co-ordinators appointed and based in Buller, Greymouth and Westland<br />
two monthly review steering group sessions to review and refine processes and roles.<br />
Discharge planning process:<br />
set up mental health discharge planning process, levering off the generic project<br />
develop a plan for change<br />
consult widely among primary and secondary care providers and consumers<br />
revise plan<br />
put new processes in place<br />
review six months later.<br />
Shared care:<br />
establish a planning group that includes consumer, whanau and Māori representation<br />
review current contracts and funding models<br />
develop model and processes for shared care, ie. reviews; agreed role boundaries; clinical<br />
accountability and responsibilities<br />
consult widely among primary and secondary care providers and consumers<br />
revise plan<br />
pilot processes in one region<br />
review and revise<br />
pilot processes<br />
transition of support workers to primary care.<br />
Brief intervention:<br />
review age group covered by primary care youth counsellor (14 – 18).<br />
Improving integration:<br />
allocate a secondary mental health team member liaison person for each practice/IFHC<br />
where facilities allow co-locate secondary mental health team in IFHCs.<br />
Addressing physical health needs:<br />
develop and implement annual health checks for long term mental health patients at<br />
their IFHC<br />
fund and encourage flu vaccinations for long term mental health patients.<br />
Extending kaupapa Māori Mental Health service:<br />
kaupapa Māori mental health services include service provision for Māori clients in<br />
primary health settings.<br />
Business case appendices V12 AC 25Feb2010 Page 96
Year two<br />
Review progress, outcome measures and adapt plan<br />
Alcohol and Drug:<br />
<br />
review the patient pathway for alcohol, drug and other addictions.<br />
Integration:<br />
develop shared patient record systems<br />
review the ownership, management and organisational accountabilities for primary and<br />
secondary mental health services to consider whether both should be merged with<br />
IFHCs (some service will need to be district wide, eg. Child and AdolescentMental<br />
Health Services).<br />
Professional development activities:<br />
<br />
integrate activities across the services.<br />
Shared care:<br />
review pilot processes and refine process for shared care<br />
roll out across the region.<br />
Support for patient self care:<br />
further up-skilling of staff in self management education<br />
review availability of self management education and support and consider establishment<br />
of group self management education.<br />
Year three<br />
Review progress, outcome measures and adapt plan.<br />
7 Capability and capacity<br />
Current configuration of adult secondary care community mental health into three teams will<br />
align well with the IFHC model and provide the capability and capacity required to deliver<br />
services to each of the three IFHCs.<br />
Current primary mental health services are delivered within general practices, and will in the<br />
future be delivered from IFHCs.<br />
Greater involvement of GPs and primary care nurses in shared care and discharge planning are<br />
dependent on current workforce issues being addressed.<br />
Business case appendices V12 AC 25Feb2010 Page 97
Further professional development for core general practice teams will be required.<br />
Increase in the Māori workforce will be required to effectively deliver kaupapa Māori services.<br />
8 Effect on inequalities<br />
Māori and low socio-economic people are over represented in mental health clientele.<br />
The Māori mental health team will work alongside the primary and secondary mental health<br />
services to ensure that clients receive a culturally appropriate service.<br />
Locating mental health services in IFHCs will help reduce the stigma and marginalisation of<br />
those presenting with mental health problems, particularly those with addictions. It will also<br />
help them to access the physical care they need from their primary health care team.<br />
9 Evidence for this initiative<br />
Aspects of this plan follow the recently released guidance paper, Towards optimal primary<br />
mental health care in the new primary care environment 57 .<br />
Placement of mental health workers within primary care has been the subject of a significant<br />
body of research. A recent Cochrane review of 42 studies 58 concluded:<br />
“This review investigated whether having mental health workers on-site to work with physicians<br />
at their offices would change the care that physicians provide. Forty-two studies were reviewed<br />
in which on-site mental health workers, such as counsellors or psychiatrists, worked alongside<br />
physicians to provide therapy to patients. The review found that when there were mental health<br />
workers on-site, patients may reduce the number of visits to their doctors; doctors may reduce<br />
how often they refer patients to off-site mental health specialists; doctors may reduce the<br />
number of drugs they prescribe to the patients who see the mental health workers; and the<br />
costs related to those drugs may be lower. However, these reductions were small and not found<br />
consistently in all the studies.”<br />
57 Ministry of Health. Towards optimal primary mental health care in the new primary care environment. MoH,<br />
Wellington, 2009.<br />
58 Harkness EF, Bower PJ. On-site mental health workers delivering psychological therapy and psychosocial<br />
interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane<br />
Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000532. DOI: 10.1002/14651858.CD000532.pub2.<br />
Business case appendices V12 AC 25Feb2010 Page 98
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Lack of clear clinical<br />
accountability for<br />
High High Establish robust guidelines re shared<br />
care arrangements.<br />
treatment<br />
Coordinator role<br />
loses focus<br />
Moderate High Ensure sufficient resource is available<br />
for role function.<br />
No capacity for GPs<br />
and nurses to take on<br />
wider role<br />
Moderate High See workforce plan.<br />
11 Engagement<br />
Working group who developed this plan: Hecta Williams, Anne Tacon, Shona McLeod, Bev Barron,<br />
Lois Scott, David Stoner, Jocelyn Tracey, Bryan Geer.<br />
Other clinicians involved: Paul Cooper.<br />
12 Organisational accountabilities<br />
The shared steering group continues to further develop and oversee the implementation of this<br />
project plan. In the short term organisational accountabilities remain the same, however after<br />
the review in year two this might change, depending on the results of the review.<br />
13 Budget<br />
2009/10 2010/11<br />
<strong>Primary</strong> Mental Health<br />
MH BIC $186,878 $186,878<br />
Child & Adolescent $90,000 $90,000<br />
Liaison/ Coordination $96,878 $290,634<br />
Discharge Planning Meetings<br />
-<br />
$5,000<br />
(50 patients with 1 meeting<br />
$100/meetings)<br />
Business case appendices V12 AC 25Feb2010 Page 99
Shared <strong>Care</strong> MDT‟s<br />
-<br />
Long Term MHS users –<br />
Physical Health<br />
$40,000<br />
(100 patients with 4 meetings/pa<br />
@$100 per 50meetings)<br />
$ 25,000<br />
(350 annual checks @ $65 & seasonal<br />
influenza vaccinations)<br />
Community Providers $ 2,164,717 $3,007,422<br />
Secondary Mental Health $9,358,288 $7,863,577<br />
Secondary IDFs $788,675 $788,675<br />
TOTAL $12,619,960 $12,199,960<br />
Business case appendices V12 AC 25Feb2010 Page 100
Appendix Eleven: Frail older people<br />
1. Aspirational statement:<br />
Frail older people and others with long term disabling conditions will be able to access support<br />
services that are timely, flexible and appropriate to their individual needs and those of their<br />
carers.<br />
The pathway of care among primary, secondary and community based services for older people<br />
and those with long term disabling conditions will operate smoothly with excellent informationsharing<br />
among all services and with people and their families.<br />
All health and support service workers will be proactive in helping the person and their carers<br />
maintain and regain their functional abilities and prevent further illness or injury.<br />
2 Problem definition<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Lack of clarity/agreement on appropriate pathway of care for frail older people, within<br />
Grey Hospital as well as between hospital and primary health services and home based<br />
and residential care services.<br />
Stroke patients not transferred to specialist care soon enough and sometimes not at all,<br />
and national stroke guidelines have not yet been adopted.<br />
Opportunities missed for keeping frail older people fit and well and preventing admission<br />
to the acute hospital and to long term residential care – lack of a pro-active approach to<br />
reducing the risks of avoidable hospital admission or rest home entry.<br />
Frail older patients admitted to the acute medical and surgical wards or presenting at<br />
ED are not always appropriately referred to specialist Health of Older Peoples services.<br />
Lack of a shared client information system even among DHB services, let alone primary<br />
care, home support or residential care.<br />
Lack of step down beds for convalescence and slow stream rehabilitation, and continued<br />
inappropriate use of long term respite care and carer support budgets for this purpose.<br />
Over use of long term residential care (particularly rest home level) due to under<br />
development of home based alternatives, (eg. flexible homecare packages, planned<br />
respite, dementia day care, support for carers).<br />
Under development of home support services – most carers are untrained and casual,<br />
with limited supervision or linkage to district nursing, community allied health, <strong>Care</strong> Link<br />
or primary health services. Home support agencies cannot always provide staff for<br />
high/complex packages<br />
Business case appendices V12 AC 25Feb2010 Page 101
Underdevelopment of support for carers – local voluntary agencies are barely<br />
sustainable as the Coast population is not large enough to support services that would be<br />
available in bigger centres, (eg. age concern befriending, continence education, dementia<br />
support). <strong>Care</strong>r burnout contributes to the relatively high rate of rest home entry.<br />
Many health and support workers and many clients still hold to a traditional dependency<br />
and entitlement model for rest home and home support services and there is limited<br />
implementation of a restorative model as yet.<br />
Very limited availability of allied health staff for community based work, (eg. supervising<br />
home carers in home based rehabilitation programmes, responding to GP referrals),<br />
reflected in high rate of inpatient admission to AT&R ward.<br />
Residential aged care facilities (in Greymouth) have had limited access to general<br />
practitioner services, reflected in a relatively high rate of referrals to the acute<br />
services. <strong>Primary</strong> health care received by residential care residents is sometimes suboptimal<br />
and would benefit from greater input from medical staff with specialist<br />
knowledge of older peoples health, including dementia.<br />
A number of residential aged care facilities have had a continued shortage of registered<br />
nurses, which has repeatedly compromised quality of care.<br />
3 OBJECTIVES<br />
Set up a clear pathway for accessing primary and community services. This would include:<br />
A hub of shared client information available to all health and support services – GPs,<br />
practice nurses, district nurses, <strong>Care</strong> Link, ward staff, allied health, residential care,<br />
home care agencies etc. This includes InterRAI and other assessments.<br />
A triage function for logging all cases and sending simple routine cases directly to the<br />
appropriate service while ensuring complex cases receive multidisciplinary assessment,<br />
case management through Chronic Conditions Programme and/or <strong>Care</strong> Link, and/or<br />
referral to specialist services<br />
Clear, agreed protocols for accessing services<br />
Co-locate <strong>Care</strong> Link with the Integrated Family Health Centres (IFHC), and link staff to<br />
specific primary health teams, thereby giving those teams easy access to expert assessment<br />
(InterRAI), community-based support packages and a case management function for people with<br />
long-term disabling conditions.<br />
Set up a restorative home-based support service based on need, accessed through <strong>Care</strong> Link and<br />
closely linked to primary and community health services:<br />
Home care workers having close connection to primary health services, community<br />
nursing and allied health, in some cases working under supervision to help clients do the<br />
Business case appendices V12 AC 25Feb2010 Page 102
ehab and treatment programmes that occupational therapists, physios, GPs etc have<br />
prescribed.<br />
<br />
<br />
All relevant health and support workers (in primary, hospital, community and residential<br />
services) trained in a restorative goal based model of care that focuses on the client<br />
being helped to regain and maintain their function and on proactively preventing illness<br />
and injury (eg. falls prevention, flu immunisation, timely equipment, active continence<br />
management and other ways of preventing carer burnout).<br />
Include a strong focus on supporting carers to prevent/reduce care burnout – <strong>Care</strong> Link<br />
will use long term funding for carer support more flexibly to support carers and<br />
voluntary patient support agencies.<br />
Make best use of specialist Health of Older People (AT&R) resources:<br />
<br />
<br />
<br />
Set up clear pathways to ensure timely transfer to specialist services for frail older<br />
people and anyone with a stroke.<br />
Set up step-down/admission avoidance beds in the main centres<br />
A greater proportion of AT&R staff time available for consultation and support for<br />
primary health services, home care services and residential care.<br />
4 Benefits and gains<br />
Output measures<br />
Indicator Baseline Target – Yr Year 2 Year 3<br />
1<br />
Percentage of stroke patients Nil 25% 100% 100%<br />
transferred to specialist stroke<br />
team<br />
Pathways implemented for the<br />
appropriate care of frail older<br />
people admitted to<br />
medical/surgical wards<br />
No Yes Yes Yes<br />
Number of people with high falls<br />
risk receiving ACC-funded falls<br />
prevention programmes (55+ years<br />
Māori, 65+ years non-Māori)<br />
Shared client record can be<br />
accessed by all appropriate staff<br />
working in primary health,<br />
community, hospital and residential<br />
care services<br />
Percentage of people receiving<br />
NASC assessment within the<br />
appropriate timeframe<br />
Single point of entry and clear<br />
pathway exists for access to all<br />
community services<br />
30 in<br />
Greymouth<br />
& Hokitika<br />
in 2009-10<br />
75<br />
throughout<br />
Coast<br />
100<br />
throughout<br />
Coast<br />
No Partially Partially Fully<br />
90% 100% 100% 100%<br />
No Partially Partially Fully<br />
100<br />
throughout<br />
Coast<br />
Business case appendices V12 AC 25Feb2010 Page 103
Outcome measures<br />
Indicator Baseline Target – Yr<br />
1<br />
Rate of admission for falls-related<br />
fracture, for people aged 75+<br />
years, over 3 year rolling period<br />
Average length of stay in specialist<br />
Health of Older People (AT&R)<br />
service<br />
Rates of re-admission to acute<br />
hospital care over a 6-month<br />
period for people aged 75+<br />
Rate of „frequent fliers‟ (6+ acute<br />
hospital admissions per year) for<br />
people aged 75+<br />
Rate of admission to permanent<br />
rest home level care per capita of<br />
people aged 75+ years<br />
Rate of ambulatory sensitive<br />
admissions 45-74 years<br />
<strong>Care</strong>r stress as measured by<br />
average years duration of<br />
employment for carers<br />
TBC<br />
TBC<br />
TBC<br />
TBC<br />
5.98%<br />
(July-Dec<br />
2009)<br />
TBC<br />
Not yet<br />
measured.<br />
Same as<br />
baseline<br />
Same as<br />
baseline<br />
Same as<br />
baseline<br />
Same as<br />
baseline<br />
Year 2 Year 3<br />
5% reduction<br />
on baseline<br />
5% reduction<br />
on baseline<br />
5% reduction<br />
on baseline<br />
5% reduction<br />
on baseline<br />
5.75% 5.5% 5.0%<br />
Same as<br />
baseline<br />
5% reduction<br />
on baseline<br />
5%<br />
reduction on<br />
baseline<br />
10%<br />
reduction on<br />
baseline<br />
10%<br />
reduction on<br />
baseline<br />
10%<br />
reduction on<br />
baseline<br />
5%<br />
reduction on<br />
baseline<br />
Baseline Baseline 5%<br />
reduction on<br />
baseline<br />
5 Deliverable / activities<br />
Implementation plan:<br />
To June 30<br />
<br />
<br />
<br />
<br />
<br />
Identify the process, timeframe, resources and accountabilities for establishing a<br />
single shared patient record that is available to all appropriate primary, community,<br />
hospital and residential care staff.<br />
Introduce clinical protocols whereby stroke patients and frail older people admitted to<br />
Grey Hospital are routinely referred to the specialist Health of Older People Service<br />
(AT&R), with their primary health teams and case managers being alerted electronically<br />
Progress the planned changes to a restorative model of homecare that have already<br />
started, aligning with similar work by Nelson Marlborough and Canterbury DHBs<br />
Complete implementation of InterRAI at <strong>Care</strong> Link and ensure read-only access to at<br />
least other DHB services<br />
Set up a robust budget management system for the long-term support services<br />
accessed through <strong>Care</strong> Link, and a plan for linking InterRAI data to volumes and<br />
expenditure data<br />
Business case appendices V12 AC 25Feb2010 Page 104
Year one:<br />
Maintain and continue the initiatives up to June 30 and also:<br />
Identify patient pathways for older people, especially those disabled by frailty and<br />
medical conditions. Create a simple, easy-to-use process for all health and support<br />
workers to access community and primary services, including primary health services,<br />
community nursing and allied health, palliative care, clinical nurse and allied health<br />
specialists, and needs assessment/service coordination for short term and long term<br />
support services, including mental health support services.<br />
Extend InterRAI read-only access to non DHB health and support services, including<br />
primary health teams, home support agencies and residential care facilities.<br />
Set up a case management function for complex older clients by linking <strong>Care</strong> Link NASC<br />
staff more closely to each primary care team to provide expert multidisciplinary needs<br />
assessment and to ensure each client has a key worker to coordinate the treatment,<br />
rehabilitation and support provided at home. This would work closely with the Chronic<br />
Conditions Programme – „frail complex older people‟ treated as one more Chronic<br />
Condition.<br />
Set up a medical and geriatric nurse specialist rotation among primary health teams,<br />
<strong>Care</strong> Link and specialist Health of Older People service (AT&R)<br />
Reconfigure AT&R service to enable greater input to primary health teams, community<br />
services and residential care facilities<br />
Set tight criteria for access to long term support services, based on reliable data and<br />
ongoing consultation with all stakeholders<br />
Change relevant protocols and contractual arrangements to allow greater allied health<br />
and nurse specialists input to home support agencies and residential care facilities<br />
Explore the best way of providing step-down beds in the main centres for admission<br />
avoidance, convalescence and slow stream rehabilitation (in the light of the experience<br />
at Waikato and Wairarapa DHBs).<br />
Prepare a <strong>Care</strong>r Support Strategy and Action Plan that identifies needs, proposes<br />
service changes and allocates funding for services to support carers.<br />
Pharmacist support:<br />
- for patients managing well – prescription dispensing, brief counseling/education<br />
as medicines added or adjusted;<br />
- supporting self management – Medication Utilization reviews and compliance aid<br />
provision as necessary;<br />
- for those requiring integrated services: compliance packaging – picked up or<br />
delivered to home or sometimes District Nursing, reminders to visit GP for three<br />
monthly prescription, liaison with hospital and GP practice at discharge, follow-up<br />
if (blister-packed) medications not collected. Scope for comprehensive<br />
medication review at this level;<br />
- General support – pharmacist involvement with various support groups, eg.<br />
cardiac and respiratory, answering patient questions, providing smoking cessation<br />
services, referral of patients to other providers, eg. diabetes nurse educator or<br />
general practice.<br />
Business case appendices V12 AC 25Feb2010 Page 105
Year two<br />
Maintain and continue the initiatives from year one and also:<br />
implement the Single Shared Patient record<br />
implement a restorative model of homecare, with greater allied health and nursing<br />
input, stronger connection to the primary health team, more skilled carers and services<br />
tailored flexibly to the needs of clients and their carers<br />
set up training in the restorative goal-based approach for all people working in health<br />
and support services for older people, linked to what Canterbury and Nelson are doing<br />
reconfigure allied health services to enable greater input to primary health teams,<br />
community services and residential care facilities<br />
establish step-down beds<br />
implement the <strong>Care</strong>r Support Action Plan<br />
extend medical an specialist nurse rotation to residential care facilities.<br />
Year three<br />
Maintain and continue the initiatives from year one and also:<br />
co-locate <strong>Care</strong> Link with the other primary and community services in the IFHC<br />
plan to move to a case-mix model of funding long term support services, based on work<br />
done by Canterbury and Auckland DHBs.<br />
6 Capability and capacity<br />
These changes are more to do with how people work and changes of treatment model than actual<br />
increase in numbers.<br />
There is a need for further upskilling of the home care workforce.<br />
7 Effect on inequalities<br />
West Coast older people will gain access to home-based and specialist health of older people<br />
services that are more similar to that available in most other areas of NZ.<br />
These changes are based on a proactive and preventive model of care for older people and their<br />
families/carers. This is highly likely to reduce the rate of illness, injury and disability, thereby<br />
reducing the rate of hospital admission and long term residential care. West Coast older<br />
people, like the rest of the West Coast population, have a higher rate of illness and injury than<br />
the NZ average, so any improvement will reduce inequalities.<br />
Business case appendices V12 AC 25Feb2010 Page 106
Māori have a higher incidence of most chronic health conditions and a higher need for long term<br />
support from a lower age, and so will benefit most from a more proactive and preventive<br />
approach to older people‟s care. The number of older Māori on the West Coast is increasing.<br />
The proposals described above will help develop services that are acceptable to Māori and<br />
effective in helping them maintain their health and fitness.<br />
8 Evidence for this initiative<br />
Evidence of the cost-effectiveness of integrating primary, community and hospital/specialist<br />
and residential care services, using a single point of entry, multidisciplinary assessment and case<br />
management to ensure that older people experience a smooth pathway among services, can be<br />
found in:<br />
The research underpinning the NZ Ministry of Health‟s Health of Older People Strategy and<br />
integrated continuum of care concept (2002 – www.moh.govt.nz/publications/hops), such as<br />
the Aged <strong>Care</strong> Literature Review on the Coordination and Integration of Services (2001<br />
www.moh.govt.nz/moh.nsf/pagesmh/6127/$File/aged-care-literature-review.pdf )<br />
UK NHS standards for older persons services, and UK evaluation of the NHS intermediate<br />
care initiative - see www.dh.gov.uk/en/Social<strong>Care</strong>/Deliveringadultsocialcare/Olderpeople/<br />
DH_4073597<br />
A major Canadian literature review: MacAdam M (2008) Frameworks of Integrated <strong>Care</strong> for<br />
the Elderly – a systematic review. See www.cprn.com/documents/49813_FR.pdf<br />
Much other overseas literature – see Wainwright T (2003), Home Thoughts from Abroad - a<br />
literature review of the cost-effectiveness of home care - see<br />
http://nzhta.chmeds.ac.nz/publications/home_care.pdf<br />
Evidence for the importance of a goal-based restorative model of home/community-based care,<br />
can be found in:<br />
A number of reports from Auckland University‟s multi-DHB study of the implementation of a<br />
restorative approach in older people‟s health and long-term support services – see<br />
www.fmhs.auckland.ac.nz/son/research/default.aspx<br />
Much overseas work on the value of community-based rehabilitation and on goal setting – see<br />
for example Kroemer DJ et al (2004). Acute transitional alliance – rehabilitation at the<br />
acute/aged care interface. Aust Health Review 28(3) 266-274 www.aushealthreview.com.au/<br />
publications/articles/issues/ahr_28_3_131204/ahr_28_3_266-274.html<br />
The rationale for moving to a community-focused specialist Health of Older Peoples (AT&R)<br />
service can be found in the NZ Guideline for Specialist Health Services for Older people – see<br />
www.moh.govt.nz/moh.nsf/pagesmh/3474<br />
The rationale for adopting the NZ national stroke guidelines (2003) may be found in the<br />
guideline at www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidelineID=37<br />
Business case appendices V12 AC 25Feb2010 Page 107
The rationale for implementing InterRAI may be found in the many reports on interRAI and<br />
assessment tools produced by the Ministry of Health and other organisations since 2003 - see<br />
www.moh.govt.nz/moh.nsf/indexmh/hop-projects-assessmentandservicecoordination<br />
9 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Lack of strong management<br />
or clinical champions for a<br />
new model of Older Peoples<br />
High Medium Discuss within EOI process.<br />
Consider basing HOP service in the<br />
community, working into the hospital.<br />
Health services<br />
Service changes span<br />
several management/<br />
funding silos, making DHB<br />
High High Discuss within EOI process.<br />
Consider basing HOP service in the<br />
community, working into the hospital.<br />
decisions difficult<br />
Many clinical staff work to<br />
a traditional model of care<br />
for older people<br />
Medium Medium Use <strong>Care</strong> Link and InterRAI to drive<br />
changes on a case by case clinical<br />
basis.<br />
Involve sector in restorative training<br />
scheme eg SMART.<br />
Difficulty in moving funding<br />
because of deficit<br />
Medium Medium Discuss in EOI process and get DHB<br />
commitment.<br />
constraints<br />
Lack of connection between<br />
PHO and its primary health<br />
care programmes and what<br />
<strong>Care</strong> Link and DHB has<br />
been doing in HOP<br />
Medium Medium Use EOI process to get greater<br />
involvement and buy-in among<br />
stakeholders.<br />
10 Engagement<br />
Working group who developed this plan: Hecta Williams, Robyn McLachlan, Diane Brockbank,<br />
Helen Rzepecky, Torfrida Wainwright<br />
Other clinicians involved: Tim Bolter, Jocelyn Tracey<br />
Business case appendices V12 AC 25Feb2010 Page 108
11 Organisational accountabilities<br />
West Coast DHB GM <strong>Primary</strong> and Community Services is accountable for:<br />
changes to <strong>Care</strong> Link location, working methods, and implementation of InterRAI<br />
changes to do with community based nurses and clinical nurse specialists (?)<br />
establishment of step-down beds at Westport and Reefton.<br />
West Coast DHB GM Planning & Funding is accountable for:<br />
the change to a restorative home support service<br />
budget management processes for long-term support services<br />
initiating a <strong>Care</strong>r Support Strategy and Action Plan.<br />
West Coast DHB GM Secondary Services is accountable for:<br />
changes to AT&R services<br />
establishment of step-down beds in Greymouth (if hospital-based)<br />
changes to do with allied health staff.<br />
12 Costs<br />
An increase in community allied health FTEs has been budgeted within the <strong>Care</strong> Link and long<br />
term home support budgets as part of the change to a restorative model of home care.<br />
Business case appendices V12 AC 25Feb2010 Page 109
Appendix Twelve: Workforce<br />
1. Aspirational statement<br />
The Integrated Family Health Centres (IFHCs) will be centres of rural excellence that have the<br />
capacity and capability to meet the health care needs of the people of the West Coast, and are<br />
attractive and rewarding work environments both the current and future workforce.<br />
2 Project overview<br />
Because of the current difficulties recruiting and retaining core general practice staff, with<br />
consequent major access difficulties for patients to primary care, the first year of this plan<br />
focuses on detailed workforce planning for the core general practice team workforce.<br />
During 2010/11 detailed planning will take place to extend the project to include other members<br />
of the multi disciplinary team (MDT) within the Integrated Family Health Services.<br />
The plan covers activities to enhance retention, recruitment, professional development and<br />
quality improvement, including the need to develop a centre of excellence for health provider<br />
training, in part to support recruitment and retention.<br />
3 Problem definition<br />
Current issues that need to be addressed are:<br />
The number of permanent GPs is low: currently there is one GP per 2000 people,<br />
including locums.<br />
There is currently one nurse per 1180 people, a low ratio considering the extent of<br />
remote rural areas covered by rural nurses.<br />
There are continuing difficulty getting GP and nurse locum cover and making new<br />
appointments.<br />
There is a high dependence on GP locums with subsequent lack of continuity and<br />
consistency of care.<br />
Long waiting times often exist for appointments.<br />
This adds to the workload of other primary care providers, eg. pharmacists.<br />
In many areas there is a dependence on nurses for first line care, without always<br />
providing adequate training and support.<br />
Business case appendices V12 AC 25Feb2010 Page 110
There are often vacancies for allied health and community nursing roles, with disruptions<br />
in service delivery as a result.<br />
Under representation of Māori working within the West Coast Health & Disability<br />
workforce.<br />
Currently there are 8 vacant positions for GPs, 4.7 for nurses and none for practice managers or<br />
admin/receptionists, as shown in the following table:<br />
General practice full time equivalent (FTE) positions on the West Coast<br />
Current<br />
FTEs<br />
Vacant<br />
FTEs<br />
Total<br />
Patients<br />
per staff<br />
member now<br />
Patients per staff<br />
member if all positions<br />
filled<br />
GPs 15.35 8 23.35 2020 1328<br />
Nurses 26.3 4.7 31 1179 1000<br />
Practice Manager 5.35 0 5.35 5794 5794<br />
Admin/<br />
Receptionist 22 0 22 1409 1409<br />
When these numbers were collected in February, a time of relatively low patient demand for<br />
appointments, the average waiting time for a routine appointment was five days.<br />
The desirable ratio of GPs and nurses per head of population is difficult to determine and<br />
depends on a number of factors such as models of care, rurality, skill sets, level of support from<br />
secondary care, and available funding. The RNZCGP suggested a ratio of 1: 990 59 , on the basis<br />
of a traditional model of care with GPs doing the majority of first contact care. Pinnacle<br />
carried out a workforce survey of staff in general practices in Waikato, Lakes, Taranaki,<br />
Eastern Bay of Plenty and Gisborne regions in 2007 60 which found a GP to patient ratio of<br />
1:1,794 and Practice nurse to patient ratio 1:1927.<br />
Activity based modeling was carried out based on a model of care where the majority of first<br />
contact care and long term condition care is done by skilled nurses, with readily available back<br />
up support from GPS, shared consultations as needed and longer review consultations with GPs<br />
for complex patients. This resulted in a ratio of one GP per 2000 patients and 1 nurse per 900<br />
patients. This was considered appropriate by the working group who produced this plan as long<br />
as extra FTEs are allocated for remoteness, travel and teaching time. Having a stable nurse and<br />
GP workforce based on these ratios has advantages over a workforce that has more GPs, but<br />
with many of them being short term locums who have a limited understanding of the local health<br />
care system.<br />
59 Fretter J, Pande M. How many general practitioners are enough? Forecasting GP workforce capacity in <strong>New</strong> <strong>Zealand</strong>.<br />
NZ Family Physician 2008; 35: 232-44.<br />
60 http://www.nzdoctor.co.nz/news?article=81145179-bd90-40cf-a249-fc1b4a719ec9<br />
Business case appendices V12 AC 25Feb2010 Page 111
Nurse practitioner positions have been added to the output targets below but not yet included<br />
in the modeling; while there is a commitment to move to including nurse practitioners in IFHCs,<br />
our ability to attract nurse practitioners to the Coast, and their roles and responsibilities within<br />
the core general practice team have yet to be determined.<br />
4 Objectives:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
To recruit sufficient GPs and nurses to provide better, sooner, more convenient care.<br />
To retain GPs and nurses so as to provide continuity and consistency of care.<br />
To provide a professionally fulfilling work environment.<br />
To provide or assist access to the professional development activities required to<br />
maintain competence.<br />
To support quality improvement activities.<br />
To develop the multidisciplinary team.<br />
To broaden the above activities to support all members of the multidisciplinary team.<br />
5 Benefits and gains<br />
Output measures<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
No. patients per practice/rural 1140 1000 900 900<br />
nurse*<br />
No. patients per permanent GP* 2000 2000 2000 2000<br />
No. primary care nurse<br />
practitioners<br />
Number Māori practice team<br />
members<br />
0 1 2 3<br />
3 nurses, 1<br />
manager<br />
5 6 7<br />
Shared recruitment agency est. No Yes Yes Yes<br />
*These ratios depend on a full complement of postgraduate students, and locum cover for holidays. They<br />
do not include teaching time. Remote areas need higher Dr/nurse: patient ratios.<br />
Outcome measures<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
% of PHO Performance Programme<br />
targets met<br />
Number of practices cornerstone<br />
accredited<br />
79% >80% >90% >90%<br />
3 6 7 7<br />
Business case appendices V12 AC 25Feb2010 Page 112
6 Deliverables / activities<br />
Programme to be in place by June 2011<br />
Attract students and new graduates to primary care on the Coast:<br />
Stimulate interest among intermediate and high school students in careers in health by<br />
offering workplace experience attachments.<br />
Greater participation in career expos at the local high schools.<br />
Greater utilization of the incubator project, designed to encourage year 12 and 13 high<br />
school students to consider a career in health.<br />
Provide 24 third year nursing student placements, each 6 weeks duration.<br />
Work in partnership with schools of nursing to include a dedicated rural component in<br />
the undergraduate training, including participation in guest speaking opportunities.<br />
Continue to utilize road shows to nursing schools for recruitment purposes and greater<br />
exposure to rural opportunities.<br />
Provide 3 rural immersion medical student 5 th year placements per year.<br />
Provide twelve 5 th year medical student placements per year.<br />
Provide 6 th year placements as possible.<br />
Develop opportunities for contact between house surgeons and general practitioners, eg.<br />
take them on a general practice tour as part of their orientation, invite to GP<br />
professional development activities and PHO activities, encourage GPs to participate in<br />
educational sessions at Grey Base Hospital, eg. radiology sessions.<br />
Develop a package to be given to all those applying to the RNZCGP to be GP registrars<br />
encouraging them to come to the West Coast for their training.<br />
Provide two full year Rural Hospital Medicine registrar placements per year and three<br />
placements for GP registrars per year, with scholarships available.<br />
Attract four GPEP2 (second and third year registrars) to the West Coast each year,<br />
for a full year placement.<br />
Provide four nurses with scholarships to complete the NETP Expansion programme in<br />
primary care.<br />
Provide one placement per year for newly graduated primary care nurse practitioners.<br />
Provide centrally co-ordinated teaching from the Rural Learning Centre in Greymouth,<br />
with local teachers in each IFHC. Utilise Buller Hospital for work experience for<br />
advanced Rural Hospital Medicine registrars and Reefton as a placement for nurse<br />
practitioners towards the end of their training.<br />
Continue to work with the Clinical Training Agency to develop rural training opportunities<br />
for doctors and nurses on the West Coast.<br />
Promote West Coast health scholarships uptake by Māori.<br />
Increase the number of Māori utilizing CTA funding.<br />
Providing opportunities for Māori intermediate and high school students and Māori<br />
second chance learners by utilizing national initiatives, eg. nursing and midwifery for<br />
Māori and Hauora as a career.<br />
Develop programme and support so that the West Coast becomes the most desirable<br />
centre for rural primary care training in <strong>New</strong> <strong>Zealand</strong>.<br />
Business case appendices V12 AC 25Feb2010 Page 113
Recruitment:<br />
Establish a Coast-wide recruitment agency for primary care to support all<br />
practices/IFHCs, recruiting in the first instance all new permanent and locum primary<br />
care nurses and GPs for the West Coast.<br />
Work with practice owners to define what will be done by central agency, what<br />
processes they will need to manage, (eg. contracting).<br />
Develop a relationship with NZ locums to avoid duplication: subcontract what they do<br />
best.<br />
Establish fair processes for allocating available locums or new staff to IFHCs<br />
(distribute according to where recruits want to go and where the patient:GP/nurse ratio<br />
is highest).<br />
Plan, co-ordinate and support the orientation of all new doctors/nurses, working closely<br />
with the IFHC managers.<br />
Support recruitment for new pharmacists as required, and develop joint appointments<br />
between DHB and private pharmacies.<br />
Obtain feedback from all locums and new staff that can be used to improve recruitment<br />
processes.<br />
Develop a plan to increase the Māori health workforce.<br />
Create an atmosphere where Māori want to come and work because there is an<br />
organisational commitment to support the Māori workforce, ie. “Māori Friendly”.<br />
Retention:<br />
Provide central co-ordination to ensure all new recruits and their families receive the<br />
support they need to integrate into the community.<br />
Provide peer mentoring of new recruits by a peer in a different IFHC as required.<br />
Assist the mentors of GPs who are under Medical Council supervision.<br />
Support collegial relationships by providing an annual weekend getaway that combines<br />
educational and fun activities for clinical staff and their families. Invite house<br />
surgeons.<br />
As part of the development of new models of care, work with each practice/ IFHC to<br />
evaluate current job content and job satisfaction for each current staff member.<br />
Review job descriptions with regard to who is the most appropriative person to do each<br />
task.<br />
Provide practice workshops that facilitate the development of a team approach.<br />
Provide comprehensive career planning and education to support this.<br />
Ensure nurses feel supported in their clinical environment and receive training to meet<br />
role specific competency requirements.<br />
Retain Māori workforce by providing a culturally appropriate working environment thus<br />
showing a clear demonstration of organizational commitment to the Māori workforce,<br />
development.<br />
Business case appendices V12 AC 25Feb2010 Page 114
Professional development:<br />
Provide monthly professional development evening meetings for GPs, nurses, practice<br />
managers, pharmacist and other members of the multi disciplinary team (MDT), with<br />
videoconference links.<br />
Provide annual PHO workshops: PHO day, practice management workshops, practice<br />
nurse workshops.<br />
Link in educational activities with those of the Rural Learning Centre.<br />
Provide training in the use of standing orders, (see Acute <strong>Care</strong> plan).<br />
Develop guidelines for direct CT access and provide educational sessions to implement<br />
them, (see Direct Access to Diagnostics plan.)<br />
Adapt Canterbury HealthPathways for Coast use and provide educational sessions to<br />
implement them, (see HealthPathways plan).<br />
Provide education about health literacy, (see Long Term Conditions plan).<br />
Link with DHB Māori health team to provide cultural competence and health inequalities<br />
training annually.<br />
Actively engage Manawhenua to give guidance and support regarding Tikanga Māori<br />
protocol appropriate to Te Tai O Poutini rohe.<br />
Ongoing implementation and utilization of CTA funded cultural supervision for relevant<br />
staff.<br />
Fund conference/course leave for all members of team.<br />
Continued and increasing utilization of PG Nursing CTA funded education.<br />
Refinement of cohort learning between medical and nursing teams.<br />
<strong>Care</strong>er planning and educational support for nurses, including pathways leading to nurse<br />
practitioner.<br />
Quality initiatives:<br />
Develop quality improvement and clinical governance systems in every IFHC.<br />
Provide Cornerstone support and co-ordination support practice quality improvement<br />
teams .<br />
Support practice improvement activities for GPs (MOPS) and nurses (accreditation and<br />
expert endorsement).<br />
Produce practice level PHO Performance Programme reports with peer comparisons.<br />
Provide practice visits by GP and nurse facilitators to review PHO Performance<br />
Programme reports and assist in the development of quality improvement plans.<br />
Provide PHO Performance Programme incentive payments according to the percentage of<br />
targets met by each practice.<br />
Support pharmacists to provide feedback to GPs on cost effective prescribing.<br />
Develop active feedback loops so that any concerns about the quality of patient care will<br />
be fed back to the health providers concerned in a constructive, educational<br />
environment.<br />
Business case appendices V12 AC 25Feb2010 Page 115
Seek feedback from Māori community to ascertain their view about the quality of<br />
patient care for Māori.<br />
Develop/adopt a patient survey to measure patient satisfaction with the care they<br />
receive at their IFHC.<br />
See also the Quality section of the business plan for an overview of the quality<br />
framework.<br />
Year two<br />
Multidisciplinary focus:<br />
Extend programme to include clinical support and educational opportunities for<br />
pharmacists, the wider nursing team (includes community nurses and practice nurses),<br />
and allied health within the IFHC.<br />
Provide integrated professional development for all mental health workers.<br />
Extend recruitment and retention programme to cover all staff.<br />
Year three<br />
Consolidate and review.<br />
Evaluate strategies pertaining to Māori patients and staff.<br />
7 Capability and capacity<br />
This plan picks up the capability and capacity requirements of the other work streams and<br />
collates them into one document.<br />
Considerable progress has made in the last few years in regards to opportunities for training,<br />
professional development activities and quality programmes. This plan extends the work already<br />
done in these areas.<br />
The formation of IFHCs provides the opportunity and resources to enable this plan to support<br />
the wider multidisciplinary workforce.<br />
8 Effect on inequalities<br />
Cultural competency training improves access for Māori and Cornerstone accreditation requires<br />
practices to meet a number of indicators that measure cultural appropriateness. Increasing the<br />
Māori workforce improves access for Māori to heath care.<br />
Business case appendices V12 AC 25Feb2010 Page 116
Mainstream arguments are concerned with projected excess health and disability workforce<br />
demand, overall, and recognition that increasing and strengthening the Māori workforce is part<br />
of a sustainable long-term solution to addressing the shortfall. Equitable health outcomes for<br />
Māori are, however, a fundamental rationale for Māori health and disability workforce<br />
development, through this does not imply a „one size fits all‟ approach. 61<br />
9 Evidence for this initiative<br />
The activities in the plan follow the Health Workforce Advisory Committee guidance in the<br />
following documents:<br />
2005 Strategic Principles for Workforce Development In <strong>New</strong> <strong>Zealand</strong><br />
2006 Report of the Health Workforce Advisory Committee on Encouraging Māori to<br />
Work in the Health Professions<br />
2006 National Guidelines for the Promotion of Healthy Working Environments<br />
2007 Rauringa Raupa, Recruitment and Retention of Māori within the Health and<br />
Disability Workforce.<br />
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
No increase in<br />
permanent staff<br />
recruited<br />
Medium High Continue reliance on locums, with an<br />
increase in support and training for<br />
provided.<br />
Staff come and move<br />
on<br />
Low Medium Exit interviews for all departing staff,<br />
so that current activities can be<br />
altered if necessary.<br />
High number of<br />
complaints to H&DC<br />
Low Medium Review content of professional<br />
development programme.<br />
11 Engagement<br />
Working group who developed this plan: Dr Paul Cooper, Mary Crooks, DrMartin London, Kathy<br />
Hines, DrAnna Dyzel, Joanne Shaw, Rosalie Sampson, Helen Rereti, Jocelyn Tracey, Karyn Kelly,<br />
Kerri Miedema, Gary Coghlan.<br />
61 Rauringa Raupa Recruitment and Retention of Maori within the Health and Disability Workforce Ministry of Health<br />
2007 Page 12<br />
Business case appendices V12 AC 25Feb2010 Page 117
12 Organisational accountabilities<br />
Organisational accountability lies with the PHO for the first year, and with the IFHS<br />
thereafter.<br />
13 Costs<br />
Draft budget<br />
Income<br />
Recruitment and retention fund - 30% 75,000<br />
Payment from practices to recruitment agency 80,000<br />
Professional development (PHO contract) 65,000<br />
PHO Performance programme 120,000<br />
Expenditure<br />
Total 340,000<br />
Project management 40,000<br />
GP registrar scholarships 15,000<br />
<strong>New</strong> grad nurse scholarships 12,000<br />
Teaching - funded by CTA 0<br />
Recruitment agency 100,000<br />
Recruitment agency advertising costs 80,000<br />
Peer mentoring 1,000<br />
Professional development activities 25000<br />
Health pathways editors 5,000<br />
Course/ conference leave support 35,000<br />
Support for Cornerstone and practice quality<br />
activities 10,000<br />
PHO Performance programme facilitation 24,000<br />
Support for Practice QI teams 20,000<br />
Pharmacy support for PPP 4,000<br />
Practice PPP incentive payments 50,000<br />
Total expenditure 421,000<br />
Surplus/deficit ($91,000)<br />
The deficit in this budget has been included in the „Implementing Service Strategies‟ aspect of<br />
the Investing in Change budget, Section 11.1 in the Business Case.<br />
Business case appendices V12 AC 25Feb2010 Page 118
Appendix Thirteen: IFHCs - Facilities<br />
1. Aspirational statement:<br />
Facilities are renovated and/or created that best progress and support the new models of care,<br />
so as to improve the health of West Coasters.<br />
2 Problem definition<br />
<strong>Primary</strong> care facilities across the Coast vary enormously. In Greymouth and Westport, in<br />
particular, the location and/or nature of the buildings that house the primary services and<br />
workforce are problematic for delivering the desired model of care. In Greymouth, the three<br />
medical centres and other private providers including pharmacies are in different parts of town<br />
(and none is connected to the hospital). No medical centres have on-site or adjacent diagnostics<br />
or pharmacy. In Westport, the medical centre is located in old hospital buildings, with other<br />
community based services on the same campus, but widely separated by long corridors - the<br />
layout/location of services is a barrier to communication between services. Some individual<br />
centres are cramped for space. A number of facilties are old and don't comply with seismic<br />
regulations (Westport in particular).<br />
3 Objectives:<br />
<br />
<br />
<br />
To integrate a variety of services alongside traditional general practice service, in line<br />
with the revised model of care and other workstreams<br />
To adapt facilities to best fit with the new ways of working, where this is feasible<br />
To purpose-build future-proofed facilities optimised for the new model of care where<br />
this is the best option and/or necessary<br />
4 Benefits and gains<br />
Output measures<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
No. of IFHCs 0 Embryonic 1 2<br />
Business case appendices V12 AC 25Feb2010 Page 119
5 Grey/Greymouth IFHC<br />
An interim step towards the development of the Greymouth IFHC, is the construction of an<br />
academic/rural training practice (an outpost of one of the three existing medical centres in<br />
Greymouth), in a re-locatable building, on the Grey Hospital site, adjacent to the Emergency<br />
Department. The floor plan is below, and opening date is scheduled for 1 Jul 2010.<br />
Work has begun on bringing the three medical centres in Greymouth together into a single<br />
facility, that might also contain other private providers (e.g., physiotherapy) and pharmacy, and<br />
that would allow the community nursing and allied health workforces currently operated by the<br />
DHB to work in an integrated way with the medical centres.<br />
The PHO led a process of engagement during Feb '10 with private provider in Greymouth around<br />
the possibility of a one-stop shop for primary care services. All three practices have indicated<br />
a significant level of interest, including providing detailed information around their current and<br />
likely future level of service delivery and space requirements. Private pharmacists have asked<br />
for space in the IFHC, though there are some limitations on their ability to relocate entirely in<br />
the short term, given their current investment in, & commitment to, existing retail premises.<br />
Physiotherapists, dentists, opticians, chiropractors, massage therapists and acupuncturists in<br />
town were all also invited to participate, as were various NGO/disability support providers. It is<br />
from this process that the following facilities proposals and options have arisen.<br />
Specifically, the proposal is that the facility be constructed such that the non-hospital, nondomiciliary,<br />
clinic-based patient contact work of the community nursing and allied health<br />
workforce, be conducted in the clinic rooms of the co-located medical centres. Whether, the<br />
facility might also contain the office bases of the community nursing and allied health<br />
workforce is being explored.<br />
Business case appendices V12 AC 25Feb2010 Page 120
A key possibility is that land at the north end of the Grey Base Hospital site is vacant and<br />
available for such a facility. It is possible that the construction of the Greymouth IFHC could<br />
be integrated with, and even physically connected to, Grey Base Hospital (in a way which colocates<br />
services initially but allows for full integration when the hospital is eventually<br />
refurbished). This option is one that is likely to deliver cost savings for both the IFHC facility<br />
development, and for the Grey Hospital redevelopment, particularly if both projects were done<br />
together.<br />
This site, however, is not the only one being considered. A key limitation of the Grey Hospital<br />
site is its Crown ownership, which reduces its attractiveness to private investors, who have<br />
expressed greater interest in options that involve freehold land.<br />
Three separate options for the Greymouth IFHC have been developed.<br />
Option 1 - greenfield IFHC<br />
The first is a greenfield option that is agnostic about location; it describes a stand alone facility<br />
that could be constructed on either a freehold site elsewhere in Greymouth, or on the vacant<br />
north end of the Grey Hospital campus. This option provides a stand-alone primary care facility<br />
with some community and allied health services relocated and/or duplicated from existing<br />
hospital facilities. Separation from hospital-based services means that this option is the least<br />
supportive of integrated multi-disciplinary health service delivery across the primary-secondary<br />
continuum, but it does deliver an integrated primary & community IFHC. The gross floor area is<br />
4,200 m 2 .and the estimated costs in the region of $14.8m, excluding land.<br />
Business case appendices V12 AC 25Feb2010 Page 121
Option 2 - IFHC integrated with Grey Hospital master plan<br />
The second option integrates with the staged development proposed in the Grey Hospital<br />
masterplan. It proposes a 3,385m2 gross floor area for the IFHC component, 1,395m2 of which<br />
is refurbishment to existing hospital buildings and 1,990m2 is new building.<br />
This option tightly integrates with the proposed new hospital, such that the strategic aims of<br />
both IFHC and hospital developments can be most effectively achieved. This option is the only<br />
one of the three that allows optimum integration of primary care, hospital-based care and<br />
community services in one location and fully supports an integrated, multi-disciplinary model of<br />
health service delivery in Greymouth across the primary-secondary continuum. It also makes<br />
most effective use of existing buildings, thereby reducing the amount of new building required,<br />
avoiding duplication of services and facilities. The combined cost estimate is $76.545m, with<br />
the IFHC component being $10.1m and the hospital component being $66.445m. The IFHC could<br />
be built as the first stage of this project.<br />
Option 3 - IFHC located adjacent to existing Grey Hospital<br />
The third option is also on the Grey Base Hospital site. However, it assumes that no funds are<br />
made available for the Grey Base Hospital rebuild, locates the IFHC adjacent to the existing<br />
hospital without connecting the two, and assumes that both allied health services and the office<br />
bases of the likes of community nurses and mental health services would remain in existing<br />
hospital buildings, even though their clinical contact with patients would occur within the IFHC.<br />
Business case appendices V12 AC 25Feb2010 Page 122
This option is effectively a Greenfield part-IFHC adjacent to the existing hospital and, as such,<br />
goes some way towards integrating health service delivery, but does not support fully integrated<br />
multi-disciplinary service models to the extent of option 2. The new build area of the IFHC is<br />
less than the other options because allied health and community services remain in existing<br />
hospital buildings, some distance away from primary services. The area of this smaller option is<br />
2,863m 2 , 2,213m2 of which is new building and 650m2 is refurbishment of the existing<br />
Corporate Building. This option requires relocation of DHB Administration to another, as yet<br />
undefined location, most likely rental accommodation off site. The cost of this option is in the<br />
region of $10.785m and includes an allowance for fitout of new DHB Admin offices elsewhere,<br />
but excludes both relocation and lease costs (though these costs should be considered as part<br />
of the overall cost of option 3). The resulting site plan is as follows:<br />
Financing<br />
Private financing of the capital cost of the IFHC is being explored; initial discussions have<br />
indicated strong potential for a private funding syndicate. A key conversation has been with<br />
Development West Coast, which has expressed its interest in the project, particularly if a<br />
freehold option is chosen, and indicated that the likely scale of the project is one that is<br />
manageable for, and attractive to, them. Mawhera Incorporation is a major Maori land owner in<br />
central Greymouth, which has also expressed interest in a financing and/or development role.<br />
Business case appendices V12 AC 25Feb2010 Page 123
It may even be possible to pull together a private funding syndicate to fund both projects - a<br />
completely integrated Family Health Centre and the eventual refurbishment of the Greymouth<br />
Base Hospital facility - if there is political interest in such an arrangement.<br />
6 Buller/Westport IFHC<br />
The West Coast DHB currently owns and operates the medical centre, Buller Medical Centre,<br />
and Buller Hospital, in the town of Westport. Westport is 107kms from Greymouth (at least an<br />
hour and a quarter by road). There is no public transport connection between the two centres.<br />
Earlier work has explored options for revamping the facilities on the Buller Hospital site. The<br />
future status and size of Buller Hospital is unclear, with discussion currently occurring in<br />
relation to the DHB contracting out aged residential care, and the impact for other services of<br />
this proposed change still somewhat unclear.<br />
A greenfields IFHC in Westport, probably on the Buller Hospital site (there is sufficient land),<br />
is a distinct possibility. A revision of the earlier proposed facility is likely to be required to<br />
match the revised model of care envisaged in this EoI business case, and to fit with any<br />
decisions regarding the future shape of secondary services.<br />
One proposed floor plan for a greenfields construction on the Buller Hospital site is as follows:<br />
This and other options are being explored. This option had a $16.3m price tag in Aug 2008.<br />
Revisions will be required to reduce the capital spend to more manageable proportions. Private<br />
financing for this facility has not yet been explored, as further work is required to understand<br />
the likely final size and scale of the project.<br />
Business case appendices V12 AC 25Feb2010 Page 124
7 Westland IFHC<br />
Facilities options are not top of the list for the Westland District.<br />
Hokitika's sole medical centre, the Westland Medical Centre, and the DHB's community nursing<br />
& mental health services at the Hokitika Health Centre, are in separate buildings across the<br />
road from each other. But the two services work well together, and a facilities revamp is<br />
thought unlikely to offer significantly greater benefits, such that the required capital spend<br />
could be justified. Both building are relatively modern and comply with health centre facility<br />
standards.<br />
In South Westland, the population is scattered over vast distances. General practice and<br />
community nursing services are currently delivered from five clinic locations.<br />
This business case does not envisage further changes to the facilities aspects of service<br />
delivery in South Westland, apart from a separate facilities development already planned in that<br />
area . This proposed development will contribute in a physical sense to the development of an<br />
otherwise virtual Integrated Family Health Centre. The project is the joint development of a<br />
combined rural health centre / ambulance station in Franz Josef, which will act as the<br />
centerpiece for the DHB's remote South Westland practice (covering Hari Hari, Whataroa,<br />
Franz Josef, Fox Glacier and Haast). Both St John and the West Coast DHB have already<br />
committed to this project, which will be built on St John owned land.<br />
An artist impression of the proposed Franz Josef Health Centre / Ambulance Station<br />
Business case appendices V12 AC 25Feb2010 Page 125
8 Deliverables / activities<br />
Implementation plan: to June 30<br />
Proto-IFHC in Greymouth<br />
Plan and build primary care academic practice on Grey Base Hospital site<br />
incorporates teaching component to support rural workforce retention &<br />
development<br />
co-located with Grey Base Hospital, with GP registrars doing work in both facilities<br />
contribution to resolving after hours cover issues<br />
Substantive-IFHC in Greymouth<br />
Plan primary and community care components of Grey IFHC<br />
relationship map completed by Feb '10<br />
understand links to and implications (both ways) of possible link with Grey Hospital<br />
site & business case by Mar '10<br />
explore site options by Apr '10<br />
explore financing options by May '10<br />
concept design by June 2010<br />
Westport<br />
Review plans for Westport<br />
assess fit with revised model of care; adapt & revise designs as necessary<br />
Year one:<br />
Proto-IFHC in Greymouth<br />
Academic practice on Grey Base Hospital site opens 1 Jul '10<br />
Substantive-IFHC in Greymouth<br />
Build substantial primary/community care facility (on Grey Base Hospital site?)<br />
preliminary design by August 2010<br />
capital funding in place by end Aug '10<br />
developed design by October 2010<br />
resource consents received by end Oct '10<br />
detailed plans completed by Feb 2011<br />
building consents received by Mar 2011<br />
building commences April 2011<br />
Westport<br />
revise designs, timelines, decanting etc by end Dec '10<br />
finalise plans and submit resource & building consent applications by end Mar '11<br />
capital funding in place by Mar '11<br />
Reefton<br />
Explore and document Reefton's facility requirements<br />
Business case appendices V12 AC 25Feb2010 Page 126
Year two<br />
Substantive-IFHC in Greymouth<br />
Substantial primary/community care facility on Grey Base Hospital site in operation<br />
building completed Feb 2012<br />
building opens 1 March 2012<br />
various tenants move in during Mar '12<br />
building fully operational from 1 Apr '12<br />
Westport<br />
first stage of building commences 1 Apr '12<br />
Reefton<br />
progress options developed<br />
Year three<br />
Westport<br />
all stages of building completed 30 Sep '12<br />
Changes to current staffing:<br />
Well configured facilities will assist in achieving optimised, efficient staffing levels.<br />
9 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Capital costs of, and<br />
therefore operating High High<br />
Revise plans to be reduce capital costs /be<br />
affordable<br />
costs in, new facilities<br />
too high<br />
Connection of Grey<br />
IFHC with Grey<br />
Hospital rebuild<br />
High High<br />
Explore options for Grey IFHC to not be<br />
dependent on Grey Hospital obtaining<br />
Crown funding for its rebuild<br />
causes delays and/or<br />
derails project<br />
Co-location does not<br />
lead to integration of<br />
services<br />
High Medium<br />
Develop Charter to sit alongside leases<br />
(Charter commits tenants to integrated<br />
way of working)<br />
PHO provides facilitation/overall<br />
management function to drive integration<br />
Community opposition<br />
to Buller IFHC, if seen<br />
as a downgrade for/of<br />
Buller Hospital<br />
High Medium<br />
Engage community leaders early<br />
Engage with community re service delivery<br />
options for Buller, and facilities<br />
implications<br />
Articulate reasons for service & facility<br />
options once chosen<br />
Business case appendices V12 AC 25Feb2010 Page 127
Private providers<br />
decide not to locate to<br />
new IFHC facility<br />
Medium<br />
High<br />
Engage early & continuously<br />
Articulate increased foot traffic/business<br />
benefits of all health providers being colocated<br />
Private financing for<br />
capital cannot be<br />
secured<br />
Medium<br />
High<br />
Ensure business case stacks up/is viable<br />
Crown land makes<br />
facilities business case<br />
unattractive to private<br />
investors<br />
Medium<br />
Medium<br />
Research financing options used in other<br />
jurisdictions<br />
Explore with MoH how to make proposition<br />
attractive for private investors<br />
Community/provider<br />
opposition to hospital<br />
location for Grey IFHC<br />
Medium<br />
Low<br />
Explore all site options with community<br />
Articulate pros & cons of different<br />
options<br />
Articulate reasons for final site selection<br />
10 Engagement<br />
Working group who developed this plan:<br />
Wayne Champion, Hecta Williams, Anthony Cooke, Darryl Haines and Darryl <strong>Care</strong>y (architects -<br />
Chow Hill and Warren & Mahoney), Neil O'Donnell (quantity surveyor - Rider Levett Bucknall)<br />
Other clinicians involved: Julie Kilkelly, Kerri Miedema, Maureen Frankpitt, Dr JD Naidoo,<br />
Barbara Smith, Jenny Robertson, Dr Jocelyn Tracey, Marie West,<br />
11 Organisational accountabilities<br />
Participants will include multiple organisations at the commencement, e.g., three separate<br />
general practices in Greymouth. There will be an over-arching organisational structure to<br />
facilitate the ongoing operation of co-located and aligned, though still separate,<br />
organisations/businesses. This facilitation function may be performed by the PHO.<br />
Tenants will sign a facility Charter as well as the lease - committing them to the revised model<br />
of care that will operate in the facility, and to integration with the expanded primary care team.<br />
Business case appendices V12 AC 25Feb2010 Page 128
12 Costs<br />
Capital costs<br />
Greymouth IFHC<br />
Westport IFHC<br />
Year 1 Year 2 Year 3<br />
$10.11-14.8m<br />
Est. $8m<br />
Assumptions:<br />
Private sources fund the capital requirements<br />
DHB/Crown land is made available on a long-term basis that is attractive to private<br />
investors.<br />
Business case appendices V12 AC 25Feb2010 Page 129
Appendix Fourteen: IFHCs – Information Technology<br />
1. Aspirational statement:<br />
Appropriate information and communication technology is in place that best progresses and<br />
supports the new models of care for West Coasters.<br />
2 Project overview<br />
One of the key elements of the West Coast Integrated Family Health Centre (IFHC) project is<br />
the electronic integration of health services, supporting an integrated model of service delivery<br />
across a range of geographically isolated service delivery locations.<br />
This plan proposes the development of an integrated health information strategy for all health<br />
providers on the West Coast, with the aim of ensuring that the right level of access to clinical<br />
information is available at each point of care encountered by patients, and that all appropriate<br />
clinical information follows the patient from carer to carer as they travel through a patient<br />
centred network of care, all in a way that minimises waste and duplication and whist<br />
safeguarding patient privacy.<br />
This plan will put the West Coast in a good position to adopt national initiatives as they become<br />
available, eg. a core set of personal health information available electronically to <strong>New</strong><br />
<strong>Zealand</strong>ers and their treatment providers, and electronic prescribing.<br />
3 Current situation / Problem definition<br />
Within primary/community care<br />
All but one of the West Coast‟s General Practices use the same patient management system<br />
(PMS) MedTech 32. Those practices that are owned by the West Coast District Health Board<br />
use the West Coast DHB PrISM system, which provides a single shared patient administration<br />
system but which has been configured in a way that restricts integration because of patient<br />
privacy concerns. A number of other services are available over the PrISM system (access to<br />
hospital health information systems on Health Views [such as discharge summaries, PACS<br />
radiology images, laboratory results], access to the DHB‟s library resources and online clinical<br />
databases, secure email, DHB intranet access). Two of the privately owned GP practices also<br />
Business case appendices V12 AC 25Feb2010 Page 130
utilize MedTech, but via their own separate installations, whilst the other privately owned<br />
practice uses a product called Profile.<br />
Most other primary health and community service organisations maintain their own independent<br />
systems, with the exception of Rata Te Awhina Trust (a Māori Health NGO), which uses the<br />
DHBs PrISM system and MedTech. The majority of non general practice services that are<br />
currently owned by the DHB, such as community nursing and allied health, use DHB‟s iSOFT<br />
patient information system, but aren‟t using its electronic patient notes capacity.<br />
Therefore, while GPs, rural and practice nurses use MedTech for their consultation notes, most<br />
other community based nurses and allied health providers who are caring simultaneously for the<br />
same patients keep paper based clinical records: this can lead to duplication and lack of coordination<br />
and consistency of care, with resulting confusion for patients. In the Buller region a<br />
recent change to all these providers using MedTech has proved very successful.<br />
Information flows between primary and secondary care<br />
Two of the key integration points between primary/community and secondary services are the<br />
referral and discharge processes. The objective is to ensure that all relevant information is<br />
made available to the receiving provider when there is a transfer of a patient‟s care (either a<br />
referral to a provider or a discharge back to the original referrer). Currently while referrals<br />
from the general practices are written in their practice management system, they are then<br />
printed out and faxed to the hospital rather than electronically transmitted. Discharge letters<br />
are sent and received electronically.<br />
DHB owned practices can use PrISM to access HealthViews for patient information as<br />
described above.<br />
Many patients arrive at the Emergency Department (ED) without a referral from their general<br />
practice: care would be safer if ED and admitting senior medical officers (SMOs) could access<br />
the patient's general practice records, particularly their problem list, regular medication list<br />
and allergies. Currently ED clinical notes are hand written and not always easy to read, which<br />
may lead to lack of appropriate follow-up by GPs/nurses or even an inpatient ward if the patient<br />
is admitted into hospital from their ED visit.<br />
Laboratory and radiology<br />
All West Coast radiological images and reports are accessible via the central iSOFT system at<br />
the DHB. All except one of the current general practices uses the hospital laboratory for lab<br />
investigations, and all results are stored in iSOFT. This means that all radiological<br />
investigations and most laboratory results are all stored in a central system, accessible by those<br />
who can access HealthViews in iSoft.<br />
Business case appendices V12 AC 25Feb2010 Page 131
Community pharmacy<br />
Community pharmacies face problems at times when dispensing prescriptions for newly<br />
discharged patients, as they try to reconcile the information on the prescription with previous<br />
medications dispensed, and without the benefit of a discharge summary providing information on<br />
what changes to regular medication have been made and why.<br />
Given the importance of a strong retail trade for the viability of pharmacy businesses, it may be<br />
that there is no pharmacy within some IFHCs. Developing the ability to send electronic<br />
prescriptions from primary care, with the ability to home deliver to frail elderly and those with<br />
transport issues, would provide more convenient care.<br />
Communications Technologies<br />
With its vast distances, small population and geographic isolation, the West Coast is ideally<br />
placed to benefit from investment in improved telecommunications technologies. The availability<br />
of telecommunications network capability (bandwidth) along the West Coast has historically<br />
limited the ability to benefit from some technologies, however this has recently been overcome<br />
with the availability of a direct fibre optic link between Hokitika, Greymouth and Westport and<br />
potentially Reefton in the future (one of the first business to business uses of this service is an<br />
upgrade of West Coast DHBs wide area network, interconnecting Buller Health with Grey Base<br />
Hospital from December 2009).<br />
The current Telepaeds network links videoconferencing between Greymouth, Westport,<br />
Hokitika, Reefton, Christchurch and over 100 other locations in <strong>New</strong> <strong>Zealand</strong>. It is currently<br />
mainly used for clinical conferences, educational sessions, and management meetings and to a<br />
lesser extent for remote patient consultations, eg. methadone clinics, surgical follow-up clinics.<br />
The new fibre optic link will enhance its usefulness, particularly in regards to linking into<br />
aspects of the hospital IT system such as PACS to review radiology images.<br />
Medical telemetry can support remote clinical support, remote consultations and remote<br />
diagnosis, potentially integrated with videoconferencing. An example of this is the CISCO<br />
Health Presence System, which is being trialed as a standalone medical telemetry and video<br />
conferencing unit linking Buller Health (ED and Outpatients) with Grey Base Hospital for remote<br />
diagnosis and outpatient consultations. This system is large, fixed, not well linked in with other<br />
DHB IT and telemedicine systems.<br />
As part of the Canterbury initiative, Dr Mike Sullivan and Bronwyn Petrie are reviewing the<br />
current clinical telemedicine capability on the West Coast, the range of potential clinical<br />
applications, and potential linkages with Canterbury. Of particular interest will be the ability to<br />
„store and forward‟ patient information, (eg. photos, ECG, spirometry etc) so that this can be<br />
reviewed at a later time by both the original clinician and a remote specialist. Their report is<br />
due in March 2010 and will inform development of the Telemedicine aspects of this plan.<br />
Business case appendices V12 AC 25Feb2010 Page 132
4 Objectives:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
To implement communications and information technology that facilitates integrated<br />
care for patients.<br />
To improve information flow between primary care, community nursing and allied health<br />
clinicians by all using the same electronic patient medical record.<br />
To improve information flows between primary and secondary care by establishing<br />
mechanisms for primary/community clinicians to view the hospital based electronic<br />
clinical medical record and vice versa.<br />
Adopt electronic prescribing.<br />
To increase the use of telemedicine for both outpatient appointments, and for seeking<br />
management advice from a distance (either real time or „store and forward‟).<br />
To enable and empower people in the community to obtain, process and understand the<br />
health information they need to make appropriate decisions about their health.<br />
To prepare local IT systems so that the West Coast in a good position to adopt national<br />
initiatives as they become available, eg. a core set of personal health information<br />
available electronically to <strong>New</strong> <strong>Zealand</strong>ers and their treatment providers, and electronic<br />
prescribing<br />
5 Benefits and gains<br />
Output measures<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
High Definition Videoconferencing<br />
interconnects all West Coast<br />
IFHCs<br />
Shared Medical Telemetry System<br />
Medical Practices move to a shared<br />
Med Tech 32 Database system<br />
Standard<br />
Definition<br />
only<br />
CISCO<br />
Health<br />
Presence<br />
being<br />
trialled in<br />
Buller<br />
All West<br />
Coast DHB<br />
Practices<br />
share same<br />
system but<br />
independent<br />
practices<br />
maintain<br />
their own<br />
All<br />
videoconferenc<br />
e-ing equipment<br />
replaced with<br />
high definition<br />
equipment<br />
Options for an<br />
integrated<br />
medical<br />
telemetry<br />
network<br />
explored<br />
Move to shared<br />
Med Tech<br />
database<br />
explored in<br />
detail.<br />
Logistics of<br />
moving iSOFT<br />
Community<br />
Nursing<br />
Addition<br />
Videoconferencing<br />
equipment<br />
deployed in<br />
IFHCs<br />
Move to<br />
shared<br />
Medical<br />
Telemetry<br />
system.<br />
Move to<br />
shared Med<br />
Tech<br />
database and<br />
move iSOFT<br />
Community<br />
Nursing<br />
functions to<br />
Med Tech<br />
Business case appendices V12 AC 25Feb2010 Page 133
separate<br />
databases.<br />
functions to<br />
Med Tech<br />
delineated.<br />
Outcome measures<br />
Indicator Baseline Target – Yr 1 Year 2 Year 3<br />
Numbers of remote outpatient TBC<br />
consultations per quarter/year<br />
Number of times medical<br />
telemetry system used to share<br />
diagnostic information with<br />
Greymouth Hospital , per<br />
quarter/year<br />
TBC<br />
6 Deliverables / activities<br />
One of the aims of the IFHC is to provide an integrated health information system that allows<br />
clinical information to be available at each point of care that a patient connects with, so that<br />
patient specific information relevant to an episode of care follows the patient from carer to<br />
carer across the entire network of integrated health services. The aim is to support an<br />
integrated model of care, whilst minimizing waste and duplication, and whist safeguarding<br />
patient privacy.<br />
One way of achieving this involves moving services that are similar in nature to the same shared<br />
information system. A logical choice for this would be MedTech 32 for all providers working in<br />
IFHCs, probably provided over the West Coast DHB developed PrISM system, as it is already<br />
well established on the West Coast. The system needn‟t be owned and hosted by the DHB; it<br />
has been developed in a way that allows it to be transferred to another provider such as the<br />
PHO or an IFHC in the future.<br />
Complete Population<br />
To be of the greatest benefit, an electronic health record needs to include all health activity<br />
provided by all health providers. With this in mind, plans have been developed to make the<br />
West Coast DHB PrISM system available to other providers, so that all relevant health<br />
information can be available when and where it is required for patient care.<br />
Self Service Access<br />
A logical next step beyond developing an integrated electronic health record is to provide<br />
access for people to see their own health information and so that they can provide updates for<br />
changes of address or provide any new health information, (such as diabetes patients entering<br />
home blood tests).<br />
Business case appendices V12 AC 25Feb2010 Page 134
Security<br />
An individual‟s health information is a taonga – it has great value and is sacred to them. It is<br />
therefore essential to ensure that health information is secure and that a patient's wishes are<br />
adhered to regarding its availability.<br />
Resilient<br />
Health Information Systems need to be resilient to external factors such as a localised<br />
disaster, so that critical information is available to those who legitimately need it wherever and<br />
whenever it is required, regardless of the challenges involved in ensuring its availability.<br />
Improving Data Quality<br />
Health information systems are large complex IT systems with numerous users and complex<br />
information flows. Data needs to be accurate and reliable as incorrect data can dramatically<br />
impact on a patients wellbeing. Continuous quality improvement philosophies need to be applied<br />
in order to ensure that the risk of error is minimized.<br />
Implementation plan: to June 30<br />
Within primary/community care<br />
<br />
<br />
Begin the process of identifying the requirements for sharing clinical notes on<br />
MedTech in a single clinical file used by all health providers in the IFHC.<br />
Understand and, as necessary, re-negotiate reporting requirements for community<br />
nursing & allied health.<br />
Between primary and secondary<br />
<br />
Establish access for all medical centres to HealthViews, through the DHB's PRiSM<br />
system.<br />
Co-ordination with ED acute care<br />
install a copy of MedTech on a computer in ED<br />
change patient registration form/casualty sheet on arrival to include consent for<br />
access to their MedTech notes for that hospital visit<br />
ensure privacy considerations are met<br />
obtain agreement from practices<br />
create link into DHB practice server.<br />
Patient access to information<br />
Publicise Health Navigator patient self management website – for providers and<br />
community, eg. pamphlet in prescription bags for (see also LTC workstream)<br />
Create link to Community & Public Health website on PHO website, (see also Keeping<br />
people healthy workstream).<br />
Business case appendices V12 AC 25Feb2010 Page 135
Year one<br />
<strong>Primary</strong> secondary<br />
create link to Heath Views for community pharmacies<br />
develop link into MedTech for outpatients, wards and hospital pharmacy.<br />
Within IFHC<br />
<br />
<br />
Develop specifications for new system and fund implementation. Work with the<br />
current health centre that does not currently use MedTech to determine the<br />
barriers and facilitators for change.<br />
Review current referral systems, considering potential role of <strong>Care</strong> Link, and change<br />
to within system request for assistance/booking. Monitor workload and waiting<br />
times and develop new priority and entry criteria as required.<br />
Telemedicine<br />
<br />
Review the Canterbury Initiative Telemedicine plan and implement proof of concept<br />
plan for telemedicine links from IFHCs, likely to include:<br />
o Increased number of outpatient clinics done at a distance using telemedicine<br />
(reducing patient travel and so making services availability better, sooner<br />
and more convenient)<br />
o Increase in the use of the medical telemetry system to share diagnostic<br />
information with Greymouth Hospital reducing patient travel and so making<br />
services availability better, sooner and more convenient<br />
Web based support for providers<br />
<br />
(see health pathways work plan).<br />
Year two<br />
<br />
<br />
<br />
<br />
extend MedTech across all health centers and for all community nursing and allied<br />
health<br />
develop link into MedTech for community pharmacy<br />
work with the private practice on Profile to overcome barriers to the use of<br />
MedTech, and assist with migration to MedTech<br />
ensure all Coast lab results are in the same database.<br />
Year three<br />
(to be developed)<br />
7 Capability and capacity<br />
There will be training requirements for new providers to use MedTech32 for consultations.<br />
Training in the use of telemedicine will also be required to ensure this methodology is used<br />
safely and appropriately.<br />
Business case appendices V12 AC 25Feb2010 Page 136
8 Effect on inequalities<br />
The increased use of telemedicine will benefit those who have difficulties with the expense of<br />
traveling from rural areas to Greymouth.<br />
9 Evidence for this initiative<br />
This plan follows the <strong>Better</strong>, <strong>Sooner</strong>, <strong>More</strong> <strong>Convenient</strong> <strong>Primary</strong> Health <strong>Care</strong> Business Case<br />
Development Process Information Pack principles:<br />
• Prioritisation and access to services (shared scheduling of primary care,<br />
community nursing and allied health appointments)<br />
• Information sharing (shared electronic clinical record, sharing electonricni<br />
information with pharmacy and between primary and secondary care)<br />
• Quality and performance (HealthPathways, patient access to web support, i.e.<br />
Health Navigator)<br />
The changes proposed will result in a more patent/whanau centred approach since with all<br />
primary and community health providers using the same electronic medical record there will be<br />
less need to repeat their same story to multiple providers and for unnecessary repeated<br />
assessments.<br />
10 Risk analysis<br />
Risk Probability Impact Contingency plan<br />
Increased risk of privacy<br />
breaches with move to more<br />
providers using the same<br />
electronic health record<br />
Low High Ensure patients understand how<br />
their information is stored and<br />
shared. Ensure all health providers<br />
understand privacy requirements<br />
Provide training in how to hide<br />
sensitive consultation notes.<br />
<strong>New</strong> users find MedTech32<br />
difficult<br />
Moderate Moderate Provide adequate training.<br />
Use enthusiastic peers to support<br />
and motivate.<br />
Larger numbers of providers<br />
using the same electronic<br />
medical record making it<br />
difficult for different types<br />
of providers to follow the<br />
flow of their consultations<br />
Moderate Moderate Review how other places have<br />
dealt with this situation, such as<br />
coding consultations according to<br />
types of provider<br />
Business case appendices V12 AC 25Feb2010 Page 137
11 Engagement<br />
Working group who develop this plan: Wayne Champion, Dr Jocelyn Tracey, Anthony Cooke.<br />
12 Organisational accountabilities<br />
The Integrated Family Health Service will be responsible for working closely with the West<br />
Coast DHB to implement the IT requirements described in this section.<br />
13 Costs<br />
Implement High Definition<br />
Videoconferencing<br />
Implement Integrated<br />
Medical Telemetry system (if<br />
practical)<br />
Migrate to shared Med Tech<br />
database (hardware and<br />
software)<br />
Year 1 Year 2 Year 3<br />
$30,000 $20,000<br />
$30,000<br />
$120,000<br />
Assumptions:<br />
Some of these costs would be borne by West Coast DHB regardless of the IFHC proposal.<br />
West Coast DHB will provide IT staff, expertise and network bandwidth at marginal cost. The<br />
cost of this contribution will be defined when each stage of the plan is investigated in detail. In<br />
the interim the above costs have been included in the Investing in Change budget, Section 11.1 in<br />
the Business Case.<br />
Business case appendices V12 AC 25Feb2010 Page 138
Appendix Fifteen: Project advisory and reference groups<br />
Principal authors of<br />
the business case<br />
Anthony Cooke, PHOcus on Heath<br />
Dr Jocelyn Tracey, PHOcus on Health<br />
Martin Hefford, LECG<br />
Also:<br />
<br />
<br />
<br />
<br />
<br />
Kim Sinclair<br />
Torfrida Wainwright<br />
Helen Reriti<br />
Wayne Champion<br />
Wayne Turp<br />
Project advisory<br />
group<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Dr Greville Wood, GP, Chair PHO clinical governance<br />
committee<br />
Dr Vicki Robertson, Chief Medical Officer<br />
Jane O‟Malley, PhD, DoN Nursing & Midwifery<br />
Hecta Williams, GM <strong>Primary</strong> & MH Services<br />
Wayne Champion, GM Hospital and Corporate Services<br />
Gary Coghlan, GM Māori, WCDHB<br />
Julie Kilkelly, pharmacy<br />
Kerri Miedema, pharmacy<br />
Lindy Mason, pharmacy<br />
Elinor Stratford, Manager, Disability Information Network<br />
Barbara Greer, CEO, Rata Te Awhina Trust<br />
Val Henry, Rata Te Awhina Trust<br />
Ann Donovan, Rata Te Awhina Trust<br />
Jem Pupich, Community & Public Health<br />
Maureen Frankpitt, Nurse leader community and primary care<br />
WCDHB<br />
Raewyn McKnight, Allied Health, WCDHB<br />
Janette Anderson, physiotherapy, WCDHB<br />
Karyn Kelly, Assistant DON, WCDHB<br />
Yvonne Anisy, RN, WCDHB<br />
Marie West, Greymouth Family Health<br />
Jenny Robertson, Manager Buller Health<br />
Barbara Smith, Clinical Services manager, Reefton<br />
Colin Weeks, GM Finances WCDHB<br />
Shona McLeod, Planning & Funding, WCDHB<br />
Project reference<br />
group<br />
<br />
<br />
<br />
<br />
<br />
Dr Anna Dyzel, GP, Hokitika, and Trustee WCPHO<br />
Dr JD Naidoo, GP, Greymouth<br />
Dr Martin London, GP, South Westland<br />
Dr Tim Bolter, Greymouth Medical Centre<br />
Dr Paul Cooper, GP Buller Health<br />
Business case appendices V12 AC 25Feb2010 Page 139