Agenda Bay of Plenty District Health Boardopen...2012/07/18 · Bay of Plenty District Health Board (open) Minutes These papers remain confidential to the Bay of Plenty District Health

Agenda

Bay of Plenty District Health Board

Venue: Conference Hall, Clinical School, Whakatane Date and Time: Wednesday 18 July 2012 at 9:00am

Our Vision: Healthy Thriving Communities

Our Values: Compassion Attitude Responsiveness Excellence

Item No.

Item Page

1

Apologies – Nil

2

Interests Register

3 Minutes and Chair Report Back 3.1 Minutes of Board Meeting

3.2 Matters Arising

1

6

4

Strategic Areas (Any items that are not standing reports must go via the Committees and will include the Chair’s report and Committee recommendation)

4.1 Chief Executive’s Report

4.2 Regionalisation – Verbal update 4.3 BOPDHB Health of Older People Strategy Plan 2012 - 2017

4.4 BOPDHB Audit Palliative Care Services Plan 2012 – 2016

7

15

94

5

Information for Noting (Items for this area will only be discussed if the Chair has been notified via GMGQ)

5.1 Work Plan

190

Item No.

Item Page

5.2 6 Monthly Board Attendance Report

5.3 Report from Organisation of Economic Co-operation and

Development on Health Spending

192

193

6

Presentations – Nil

7

General Business

8

Resolution to Exclude the Public

9

Next Meeting – Wednesday 15 August 2012.

Bay of Plenty District Health Board (open) Minutes These papers remain confidential to the Bay of Plenty District Health Board

Minutes Bay of Plenty District Health Board

Venue: Education Room 2, Education Centre, 889 Cameron Road, Tauranga Date and time: Wednesday 20 June 2012 at 9:00am

Board: Sally Webb (Chair), David Stewart, Yvonne Boyes Gail McIntosh, Jeff Williams, Mark Arundel, Ron Scott, Tamarapa Lloyd, Matua Parkinson, Mogens Poppe, Marion Guy, P McCausland (Runanga Rep)

Attendees: Gail Bingham (GM Governance & Quality), Letham White (GM Corporate Services), Helen Mason (Acting CEO), Phillip Balmer (Chief Operating Officer), Jeff Hodson (GM Property Services), Mike Agnew (Acting GM Planning and Funding)

Public Attendees: Ewen Lowden,

Item No.

Item Action Who

1

Apologies No apologies were received

2

Interests Register The Board was asked if there were any conflicts in relation to items on the agenda. No conflicts were identified.

3

Minutes of Previous Meetings 3.1 Minutes of Board Meeting

Resolved that the Board receive the minutes of the meeting held on 16 May 2012 and confirm as a true and correct record.

Moved: Y Boyes

Seconded: J Williams

3.2 Matters Arising

As per report circulated with the agenda.

1


Item No.

Item Action Who

3.3 Minutes of CPHAC/DSAC

Resolved that the Board receive the minutes of the committee meeting held on 23 May 2012.

Moved: R Scott

Seconded: Y Boyes

4

Strategic Areas 4.1 Chief Executive’s Report

The Board discussed the report as circulated with the agenda The Board requested more information about potential commercialisation of DHB projects. The Acting CEO provided an update on the development of the National Innovation Hub Project. GMGQ reported her team is currently working on a project for the potential commercialisation of the QCMS. The Board discussed the poor uptake of the flu vaccine among nursing staff. April was slightly ahead of budget. Still slight risk for year-end but the risk is diminishing. The use of solar panels in Whakatane was investigated and it was determined that they were not a viable option. Resolved that the Board congratulated the Provider Arm on all the successful projects to control the budget over the last quarter.

Moved: M ArundelSeconded: R Scott

Resolved that the Board receives the CEO report.

Moved: S WebbSeconded: Y Boyes

2


Item No.

Item Action Who

4.2 Regionalisation

There was no regionalisation update.

4.3 Health Targets

The Board discussed the report as circulated with the agenda. The PHO target report was tabled. Resolved that the Board receives the report

Moved: T LloydSeconded: M Parkinson

4.4 Quarterly Risk Report

The Board discussed the report as circulated with the agenda. Resolved that the Board receives the report.

Moved: M ArundelSeconded: J Williams

4.5 Quarterly OSH Report


Moved: M GuySeconded: M Arundel

4.6 Q3 Annual Plan Report


Moved: Y BoyesSeconded: T Lloyd

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Item No.

Item Action Who

4.7 Q3 IDP Report


Moved: M ArundelSeconded: M Guy

4.8 Approval to Lease Land for Construction

of Linear Accelerator The Board discussed the report as circulated with the agenda. Resolved that the Board endorse the proposal to enter into a lease of land with Bay Radiotherapy Services for the purpose of constructing a facility to house a linear accelerator.

Moved: J WilliamsSeconded: S Webb

4.9 Quarter 3 2011/12 Final Confirmed Rating

and Feedback The Board discussed the report as circulated with the agenda. Resolved that the Board receives the report.

Moved: S WebbSeconded: M Arundel

5

Information for Noting 5.1 Work Plan

The Board noted the information.

5.2 Correspondence The Board noted the information.

4


Item No.

Item Action Who

6

Presentations There were no presentations.

7

General Business

8

Resolution to Exclude the Public Resolved: That Pursuant to s 9 of the Official Information Act 1982 and Schedule 3, clause 33 of the New Zealand Health and Disability Act 2000 the public be excluded from the following portions of the meeting because public release of the contents of the reports is likely to affect the privacy of a natural person or unreasonably prejudice the commercial position of the organisation: Chief Executive’s report Regionalisation Midland Regional Services Plan – Final Draft Laboratory Services Evaluation Dash Board Report Pathlab Whakatane Update Correspondence That the following persons be permitted to remain at this meeting, after the public have been excluded, because of their knowledge as to organisational matters or for the purpose of legal records. This knowledge will be of assistance in relation to the matter to be discussed: Gail Bingham Letham White Helen Mason Phillip Balmer Mike Agnew Resolved that the Board move out of confidential.

Moved: S WebbSeconded: J Williams

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Next Meeting – Wednesday 18 July 2012.

The open section of the meeting closed at 10:00am. The minutes will be confirmed as a true and correct record at the next meeting.

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Bay of Plenty District Health Board

Matters Arising (open) – 18 July 2012

Meeting Date

Item Action required Action Taken

18 April 12 6.0 Presentation on Excellence Through Patient and Family Centred Care Project – Schedule patient story for June meeting.

Will be on the agenda for the August meeting.

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CEOs Report (Open) – June 2012 CLINICAL SCHOOL Student Placements

2011/2012 quarterly student feedback Q1

Jul - Sep

Q2 Oct - Dec

Q3 Jan - Mar

No of hospital-based placements 215 196 151

% overall satisfaction with the placement experience

99% 99% 100%

% wanting to remain with or return to the DHB as employees once qualified

96% 92% 94%

% who will encourage other students to seek placements at the BOPDHB

100% 98% 100%

Q3 numbers are down as Jan – Mar 2012 we get fewer students, as their student year starts later in this period. A student house has been sourced for the Tauranga based students, this will be operational at the end of July with priority given to University of Auckland medical students. Education and Training The final workshop for Midlands Health Leaders Advanced course took place on 12 June 2012. Feedback from BOPDHB participants was unanimously positive and all identified development of their leadership skills. Participants for 2012 were:

1) Julie Williams, Hospital Co-ordinator, DON office 2) Sarah Davey, Portfolio Manager, Planning & Funding 3) Jeremy Trishaw, Paediatrician/HOD, Paediatrics Dept 4) William McAuley, Consultant Obstetrician & Gynaecologist, Women& Child Health 5) Joe Bourne, GP Liaison, COO Office

The selection process for the August 2012 Midland Leadership in Practice course has been finalised. 11 Staff from BOPDHB will participate along with other leaders/managers from Lakes and Waikato DHB. There was an outstanding response to a recent short workshop held by Dr David Keane at the Education centre in June 2012. David’s topic “being successful in turbulent times”, focussed on his concept of DELIBERATE (Decide, Eliminate, Language, Information, Beliefs, Energy, Responsibility, Action, Time, Evaluate), living and encouraged staff to manage themselves and others to achieve successful outcomes.

SURGICAL, ANAESTHESIA AND RADIOLOGY SERVICES Autoclave Installation at Whakatane Central Sterilising Unit The new autoclave has been installed at Whakatane Central Sterilising Unit. The installation occurred over one week was an unqualified success. Planning for the installation focused on maintaining normal business through the department and Surgical Admission Unit throughout

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installation. Therefore equipment was transferred to Tauranga Central Sterilising Unit for processing, elective sessions were moved throughout the week to accommodate. Validations of the machines have been successful and the new autoclave is fully functional. The efforts of Clinical Nurse Managers. Irenee Whitehead and Ali Fraser are acknowledged as they took the lead in the operational contingency plan for the installation. Both Mercer and property services worked well together and as a collective achieved a seamless installation. Elective Services Productivity and Workforce Projects The Multidisciplinary Team meetings in the orthopaedic ward now incorporate medical staff. This initiative from the Ministry of Health project has significantly improved the quality and inclusiveness of the Multidisciplinary Team meetings. MEDICINE Cardiology Staff have now been trained in the data management for the ANZAC – QI database. This database is being piloted in the Midland region with each DHB entering data on patients who present with acute coronary syndrome; this will include diagnostic information through to treatment and management including Percutaneous Coronary Intervention. This database will replace the current cumbersome reporting system for identification of service delivery and delays across the Midland region and will eventually provide benchmark information nationally around cardiology service performance and outcomes. Tauranga will be the first site in the Midland region to be recording its Percutaneous Coronary Intervention patients directly onto ANZAC- QI. MIX AND MATCH RESEARCH PROJECT BOPDHB Provider Arm was approached and has agreed to be a research site for the evaluation of one of the tools piloted here originally under the Care Capacity Demand Management initiative which commenced in 2009. An important part of the work of the National Safe Staffing Healthy Workplaces (SSHW) Unit has been about developing tools that help a service to identify what is the right number of staff, what is the best skill mix, and what is the best roster to deliver a safe and effective service. One of the main tools that have been developed is the Mix & Match staffing design tool. In this research project SSHW will be looking at the three wards that have used the Mix & Match staffing design tool. The three wards are HIA, 3A and 3B. The research will evaluate what happens for patients, staff and service effectiveness on days when the recommended staffing design was met and what happens on days when the recommended staffing design was not met. The researcher and 2 research assistants will be on site for six weeks from mid-July using both staff feedback surveys completed at the end of each shift as well as selected patient feedback through face to face interviews. The results will be reported back to the service and the DHB first. The results will be used to provide evidence that answers the question: does the Mix & Match methodology predict

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optimum staffing design? This is the first New Zealand based research to evaluate the use of the methodology. WOMAN, CHILD AND FAMILY

New Paediatric Unit, Tauranga Hospital The new unit is fully operational, the move was completed smoothly thanks to the excellent preparation and planning by Lynnece Dowle, Nurse Manager, with the support of her team and Property services and others. A fundraiser organised by the Skin services raised money to fit out the isolation room. The unit has been supported by several organisations and community groups over the years. A celebration of the community support and the new unit was held on Friday 22nd June 2012. Russell Wills, the Children’s Commissioner, was present. SERVICE IMPROVEMENT UNIT Releasing Time to Care: Productive ward Efficiency of care Tauranga Health In Aging are seeing positive results in hours of direct care time as a result of WOW of hoists relocation. This is saving 1 hour per day of nursing and HCA "looking" "collecting" and motion time. This equals 365 hours additional Direct Care Time per year. Patient Satisfaction Assessment /Planning Unit- 100% of patients completing the Releasing Time to Care Patient Satisfaction Survey in the first Quarter 2012 rated overall stay in unit as Good or Excellent. This has been consistent over last 3 surveys. Patient Safety Observations Module- Ward 4b Orthopaedic, changes made to ward practice to meet standards expected for usage of patient observation Medical Early Warning charts. These changes have been sustained and are reported through the Clinical Audit calendar. CORPORATE SERVICES Website A project to redesign the Bay of Plenty District Health Board’s website is progressing. The new improved Bay Navigator website went live during May including the pathway tool. Attention focussed on the main DHB website which will go live in August. The scope has been altered to incorporate additional feedback time for the Provider ARM. Communications Highlights A film on the Emergency Department has been filmed for Bay of Plenty Health TV. The scripts were written, the shot list compiled and talent organised including Dr Derek Sage playing himself. A Tauranga-based film crew offered their services to us to do the filming. The BE WISE immunise banners have been taken down from supermarkets throughout the Bay of Plenty. Their presence caused media coverage and health workers continue wearing the BE WISE T-shirts on Tuesdays.

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GOVERNANCE AND QUALITY

ACC Partnership Audit The ACC Partnership audit was completed on the 27th of June. The Auditor is recommending to ACC that the BOPDHB remains at Tertiary Level. Report expected at the end of July.

HUMAN RESOURCES HealthShare Ltd Regional Programme Director of Training. This position has been advertised with a close off of 9 July. The position will be the key link for the Regional Training Network to Health Workforce New Zealand. INFORMATION MANAGEMENT Following the example of Mental Health services which has been using Video Conferencing (VC) for number of years a growing number of clinical areas are using the new VC capability to support service provision:

Supervision of Rural GP based at Opotiki GP cover at Te Kaha to cover GP leave Community speech language therapy sessions with isolated/rural clients

Apart from the ability to provide distance support for clinical areas, significant cost savings are being generated via avoidance of travel. Despite positive results for BOP, work continues to determine how this option can be expanded into a regional setting. The work underway at BOP continues to attract significant interest from sector stakeholders with at least one other region indicating its interest in following the BOP/Midland model. PLANNING AND FUNDING PHOs/Business case implementation Three additional Year 3 deliverables have been identified and communicated to the Ministry. These are After Hours, Workforce Review and Maori Disparities. The existing deliveries of Te Whiringa Ora, Whanau Ora, chronic conditions management and health target achievement will continue through the auspices and contracts of the Eastern Bay Primary Health Alliance. Work continues on an After Hours review through an After Hours Service Alliance Leadership Team with a focus on Whakatane Hospital’s emergency department and a community sustainable After Hours structure. Draft Project Initiation document and Terms of Reference have been completed for review. Terms of Reference have also been developed for the Workforce and Maori Disparities SALTs. Work has commenced on the business case evaluation through the Health Research Council funded Request for Proposal with two interested parties engaged to assist with the evaluation process.

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Te Whiringa Ora Complex Case Management project continues to deliver and meetings have occurred with senior DHB Management around increasing the utilisation of Te Whiringa Ora as part of discharge planning activities. Whanau Ora Opotiki continues to deliver services and the Whanau Ora SALT has requested funding to relook at the delivery structure with regard to rolling the project out more extensively across the wider Eastern Bay of Plenty. Home & community support: The Midland Region project to redesign home based support services has been progressed this month with a regional meeting of portfolio managers taking place. Support is being provided by the University of Auckland on developing a model in alignment with the Auckland case mix model and the restorative home support service specifications developed by the Ministry of Health. Contracts for Long Term Supports for People with Chronic Health conditions are also in the process of being renewed for 2012/13. Contracts and funding for this service were devolved from the Ministry of Health in 2011. New service specifications have been developed and new contracts will be put in place from 1 July 2012 with the new specifications and DHB purchase unit codes. Arrangements to expand the number of potential providers and therefore patient choice has been approved by FMC. The decision should also expand opportunities to negotiate new agreements. Annual Plan The Annual Plan has been signed by the Minister and the Statement of Intent tabled in Parliament. Copies of the AP will be provided to the Board at the Board meeting. An AP Light has been drafted and will be circulated to the Board once finalised. CARE – Compassion – Attitude – Responsiveness – Excellence Good progress is being made on implementing CARE across the organisation. The Executive Team is undertaking a review of activity to share progress, lessons learnt, and opportunities for further imbedding CARE. MAORI HEALTH PLANNING AND FUNDING Breastfeeding: Due to the discontinuation of HEHA funding post 30 June, the focus has been on managing the exit of HEHA service providers which includes breastfeeding support programmes. The Portfolio Manager is continuing to explore whether any funding is available to support Breastfeeding Awareness Week and the Big Latch on events across our region during the first week of August 2012. Integrated Contracts Work with our clinical team and providers have continued towards reviewing and developing outcomes that ensure aspirations of whanau and DHB accountability. Discussions have continued towards exploring and executing opportunities around compliance and reporting with a meeting scheduled for July with other funders of Integrated Contracts. Deed of Settlement Maori Health GM Planning and Funding, Senior Portfolio Manager Maori Health Planning and Funding and Acting CEO attended the Nga Hapu o Ngati Ranginui Deed of settlement. The Nga Hapu o Ngati Ranginui Deed of settlement is the final settlement of all historical Treaty of Waitangi claims of Nga Hapu o Ngati Ranginui resulting from acts or omissions by

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the Crown prior to 21 September 1992. This was a significant occasion being the first Iwi of Tauranga Moana to settle as well as the first pan hapu settlement. FINANCIAL RESULTS AND FORECAST: The result for the month ended 31 May 2012 is a small positive variance to the AP budget of $13,000. The year to date surplus was $0.392m compared to an AP budget $0.203m, a positive variance of $0.189m. The forecast full year result to the end of June is to achieve the AP budget.

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All amounts are $000s unless otherwise stated

ActualAnnual Plan

Budget VarianceDAP

BUDGET Y/E Estimate VarianceOperating Result - Surplus / (Deficit) 392 203 189 2 2 0

2 2 0* Note the net result is adjusting for the expected Mental Health Ringfence at year end along with the below variance.

Mental Health Ringfence 0 0

Status: UNAUDITED

All amounts are $000s unless otherwise stated

KEY MEASURES ActualAnnual Plan

Budget Variance

STAFFFTE Numbers 2,391 2,348 (43)

CASH & BANK ($000) Net Operating Cash flow 17,322 23,207 (5,885) Balance 4,386 4,267 120 Days Cash 2.35 2.32 0.03

TERM ASSETS ($000) 228,981 241,433 (12,452)

WORKING CAPITAL ($000) (36,347) (44,922) 8,574

TERM LOANS ($000) 107,200 106,625 (575)

CROWN EQUITY ($000) 84,588 89,035 (4,447)

KEY FINANCIAL RESULTS SUMMARY

Year to Date YEAR END ESTIMATES

BAY OF PLENTY DISTRICT HEALTH BOARDPRELIMINARY RESULTS FOR THE PERIOD ENDED 31 MAY 2012

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12

YTD Actual 549 56 256 424 220 880 1,277 976 675 1,520 839 449 392

YTD Budget (12) (491) 247 394 920 1,274 1,228 918 577 1,418 709 273 203

Mth Actual (218) (493) 256 168 (204) 659 397 (301) (301) 845 (681) (390) (57)

Mth Budget (190) (479) 247 146 527 354 (46) (310) (341) 841 (709) (436) (71)

(900)

(700)

(500)

(300)

(100)

100

300

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700

900

1,100

1,300

1,500

MONTHLY AND CUMULATIVE RESULT

Cash, 4,386

Budget, 4,267

(1,300)(550)

200950

1,7002,4503,2003,9504,7005,4506,2006,9507,7008,4509,2009,950

10,70011,45012,20012,950

05/1

1

06/1

1

07/1

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08/1

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11/1

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12/1

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01/1

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Axi

s T

itle

Cash

© Bay of Plenty District Health Board 2012 1 of 1 12/06/2012

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ADMINISTRATION AND MANAGEMENT FTE CAP:

Definitions: Accrued FTE: per MoH definition

Paid FTE: actual hours paid for (includes casuals and overtime) we have an obligation to honour

Month A/M FTE Accrued

A/M FTE Paid

A/M FTE Contracted

A/M as % of Total Accrued

A/M as % of Total Paid

A/M as % of Total Contracted

Dec-08 489.54 471.29 437.16 20.92% 21.37% 20.40% Mar-09 476.63 473.56 453.43 21.15% 20.53% 20.76% Jun-09 484.70 467.40 448.68 20.15% 20.40% 20.87% Sep-09 486.07 472.65 446.75 20.10% 19.92% 20.30% Dec-09 491.84 478.56 449.53 19.99% 19.89% 20.01% Mar-10 478.50 462.14 440.81 19.66% 19.26% 19.51% Jun-10 454.57 445.25 427.04 18.64% 19.16% 19.37% Sep-10 450.26 436.71 410.55 19.38% 18.75% 18.89% Dec-10 462.58 443.51 414.07 19.66% 17.51% 18.82% Mar-11 448.34 439.07 410.60 19.01% 18.68% 18.79% Jun-11 454.24 441.10 413.02 18.75% 18.69% 18.71% Sep-11 450.99 446.70 414.41 18.76% 18.67% 18.46% Dec-11 459.48 447.13 417.99 19.12% 18.65% 18.36% Mar-12 453.77 451.26 415.84 19.08% 18.78% 18.59% Apr-12 442.34 442.92 410.09 18.18% 18.55% 18.46% May-12 456.15 446.72 414.85 18.74% 18.89% 18.55% Jun-12 457.49 443.85 413.70 18.86% 18.70% 18.45%

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BOPDHB Health of Older People Strategic Plan 2012-2017 SUBMITTED TO: Board Meeting: 18 July 2012 Prepared by: Sarah Davey, Portfolio Manager, Health of Older People, Planning and Funding Kiri Peita, Senior Portfolio Manager, Maori Health Planning and Funding Endorsed by: Helen Mason, General Manager, Planning and Funding Janet McLean, General Manager, Maori Health Planning and Funding Submitted by: Helen Mason, Acting Chief Executive RECOMMENDED RESOLUTION: That the Board:

1. Endorses the BOPDHB Health of Older People Strategic Plan 2012-2017 (“the Strategy”), a copy of which is attached.

2. Notes that the Strategy has been endorsed by CPHAC/DSAC and the Clinical Board. 3. Notes the proposal for the Implementation plan and next steps outlined in Section 10 of the

Strategy. 4. Notes that the full version of the Strategy is proposed to be prepared for publishing by the

Communications team. The published version will include photographs and may incorporate some minor formatting and style changes.

5. Notes that a ‘”light” version of the Strategy is proposed to be developed by Planning and Funding in conjunction with the Communications Team. A draft of the proposed light version is attached for the Board’s information.

ATTACHMENTS:

1. BOPDHB Health of Older People Strategy 2012-2017 – Full Strategy. 2. Draft ‘light’ version of the Strategy.

BACKGROUND: At its meeting on 27 July 2011, CPHAC/DSAC approved the development of a 5 year Strategic Plan for Health of Older People for the Bay of Plenty District Health Board (“the Strategy”) and endorsed the proposed approach to development of the Strategy. An outline of the proposed approach to development of the Strategy and key drivers was also presented to the Clinical Board at its meeting in January 2012. The Strategy has been developed by a Steering Group with input from a wide range of people and stakeholder groups. The process undertaken is outlined in Section 11 of the Strategy.

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Each standard in the Strategy links to the eight objectives and actions in the Government’s national Health of Older People Strategy, the Minister’s priorities and the BOPDHB Board’s values, and sets out relevant background information, the evidence-base where this exists, examples of good practice in the Bay of Plenty and elsewhere, and the case for change. A set of recommendations follows. This Strategy does not include an implementation plan and it is recommended that one is developed as part of our next steps to achieve the Strategy’s objectives. Refer to Section 10 of the Strategy – Implementation plan and next steps. Full budget analysis will be developed as part of the implementation work. Following the Board’s endorsement it is envisaged that the Implementation Committee will prioritise the recommendations however, it is to be noted that the 2012/13 BOPDHB Annual Plan reflects priority actions for older people for 2012/13 that are included in the Strategy. These include:

1. Developing and implementing organised stroke services 2. Redesigning home based support services to a restorative model 3. Developing a clinical pathway for dementia services 4. Scoping an intermediate care service (links with, and is an enabler for, action 1 above). 5. Promote training for health professionals in Advance Care Planning.

These priorities also align with our goals and the Minister’s expectations towards integrated services for older people and are reflected in our Regional Service Plan. It is envisaged that, while this document will form a basis for the strategic direction for health of older people services, it will be reviewed annually to ensure its assumptions and recommendations remain valid and up to date. It is intended that a “light” or condensed version of the Strategy is developed by Planning and Funding in conjunction with the Communications Team. A draft of the proposed light version is attached. The light version will be made available to the public via the BOPDHB website, with hard copies available where requested. The Strategy has been endorsed by CPHAC/DSAC and the Clinical Board and is now submitted to the full Board for its endorsement.

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Health of Older People Strategy 2012‐2017

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Contents _____________________________________________________________________

1. Foreword ........................................................................................................ 4

2. Executive Overview ......................................................................................... 6

3. Goals and Objectives ....................................................................................... 9

4. Summary of Standards and Recommendations ............................................... 9

A. Community health, prevention and information ............................................... 10 B. Person‐centred care ............................................................................................ 10 C. Integrated care and community services ........................................................... 11 D. Hospital care ....................................................................................................... 12 E. Aged residential care .......................................................................................... 12 F. Dementia and Mental Health in Older People ................................................... 13 G. Stroke and TIA ..................................................................................................... 14 H. Falls and Bone Health ......................................................................................... 14 I. Medications Management .................................................................................. 14

5. Drivers for Change ......................................................................................... 16

Our ageing population .................................................................................................. 16 Definition of “older people” .......................................................................................... 17 Older people and healthcare costs ............................................................................... 18 Opportunities ................................................................................................................ 19

6. Underpinning Principles ................................................................................ 22

7. Services Covered by This Strategy ................................................................. 23

8. Standards and Recommendations ................................................................. 24

A. Community health, prevention and information ............................................... 24 Recommendations .............................................................................................. 28

B. Person‐centred care ............................................................................................ 29 Culturally appropriate care ................................................................................. 29 Tackling elder abuse ........................................................................................... 30 Advance care planning ........................................................................................ 30 Recommendations .............................................................................................. 31

C. Integrated Care and Community Services .......................................................... 32 Integrated Care ................................................................................................... 32 More flexible care in the community .................................................................. 33 Needs assessment and service co‐ordination ..................................................... 35 Recommendations .............................................................................................. 37

D. Hospital Care ....................................................................................................... 39 Intermediate Care ............................................................................................... 42 Allied Health ........................................................................................................ 43 Recommendations .............................................................................................. 44

E. Aged Residential Care ......................................................................................... 45 Recommendations .............................................................................................. 47

F. Dementia and Mental Health in Older People ................................................... 49 Promoting good mental health ........................................................................... 49 Early identification and treatment ...................................................................... 50 Secure residential facilities .................................................................................. 51

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Recommendations .............................................................................................. 51 11. G. Stroke and Transient Ischaemic Attack (TIA) .................................................. 53

Preventing stroke ................................................................................................ 54 Organised stroke services ................................................................................... 54 Recommendations .............................................................................................. 55

H. Falls and Bone Health ......................................................................................... 56 Preventing falls ................................................................................................... 57 Treating osteoporosis ......................................................................................... 58 Recommendations: ............................................................................................. 59

I. Medications Management .................................................................................. 60 Medicines reconciliation ..................................................................................... 61 Regular review of older people’s medicines ........................................................ 61 Recommendations .............................................................................................. 62

9. Delivery ......................................................................................................... 63

Workforce ..................................................................................................................... 63 Recommendations ........................................................................................................ 65

10. Implementation Plan and Next Steps ............................................................ 66

11. Supporting Information ................................................................................. 67

Development of the Strategy ........................................................................................ 67 Background Documents ................................................................................................ 68

12. Appendices ................................................................................................... 69

Appendix 1: Terms and Abbreviations .......................................................................... 70 Appendix 2: Intermediate Care Service ‐ Proposed Model ......................................... 71 Appendix 3: Measures of Success ................................................................................ 72 Appendix 4: Acknowledgements ................................................................................... 75

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1. Foreword _____________________________________________________________________ The New Zealand Health of Older People Strategy was published in 2002 and set out the Government’s policy for the future direction of health and support services for older people. It identified the need for significant change in the way services are provided and a framework for implementing those changes. Eight objectives were identified:

1. Older people, their families and whanau are able to make well‐informed choices about options for healthy living, health care and/or disability support needs.

2. Policy and service planning will support quality health and disability support programmes integrated around the needs of older people.

3. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

4. The health and disability support needs of older Maori and their whanau will be met by appropriate, integrated health care and disability support services.

5. Population‐based health initiatives and programmes will promote health and wellbeing in older age.

6. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

7. Admission to general hospital services will be integrated with any community‐based care and support that an older person requires.

8. Older people with high and complex health and disability support needs will have access to flexible, timely and co‐ordinated services and living options that take account of family and whanau carers for people who are disabled.

Within these objectives, the Ministry of Health identified a number of key actions including:

Promoting positive attitudes towards older people;

Better information for older people and their carers;

A focus on health promotion and prevention, including physical activity, better nutrition, reduced social isolation, and falls prevention;

Early detection and better management of illness and chronic disease, including older people living in rural areas;

Processes to tackle elder abuse;

Provision of community‐based rehabilitation, including a review of the need for Intermediate Care;

A review of specialist services for older people, including mental health services;

Strengthening the health workforce to meet the needs of an ageing population;

Integrated care between secondary services and community‐based ones, including a single, comprehensive integrated assessment process;

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Supporting older people to live in their own homes for as long as possible;

Better advance care planning, including palliative care when appropriate, for those in long term care;

The provision of a full range of culturally appropriate health and disability support services for older Maori.

The Ministry of Health and District Health Boards are responsible for implementing this strategy. There is a growing recognition that population ageing is a significant factor in the Bay of Plenty. The district has one of the highest proportions of older people in New Zealand (Ministry of Health, 2007) and is projected to grow further. While the Bay of Plenty District Health Board (BOPDHB) has been a leader in developing innovative models of care and investing in services that support people to continue living in their own homes, the current fiscal climate has necessitated a re‐think about how we can meet the demographic challenges of the future. The purpose of this document is to review current services for older people in line with the New Zealand strategy, current Government policy, international and New Zealand best practice, and identify and prioritise actions for local services to meet the challenges ahead. Given our ageing population, making savings or significant reductions in services for older people is unrealistic. However, implementation of this strategy will result in better management of the current and predicted rate of growth to levels that will be more sustainable in the future.

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2. Executive Overview _____________________________________________________________________ The Bay of Plenty’s population is ageing, with the number of people aged over 80 predicted to grow at a rate of approximately 6% per annum. 1 For New Zealand as a whole, health expenditure consumed by older people is projected to increase from 40% in 2002 to 63% in 2051. 2 Most older people are well, independent and living in their own homes. However, disease and chronic conditions are more common in old age. The BOPDHB’s Board has identified that we need to live within our means, avoid duplication and consider services “instead of” rather than “as well as”. However, the current annual planning cycle is not fit for purpose to address the impact and opportunities arising from an ageing population. Therefore, the purpose of this strategy is to provide an over‐arching five year plan to do this. Health of older people is a priority area for the Government and has been identified in the Minister’s Letters of Expectations for the last two years. The BOPDHB’s Board has also identified health of older people as a priority, and aims to be proactive in the management of services for the future given the predicted population increase and the associated high cost of care for this group.

Better care; better value A great deal of evidence exists that better quality health and disability care for older people can result in improved health outcomes and reduced projected costs in the future. Healthcare in older people is more complex than in the young. What are, in fact, medical problems are often labelled as inevitable consequences of “old age” that cannot be treated. This attitude leads to unnecessary disability and costs, and the opportunity for diagnosis, treatment and rehabilitation is lost.

It is preferable to keep older people independent and living in their own homes for as long as possible. This costs less and is preferred by the vast majority of service users. However, this requires a change in focus and a different way of doing things. Increasing demand over time will not be able to be met merely by

1 Stats NZ DHB Forecast Sep 2011. 2 Ministry of Health. Population Ageing and Health Expenditure: New Zealand 2002‐2051.

ThenumberofpeopleintheBayofPlentyover80yearsispredictedtogrowatarateofapproximately6%perannum. Healthexpenditureconsumedbyolderpeopleisprojectedtoincreasefrom40%in2002,to63%in2051.

Systems need to change in order to respond to increased demand alongside a relative constriction of supply.

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ramping up the existing systems of care. Systems need to change in order to respond to increased demand alongside a relative constriction of supply. This Strategy identifies nine standards that encompass the Government’s Health of Older People Strategy (2002) as well as health problems that are particularly significant for older people, namely:

Stroke;

Falls and bone health;

Dementia and mental health in older people; and

Medications management. In each of these areas, timely intervention by evidence‐based services reduces long‐term needs and healthcare costs, but these services are not uniformly available and access to them can be haphazard.

Minister of Health’s Letters of Expectations The Minister of Health each year outlines his expectations for District Health Boards in his Letter of Expectations, which enables us to plan and prioritise activity for the coming year. In the 2012/13 year, the Minister’s expectations reinforce the Government’s commitment to a public health system that delivers “better, sooner, more convenient” care and improves health outcomes for patients within constrained funding increases. All DHBs are expected to work co‐operatively with the Ministry of Health on implementing the Government’s commitments. Particular expectations for older people include better engagement with primary / community care to develop integrated services for older people that support their continued safe, independent living at home, especially after hospital discharge, and an emphasis on developing organised stroke services and better dementia care.3

CARE – Compassion, Attitude, Responsiveness and Excellence The Board reviewed the BOPDHB’s values and chose CARE as our values acronym – “Compassion, Attitude, Responsiveness and Excellence”. CARE reflects values of importance to the DHB. The Runanga has affirmed He Pou Oranga Tangata Whenua4

(HPO) and believes there is good alignment between the HPO principles and CARE.

3 By letters dated 26 January and 3 February 2012. 4 HPO represents the culmination of over two years of consultation, workshops, hui and development work between Te Runanga Hauora o Te Moana a Toi (the Māori Health Runanga), the BOPDHB, whanau, hapu, Iwi, the health sector and the wider community of the Bay of Plenty (Te Moana a Toi). HPO provides a conceptual framework for Toiora: optimum health and well‐being, that is acceptable to the collective of Iwi within Te Moana a Toi.

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This Strategy Each standard in this Strategy links to the eight objectives and actions in the Government’s national Health of Older People Strategy, the Minister’s priorities, and the Board’s values, and sets out relevant background information, the evidence‐base where this exists, examples of good practice in the Bay of Plenty and elsewhere, and the case for change. A set of recommendations follows. This Strategy does not include an implementation plan and it is recommended that one is developed as part of our next steps to achieve the Strategy’s objectives (see Chapter 10 – Implementation plan and next steps). It is envisaged that, while this document will form a basis for the strategic direction for health of older people services, it will be reviewed annually to ensure its assumptions and recommendations remain valid and up to date.

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3. Goals and Objectives _____________________________________________________________________

Goal The goal of this Strategy is to provide direction to the Bay of Plenty health and disability sector for the next five years by, in collaboration with our stakeholders, identifying areas where the DHB intends to focus its time, energy and resources. The content of this Strategy will also inform our Annual and Regional Plans.

Objectives The objectives of this Strategy are to provide quality health and disability services for our growing older population that:

Promote, improve, and support healthy, independent and dignified ageing;

Have an integrated approach across the continuum of care;

Reduce the demand on related high cost service expenditure to levels that can be sustained within current financial constraints;

Reduce duplication in the health system;

Are simple, streamlined and efficient.

OurgoalistoprovidedirectiontotheBayofPlentyhealthanddisabilitysectorforthenextfiveyearsby,incollaborationwithourstakeholders,identifyingareaswheretheDHBintendstofocusitstime,energyandresources.

Insertphoto

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4. Summary of Standards and Recommendations _____________________________________________________________________ Listed below is a summary of the standards and recommendations. The full version and associated commentary is covered in Chapter 8.

A. Community health, prevention and information

1. Promote risk assessment for all people over the age of 75 years. 2. Promote proactive risk stratification for all those who have not received an

InterRAI assessment. 3. Introduce targeted interventions for those at highest risk to avoid or reduce

health deterioration and subsequent hospital admission and/or dependence on residential care.

4. Provide older people and their carers with clear and accessible information to make informed decisions about their health and enable them to plan appropriately for their future needs and the transitions that may be necessary as their health and support needs change.

5. Develop an information strategy to do this, consider the recommendations from the Elderlink Research 2008 and conduct an analysis of current available information and websites funded by the BOPDHB.

6. Promote development of programmes and policies across government agencies and local government that promote active ageing including the WHO Global Age‐Friendly Cities Guidelines. Provide advice and expertise on population ageing through representation on the Population Ageing Technical Advisory Group, the Population Health Advisory Group, Strategic Partners forum and Collaboration Bay of Plenty, and other mechanisms that may from time to time be required.

7. Actively contribute to the review of the SmartGrowth Strategy5 in the Western Bay of Plenty and make advice available to local government in the Eastern Bay of Plenty.

B. Person‐centred care

1. Review any existing “blanket” upper age‐limited BOPDHB policies that may be barriers to older people accessing appropriate services, particularly for Maori.

2. Develop a checklist by which all services used by older people can be evaluated in terms of older people friendly, person‐centred care.

3. Increase awareness by all BOPDHB staff of the policies and referral protocols to support the early detection and management of elder abuse.

8. Enhance access to health services for older Maori through a knowledge exchange between Maori and mainstream providers to support mainstream responsiveness. Increase capacity and capability to meet the health and

5 SmartGrowth is a programme aimed at implementing a plan for managing growth in the Western Bay of Plenty. The

programme is being led by Bay of Plenty Regional Council, Tauranga City Council, Western Bay of Plenty District Council, and Tangata Whenua who work with community groups and government agencies such as the NZ Transport Agency. The context for the Strategy is a sub‐region facing long term growth pressure while at the same time many sectors of the community are demanding greater consideration of quality of life issues and protection of the core values that make the sub‐region such a desirable place to live, work and play. A review of the SmartGrowth Strategy commenced in 2011.

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disability needs of older Maori and their whanau by promoting training targeted to the Aged Care and non‐regulated health and disability workforce.

9. Promote training for health professionals in Advance Care Planning in accordance with the Advance Care Planning Co‐operative Guidelines and training programme.

C. Integrated care and community services

1. Progress integrated models of care. Evaluate outcomes of activity focusing on integrated care and chronic disease management (including Eastern Bay Primary Health Alliance (EBPHA) Te Whiringa Ora Service and the Midland Health Network Service Level Alliance Team (SLAT) pilot on stratified assessment in primary care) to inform recommendations for further structural changes to primary care.

2. Develop specific Bay Navigator pathways that are relevant to older people e.g. falls prevention, osteoporosis, dementia, Transient Ischemic Attack (TIA), ie stroke.

3. Improve access to specialist advice by primary care. 4. Promote and support education for aged residential care and home and

community support providers by primary care. 5. Implement a redesign of home and community support services in conjunction

with the Midland Region DHBs as part of a regional project to a restorative model of care. Consider changes the current funding model from an uncapped demand driven model to a capped bulk funding model with adjustments for demographic growth in future years where appropriate.

6. Implement use of InterRAI for all needs assessments for long term support services which are carried out in secondary care across all specialties when planning a discharge.

7. Consider implications arising from amending the current criteria for access to service assessed and co‐ordinated by Support Net by removing the requirement for a disability lasting longer than six months.

8. Review needs assessment and service co‐ordination (NASC) functions carried out by district nursing for short term support services.

9. Fund and support roll out of InterRAI Long Term Care Tool in Aged Residential Care in accordance with the national business case and implementation plan.

10. Review funding and contracts for provision of NASC services in light of recommendations above.

11. Reduce the need for duplication and multiple assessments for people and recording errors of patient information by providing read‐only access to InterRAI to home and community support providers.

12. Develop a seamless user‐friendly referral and triage process for access to health services for older people, potentially utilising Bay Navigator as the mechanism.

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D. Hospital care

1. Specialist Services for Older People are developed in line with the Government’s Guidelines for Specialist Services for Older People (Ministry of Health, 2004).

2. Expand the specialist geriatric workforce to recommended levels (including geriatricians, registrars and junior medical officers, nursing and allied health professionals) to encompass the patient journey from acute admission to discharge and community based care. This will require increased capacity and capability for Specialist Health Services for Older People to work within acute medical, surgical and orthopaedic services.

3. A particular focus is recommended to address ways to increase allied health input across the range of services, both hospital and community based, as a key enabler for a number of recommendations in this Strategy.

4. Develop an acute geriatric ward in addition to the existing 39‐bed (Health In Ageing) HIA unit, which would incorporate Comprehensive Geriatric Assessment for frail older people admitted to hospital as an emergency and specialist care for older people with delirium (a condition with significant mortality and morbidity). This is also an enabler to develop an organised stoke service (refer to Section G).

5. Through the provision of expanded geriatric workforce, provide essential specialist services to Whakatane and expand existing community work, education, “in‐reach” services, advice and education to support primary and community care, service and pathway development and outpatient capacity.

6. Provide education and support to build the ability for all services that treat older people acutely in the hospital to deliver Comprehensive Geriatric Assessment in the future.

7. Make better use of existing resources by developing different, cost effective, evidence‐based models of care such as increased community rehabilitation or “Intermediate Care”

8. Make funding provisions to increase the numbers of beds for specialist Geriatric Medicine services in line with national recommendations for the proportion of beds to the population of the Bay of Plenty and the planned redevelopment of Tauranga Hospital by 2017.

9. Implement better communication between secondary and primary care on discharge from hospital, so that any Comprehensive Geriatric Assessment can inform the InterRAI assessment process and community care as well as the patient’s GP.

E. Aged residential care

1. Plan and budget appropriately for the forecast growth in demand in aged residential care.

2. Manage demand on scarce high cost resources by developing new flexible, integrated and restorative models of care with ARC e.g. short term care, Intermediate Care, integrated community facilities.

3. Improve access to education, specialist advice and support by residential care providers to improve their quality and capacity to access primary healthcare

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and thereby avoid or reduce unnecessary admissions to hospital and improve resident outcomes (refer to Section D)

4. Fund and support roll out of the InterRAI Long Term Care Tool (refer to Section C) in ARC in accordance with the national business case.

5. Consider and recommend what opportunities might be feasible by splitting the accommodation and care service provision eg the asset/income testing could be managed under Housing New Zealand while the care component could be a full or partial government funded service.

6. Streamline contracts and auditing processes to reduce compliance costs. 7. Consider ways in which Primary Care and Aged Residential Care can identify

those nearing the end of their lives and offer/implement Advanced Care Planning.

F. Dementia and Mental Health in Older People

1. Promote recognition and assessment of mental health status of the older people by all health care providers as central to supporting healthy ageing. This includes depression, underlying mental illnesses or dementia.

2. Provide greater accessibility and seamless clinical service delivery for people with dementia through establishment of a coordinated, integrated dementia service including an early detection and management service for people with dementia in all settings, including acute inpatient services, community and residential care facilities.

3. Improve access to specialist advice and support for community providers. 4. Improve support to primary carers of people with dementia through education

and training and a range of flexible respite, day and home based support options.

5. Introduce training requirements in service specifications for home based support services where staff work with people with dementia.

6. Develop a dementia pathway for people with behavioural support needs through Midland Region Dementia Advisory Service, specialist health services for the older person, MHSOP and Bay Navigator.

7. Develop a future bed forecast for Stage 3 dementia and psychogeriatric level residential care for the next five years and make appropriate budget provision for increased numbers of beds as per the forecast. Identify and actively seek suitable psychogeriatric level providers in the west of the western BOP and eastern BOP.

8. Better manage access to and utilisation of psychogeriatric level beds by requesting regular re‐assessments of people to identify changes in levels of need.

9. Advocate at a national level for a standardised needs assessment process for access to psychogeriatric and Stage 3 dementia level care.

10. Support best practice in residential care by developing a set of best practice guidelines to support approvals of applications for new Stage 3 dementia and psychogeriatric units and support existing providers to improve quality of care and environment.

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G. Stroke and TIA

1. Complete the development of a TIA pathway through Bay Navigator. 2. Establish an organised stroke service – see Section D on the development of

an acute geriatric ward. 3. Increase the number of specialist geriatric medicine workforce to provide

appropriate treatment of TIAs and Stroke – see Section D. 4. Continue with on‐going specific thrombolysis training for Emergency

Department (ED) and general medical registrars/consultants in accordance with international best practice.

5. Develop a BOPDHB stroke guideline that sets out how the national New Zealand Clinical Guidelines for Stroke will be implemented locally.

H. Falls and Bone Health

1. Assess the impact of Accident Compensation Corporation’s withdrawal of funding for falls prevention programmes for older people.

2. Promote a population‐based falls prevention strategy for older people, including the identification of those at risk of falls living in their own home or in care homes.

3. Develop an education strategy for patients, carers and health professionals around falls and osteoporosis.

4. Develop a specialist falls service for people with recurrent falls, “unexplained falls” or dizziness. Assess how this could work across the Bay of Plenty, working with GPs in more rural areas.

5. Implement a falls pathway through Bay Navigator that facilitates the evidence‐based assessment and treatment of older people who have fallen in both Primary Care and Secondary Care.

6. Implement an osteoporosis pathway through Bay Navigator that links with the falls pathway, facilitating the evidence‐based assessment and treatment of older people with risk factors for osteoporosis or a previous fragility fracture.

I. Medications Management

1. Adopt Health Quality and Safety Commission (HQSC) national medication safety programme for identification of high risk patient populations and provide Medicines Reconciliation for all patients identified as high risk of admission to hospital in the BOPDHB region.

2. Develop the role of Clinical Pharmacist to support safe medication management for high risk patients across inpatient, primary and community care, including Aged Residential Care (ARC). This will include medication reconciliation for complex patients on transfer of care or discharge.

3. Develop resources to support patients and families health literacy in relation to medication self management on discharge (including better information and the involvement of family and carers).

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4. Participate in the development of medication management processes which support the safe transfer of medication information between care environments, e.g. secondary, primary and community services. This will include national HQSC projects such as electronic prescribing, medication reconciliation and health information transfer.

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5. Drivers for Change _____________________________________________________________________

Our ageing population

New Zealand is an ageing society. The Western Bay of Plenty’s warm sunny climate and pleasant coastal geography have provided an attractive retirement destination for many decades. The district experiences one of the highest proportions of older people in New Zealand and the annual growth rate is the highest in the Midland region. Our population of people aged over 65 is projected to grow by 84% in the 20 years between 2006 and 2026, the majority in the western BOP.6 However, the populations of rural or smaller towns in the Bay of Plenty, particularly the eastern BOP, while declining are also ageing. By contrast, the eastern BOP has a high Maori birth rate and a relatively high proportion of people aged less than 20 years. In 2011, the number of people in the BOP aged over 65 was approximately 37,500. Of particular importance is the estimated number of people aged over 80 that is predicted to grow at a rate of approximately 7% per annum, from less than 3,000 in 2006 to 35,000 in 2050 (see Figures 1 and 2). Figure 1

Figure 2

6 Statistics New Zealand DHB Forecast: September 2011.

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Most older people are well, independent and living in their own homes. However, as a group they have a much greater need for health and disability services than the young, so a significant proportion of health and social care resources are directed at their needs. Disease and chronic conditions are more common in old age. The World Health Organisation (WHO) describes care for chronic conditions as being “the health care challenge of this century” with such conditions currently responsible for 60% of the global burden of disease.7 It recommends a new approach that integrates health and welfare services, connects families and communities, and the development of programmes that delay the onset of disability, ameliorate its trajectory and enhance older people’s capacity to take better care of themselves. Other factors driving the need for change include:

People with complex health needs are living longer;

The growing number of people living with dementia;

Increased utilisation of Maori as a result of more appropriate and culturally responsive services;

Changing family structures, with more people living alone with little or no family support, or carers who are themselves elderly.

Society has changed ‐ retirement is no longer seen as a preparation for decline. Older people are active participants in society and attitudes towards ageing are changing. However, for frail older people in particular, there are reports of poor, and in the worst cases, discriminatory, services. This is usually inadvertent, a result of failure to keep pace with advances in the capacity of professionals to make a difference. What are in fact medical problems are often labelled as inevitable consequences of “old age” that cannot be treated. Such attitudes are exemplified in specific areas such as the lack of access to specialist geriatric care, rehabilitation and stroke services.

Definition of “older people”

Older people are not a uniform group and they have a wide range of needs. They may be broadly seen as three groups:

Entering old age – people who have completed their career in paid employment and/or child rearing. This is a socially‐constructed definition of old age, but generally means retirement age (over 65). These people are usually active and independent and many remain so. The goals of health and disability services are to promote and extend healthy, active life, and to “compress morbidity” (the period that may be spent in frailty and dependency before death).

Transitional phase – people who are in transition between healthy, active life and frailty. This transition often occurs around age 75‐85 but can occur at any

7 Innovative Care for Chronic Conditions: Building Blocks for Action. Geneva World Health Organisation; 2002.

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stage. The goals of health and disability services are to identify emerging problems ahead of crisis, and ensure effective responses that will prevent crises and reduce long‐term dependency.

Frail older people – people who are vulnerable as a result of several interacting health problems and disability. Frailty is often, but not necessarily, experienced in late old age (over 85), so services for older people should be designed with their needs in mind. The goals of health and disability services are to anticipate and respond to problems, recognising the complex interaction of physical, mental and social care factors, which can compromise independence and quality of life.

Older people and healthcare costs

In New Zealand, expenditure on personal health and disability support for the over 85s is the highest for any age group with a yearly per capita expenditure of $13,640 for women and $12,144 for men (2006 figures). Our ageing population has obvious and serious implications for health services in the future. In 2011, there were approximately 5,900 people a year receiving long term support services funded by BOPDHB. Of these, approximately 1,500 people were in full time residential care at any one time. Of these, 770 are at rest home level, and 740 at hospital level. Rest home level care total expenditure (volume and cost) has grown by only 2.6% over the last five years reflecting our increased investment in home and community support services (see Figures 3 and 4).

Figure 3

Figure 4

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However, hospital level care has grown by 65% (cost and volume) over the same period (see Figure 5), reflecting the fact that people are either entering residential care at higher levels or have changing needs. The total cost of residential care in the Bay of Plenty was $44 million in the year ending June 2011 which represented.

Figure 5

The report Population Ageing and Health Expenditure: New Zealand 2002‐2051, published by Public Health Intelligence, Ministry of Health, predicts that the share of total Government health expenditure consumed by older people is projected to increase from 40% in 2002 to 63% in 2051. Population ageing will drive increased health expenditure because per capita health expenditure is strongly related to age. In the BOPDHB, older people account for the largest increase in hospital admissions. In 2010 in Tauranga hospital, 63% of all acute and elective medical admissions were in people aged over 65. Of these the majority of patients were aged 75‐84. In 2011, a team of specialists in Geriatric Medicine performed a snapshot audit of in‐patients aged over 65 in Tauranga Hospital. It found that just over 10% of hospital beds were occupied unnecessarily due to a lack of (cheaper) community rehabilitation services.

Opportunities

Due to medical advances we have gained an extra 20 years of life expectancy. There is a need to know more about advanced age as the oldest age group is the fastest growing and disability and dependence restricts quality of life and results in excess health and welfare spending. Life and Living in Advanced Age a Cohort Study in New Zealand (LILACS NZ), is a longitudinal cohort study enrolling those in the top survival group: aged 85+ for non‐Maori and 80‐90 years for Maori looking at the health and well‐being of 1200 elderly people in the Bay of Plenty region. Early findings from the study are due out this year and can inform our Strategy further. Older people are a resource for their families, communities and economies in supportive and enabling living environments. The World Health Organisation regards active ageing as a lifelong process shaped by several factors that alone and acting together favour health, participation and security in older adult life. Active, civil and social engagement factors have been shown to be key influences on an older person’s health.

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Local Government in the region are recognising the importance and impact that the wider determinants of health have on older people’s ability to age positively and remain living independently in their own homes for as long as possible. A review of the SmartGrowth Strategy – 50 year growth strategy for the Western Bay of Plenty, has identified population ageing as a key factor shaping our region and the necessity for a collaborative multi‐agency approach to planning. Local Government policies and plans are beginning to reflect an awareness of their ability to influence positive ageing. Advancements in technology, telecare and telemedicine are being used to complement models of care. In the eastern BOP, the Better Sooner More Convenient (BSMC) primary care business case is using telemedicine to assist with the management of older people with chronic health conditions in remote or rural areas. Learnings from the initial pilot can be used to inform our strategy further. Maori have the highest relative growth rate of all populations for people age over 65. Strategic direction for services for older people and other mainstream/national directions are in line with many traditional Maori values. Kaupapa Maori providers have often developed services in relative isolation from the mainstream, using innovation and knowledge of their people. There are opportunities for Maori providers to share their knowledge for the development and responsiveness of mainstream services. There are numerous positive developments nationally, regionally and locally that impact on services for older people. The Ministry of Health is currently developing a new service specification for home and community support services that has a restorative focus, includes enhanced training requirements for support workers, includes compliance against Home and Community Sector Standards, and allows for a flexible purchasing model. The service specification is scheduled to be complete and ready for use by October 2012. A number of integration initiatives across and secondary and primary care services are taking place resulting from the Government’s Better Sooner More Convenient Primary Care policy, including the eastern BOP which has a focus on the management of people with complex chronic conditions. Promotion and support of the Whanau Ora approach to service delivery and integrated contracts provide opportunities for holistic, client and whanau centred service delivery. There is further work being developed nationally arising from the Grant Thornton Aged Residential Care Services Review 2010. We can learn from various developments and pilots to inform our work further.

Local Government in the region are recognising the importance and impact that the wider determinants of health have on older people’s ability to age positively and remain living independently in their own homes for as long as possible.

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The BOPDHB has been a leader of many developments in services for older people, providing us with an excellent foundation on which to further develop the recommendations in this Strategy. Examples include the use of the InterRAI Tools for all assessments of older people for long term support services; the implementation of the Community Response Team focusing on admission avoidance; establishment of a model for flexible restorative home based support services; and Kaupapa Maori early intervention and support services including dedicated respite care.

[insert photo]

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6. Underpinning Principles _____________________________________________________________________ This strategy has been developed with the following principles in mind: 1. Treaty of Waitangi – recognition of the

Treaty of Waitangi as the founding document of New Zealand and acknowledgement of Treaty principles, that Maori will have an equal role in developing and implementing health strategies for Maori.

2. Promoting health in older age – focus on a wellness model that takes into account all the factors affecting an older person’s health, including strengthening local authority and community liaison through promotion of “Age Friendly Communities”, “Positive Ageing” and “Whanau Ora” strategies.

3. Person‐centred – older people are respected, treated with dignity, and all adult service development and reconfiguration is executed with the needs of older people in mind.

4. “Ageing in place” – the place that is the most appropriate for an older person to live is usually their own home. If required, access to high quality aged residential care is available and health service access for those residents is equitable.

5. Integration – services will be co‐ordinated and work together so that older people receive the right service from the right provider, first time.

6. Preventative and restorative – a strong focus on preventing illness and injury occurring or getting worse through health promotion, early treatment and access to rehabilitation.

7. Best use of resources and living within our means – we are operating within a tighter financial framework and our rate of funding growth has significantly reduced. We consider the most efficient and innovative use of resources within a constrained fiscal environment, avoid duplication and consider services “instead of” rather than “as well as”.

8. Collaboration and partnership – the knowledge and experience of older people, their families and whanau, and people working in services will be valued and utilised in all planning and implementation.

9. Evidence‐based – initiatives and service redesign will be evidence‐based and take in to account examples of innovation and good practice elsewhere.

10. Leadership – the opportunities and implications of population ageing require the highest levels of leadership in all service providers.

The Bay of Plenty District Health Board’s vision for older people is: ‘healthy, independent and dignified ageing’.

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7. Services Covered by This Strategy _____________________________________________________________________

Existing health of older people services for the BOPDHB generally refers to specialist health services for older people and long term disability support services for those aged over 65 (or those over 50 with age‐related needs). These are: However, this Strategy is not restricted to current and existing service provision and it is recognised that the preferred model is one that supports health and well‐being with a focus on prevention.

Specialist health services

Primary care

DHB Allied Health

District nursing

Pharmacy

Mental Health Services for Older People

Palliative care

Department of Health in Ageing (based at Tauranga Hospital)

Long‐term disability support services

Needs Assessment and Service Co‐ordination

Home based support services – generally includes home help and personal care

Limited short term support services following an admission to hospital

Day services

Kaumatua and Kuia Early Intervention Services

Respite care and carer support

Information and advocacy services such as Alzheimers Tauranga, Stroke Foundation, and Age Concern.

Accredited visiting services

Aged residential care

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8. Standards and Recommendations _____________________________________________________________________

A. Community health, prevention and information

There is a growing body of evidence to suggest that modification of risk factors for disease even in old age can have health benefits for the individual with increased or maintained levels of functional ability as well as disease prevention. 8 Active ageing depends on a variety of influences or determinants that surround individuals, families and whanau. They include material conditions as well as social and health factors (see Figure 6). Figure 6 – Determinants of Active Ageing9

A framework for promoting active ageing has been developed by the World Health Organisation (WHO) known as the Global Age‐Friendly Cities Guidelines. Strong evidence exists that by developing policies and promoting activity that promotes active ageing, reductions in functional decline in older people can be achieved and

8British Geriatric Society: Compendium of Guidelines. BGS, London, 1997.

9 World Health Organisation Global Age‐Friendly Cities Guide

National StrategyPopulation‐based health initiatives and programmes will promote health and wellbeing in older age. Older people, their families and whanau are able to make well‐informed choices about options for healthy living, health care and/or disability support needs. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

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thereby reducing dependency on funded disability support services. Below is an extract from the guidelines:

“These determinants have to be understood from a life course perspective that recognises that older people are not a homogeneous group and that individual diversity increases with age. This is expressed...[see Figure 7 below] which illustrates that functional capacity (such as muscular strength and cardiovascular output) increases in childhood, peaks in early adulthood and eventually declines. The rate of decline is largely determined by factors related to lifestyle, as well as external social, environmental and economic factors. From an individual and societal perspective, it is important to remember that the speed of decline can be influenced and may be reversible at any age through individual and public policy measures, such as promoting an age‐friendly living environment. Because active ageing is a lifelong process an age‐friendly city is not just ‘elderly friendly’. Barrier‐free buildings and streets enhance the mobility and independence of people with disabilities, young as well as old. Secure neighbourhoods allow children, younger women and older people to venture outside in confidence to participate in physically active leisure and in social activities. Families experience less stress when their older members have the community support and health services they need. The whole community benefits from the participation of older people in volunteer or paid work. Finally, the local economy profits from the patronage of older adult consumers. The operative word in age‐friendly social and physical urban settings is enablement.”

Figure 7 – Kalache & Kickbusch

“…an age‐friendly city is not just ‘elderly friendly’. Barrier‐free buildings and streets enhance the mobility and independence of people with disabilities, young as well as old.”

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Activities that promote healthy active life for older people include:

Wider multi‐sector initiatives to promote “positive ageing”: health, well‐being and independence in old age;

Optimising the opportunities for health, participation and security in order to enhance quality of life ;

Recognising the wide range of capabilities and resources among older people, and respecting their decisions and lifestyle choices;

Protecting those who are most vulnerable;

Promoting inclusion of older people and their contribution to all areas of community life ;

Access to mainstream health promotion and disease prevention programmes;

Health promotion activities of specific benefit to older people, tailored where necessary to reflect cultural diversity.

The WHO Global Age‐Friendly Cities recommends a programme of development that encompasses eight characteristics of age‐friendly communities: transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, community support and health services, outdoor spaces and buildings. The BOPDHB and SmartGrowth have collaborated to establish the Population Ageing Technical Advisory Group (PATAG) which advises its two partners on the opportunities and issues related to population ageing. The BOPDHB, through PATAG, promotes the WHO Global Age‐Friendly Cities programme and development of policies, structures, environment, services and policies that reflect the determinants of active ageing. Older people benefit also from increasing physical activity, improved diet and nutrition, and immunisation programmes for influenza. They also benefit from specific strategies to prevent falls and their consequences and to prevent stroke.10 Many older people and their carers are poorly informed about their health problems, often assuming they are inevitable consequences of old age, an attitude sometimes reinforced by health professionals and carers. They may be unaware of what services are available to help them remain healthy and independent in their own homes. Adult children and whanau members are not necessarily well prepared to become carers of their parents later in life. For example, knowing what is important for older people to maintain function and independence, and being able to recognise a treatable medical condition. By learning to care for an older person, people also learn about how to care for themselves as they move into older age. Because unpaid carers, family and whanau make up the vast majority of carers for older people, investment in education for this group would have far reaching

10 National Institute for Health and Clinical Excellence (NICE). The assessment and prevention of falls in older people. Clinical

Guideline 21, 2004 and Stroke Foundation/New Zealand Guidelines Group. New Zealand Clinical Guidelines for Stroke Management, 2010].

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benefits. Health promotion for older people is not specifically funded through Public Health Units so solutions would need to be found locally. International research shows that poor health literacy is linked to poor health status and may also be a strong contributor to health inequalities. Māori aged 50‐65 years have significantly lower skills to obtain, process and understand basic health information in order to make informed and appropriate health decisions compared to non‐Māori.11 Health literacy is broadly defined as someone’s ability to get and use basic health information needed to make good health decisions. It’s more than about the ability to read and write; it is about understanding a range of health messages, from mass media campaigns to what a doctor or nurse prescribes, and even correctly following instructions on medicine labels. It also includes health professionals giving clear and appropriate messages, and health services being user‐friendly. The introduction of proactive care for those at highest risk is arguably the most significant change and has the potential to result in the greatest impact. Identification of those at highest risk should occur to ensure that resources are intensified for those at greatest risk. This is known as proportional universalism. A two pronged approach is recommended.

Proactive: Risk stratification for those at highest risk (various tools exist some of which are self administered); and

Reactive: use of InterRAI (which requires trained health care professionals to administer).

It is acknowledged that risk assessment is not an intervention but an identification tool therefore intervention is required to manage risk. The provision of intermediate care referred to later in this Strategy to manage risk is an essential component to this model. In alignment with the Government’s policy of Better, Sooner, More Convenient healthcare, if the care required is not acute or highly specialised, then the care provision should be in primary care. There are a number of ways that enhanced intermediate care can be provided and various recommendations are made within the Strategy. However, the majority of intermediate care provision will need to come from realignment of existing resources and as appropriate a transfer of resources from secondary to primary where a greater impact at the same or reduced cost is anticipated. In essence this Strategy recognises the imperative to stratify and manage risk providing increasing intensity (such as intermediate care) for those at highest risk. This should ensure effective usage of scarce resource and aligns with the Strategy’s objectives.

11 Tatau Kura Tangata: Health of Older Maori Chart Book.

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Recommendations

1. Promote risk assessment for all people over the age of 75 years. 2. Promote proactive risk stratification for all those who have not received an

InterRAI assessment. 3. Introduce targeted interventions for those at highest risk to avoid or reduce

health deterioration and subsequent hospital admission and/or dependence on residential care.

4. Provide older people and their carers with clear and accessible information to make informed decisions about their health and enable them to plan appropriately for their future needs and the transitions that may be necessary as their health and support needs change.

5. Develop an information strategy to do this, consider the recommendations from the Elderlink Research 2008 and conduct an analysis of current available information and websites funded by the BOPDHB.

6. Promote development of programmes and policies across government agencies and local government that promote active ageing including the WHO Global Age‐Friendly Cities Guidelines, Provide advice and expertise on population ageing through representation on the Population Ageing Technical Advisory Group, the Population Health Advisory Group, Strategic Partners forum and Collaboration Bay of Plenty, and other mechanisms that may from time to time be required.

7. Actively contribute to the review of the SmartGrowth Strategy12 in the Western Bay of Plenty and make advice available to local government in the eastern Bay of Plenty

8. Promote physical activity, better nutrition (including increased calcium and vitamin D) and annual influenza vaccines for older people through public education and collaboration with Primary Care and Aged Residential Care.

9. Promote health literacy and education (both formal and informal) for older people and unpaid carers. Work with education providers and other agencies to develop targeted education and training programmes for families and unpaid carers.

12 SmartGrowth is a programme aimed at implementing a plan for managing growth in the Western Bay of Plenty. The

programme is being led by Bay of Plenty Regional Council, Tauranga City Council, Western Bay of Plenty District Council, and Tangata Whenua who work with community groups and government agencies such as the NZ Transport Agency. The context for the Strategy is a sub‐region facing long term growth pressure while at the same time many sectors of the community are demanding greater consideration of quality of life issues and protection of the core values that make the sub‐region such a desirable place to live, work and play. A review of the SmartGrowth Strategy commenced in 2011.

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B. Person‐centred care

Older people and their carers should receive person‐centred care and services which respect them as individuals and are arranged around their needs. Person‐centred care requires managers and professionals to:

Listen to older people;

Recognise individual differences and specific needs including cultural and religious differences;

Communicate in ways that meet the needs of all users and carers, including those with sensory impairment, physical or mental frailty, or those whose preferred language is not English;

Respect their dignity and privacy, meeting personal hygiene needs sensitively

In hospital, if patients choose to wear their own clothes, enable them to do so;

Support those with a long term illness or disability and their carers to develop expertise in their own care;

Enable older people to make informed choices, involving them in all decisions about their care;

Involve and support carers whenever possible;

Recognise the signs of possible elder abuse and take action if necessary. Denying access to services on the basis of age alone is not acceptable. Decisions about treatment and health care should be made on the basis of health needs and ability to benefit rather than a patient’s age alone.

Culturally appropriate care

We acknowledge that Maori develop age‐related conditions at an earlier age than average and that there are disparities and inequalities in access to support and health services by Maori. Kaumatua are very important in the leadership echelons of Maoridom and Iwi. As such, programmes that are culturally strong that can provide Maori models within service delivery are an essential part of the support system of kaumatua. Drawing strength from traditional practices strengthens the spiritual and cultural dimensions of kaumatua contributing to overall well being.

National StrategyPolicy and service planning will support quality health and disability support programmes integrated around the needs of older people. The health and disability support needs of older Maori and their whanau will be met by appropriate, integrated health care and disability support services.

Kaumatua are very important in the leadership echelons of Maoridom and Iwi.

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Maori comprise 14% of the total population and 2% of those over 80 years. However, they have the highest relative growth rate of all populations for people aged over 65. Of those Maori who reach age 75, many have multiple health problems but may not have readily available whanau to care for and support them due to migration of whanau members from rural to urban areas, often for employment. This leads to disparities in both longevity and disability levels for Maori. Demographic projections suggest that Maori people can expect to live longer than currently, potentially expanding the population of Maori living to advanced age and increasing the disparities in disability. Strategic direction for services for older people and other mainstream/national directions are in line with many traditional Maori values. Kaupapa Maori providers have often developed services in relative isolation from the mainstream, using the innovation and knowledge of their people. There are opportunities for Maori providers to share their knowledge for the development and increased responsiveness of mainstream services.

Tackling elder abuse

Abuse of an older person is defined as any pattern of behaviour that causes physical, psychological or financial harm. It can be intentional or unintentional. Abuse or neglect occurs in a relationship of trust and anyone with a long‐term disability is at increased risk. Institutional abuse occurs when an institution actively or passively allows, or accepts, any form of abuse or neglect to occur. This may arise from the action or inaction of an individual as an employee, or it may be embodied in organisational systems that fail to provide adequately for the safety and well being of individual patients or service users. The BOPDHB has a clinical policy in place: “Older Person – Abuse and Neglect Management and Reporting”, supported by an Elder Abuse Co‐ordinator. Any staff member who suspects abuse or neglect of an older person, or to whom abuse/neglect is disclosed, has a mandatory responsibility (now a legal requirement) for reporting of that abuse. The policy outlines ten principles of adult protection services to help guide decision making, and outlines what action should be taken either in an emergency, or in a non‐urgent situation.

Advance care planning

Advance care planning (ACP) is a voluntary process of discussion and review to help individuals (who have the capacity to do so) who have been diagnosed with a terminal illness anticipate how their condition may affect them in the future and, if they wish, set on record choices about their care and treatment and / or an advance decision to refuse a treatment in specific circumstances. These can be referred to by those responsible for their care or treatment (whether professional staff or family or

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carers) in the event that they lose their capacity to participate in decision making once their illness progresses. Primary care is encouraged to identify its patients nearing the end of life so that the wishes of the patient and their family are identified and systems put in place to allow appropriate care to happen when the time comes. In New Zealand the Advance Care Planning Co‐operative has developed a guideline for the New Zealand healthcare workforce in response to the increasing focus on the need for clear and accurate information and guidance regarding advance care planning. The intended audience encompasses providers, funders and planners in all areas of health care. Training tools which have been developed are intended for health professionals. Formal outcomes of advance care planning might include one or more of the following:

Advance statements to inform subsequent best interests decisions;

Advance directives which are legally binding if valid and applicable to the circumstances at the time;

Appointment of a Power of Attorney (“health and welfare” and/or “property and affairs”).

Not everyone will wish to make such records. But for those who have the capacity and desire to participate, advanced care planning can be an integral part of the wider care planning process. The BOPDHB has endorsed the principles and approach developed by the Advance Care Planning Co‐operative for use throughout the DHB where appropriate.

Recommendations

1. Review any existing “blanket” upper age‐limited policies in BOPDHB that may be barriers to older people accessing appropriate services, particularly for Maori.

2. Develop a checklist by which all services used by older people can be evaluated in terms of older people friendly, person‐centred care.

3. Increase awareness by all BOPDHB staff of the policies and referral protocols to support the early detection and management of elder abuse.

4. Enhance access to health services for older Maori through a knowledge exchange between Maori and mainstream providers to support mainstream responsiveness. Increase capacity and capability to meet the health and disability needs of older Maori and their whānau by promoting training targeted to the Aged Care and non‐regulated health and disability workforce.

5. Promote training for health professionals in Advance Care Planning in accordance with the Advance Care Planning Co‐operative Guidelines and training programme.

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C. Integrated Care and Community Services

Integrated Care

The majority of medical care for older people is carried out in general practice. It is recognised that primary, community focused, fully integrated health systems improve health outcomes, access to and delivery of care and an improved quality of life, for patients.13

While there is no single accepted definition of integrated care, most definitions include references to co‐ordination, “complementarity”, seamlessness and continuity for the client.14 Disease and chronic conditions are more common in old age. As part of the Government’s plan for Better, Sooner, More Convenient (BSMC) Primary Health Care, the BSMC Eastern BOP Business Case has, as one of its priorities, a focus on chronic disease management. A pilot being conducted by Te Whiringa Ora in the Eastern Bay of Plenty is developing a model of care that reflects connectivity and integration between primary and specialist services and case management for people with multiple chronic conditions who are rural or isolated and have had frequent admissions to hospital. Early results support the use of telemedicine for patient monitoring, encouraging self‐management and using a holistic model of case management and support.

13 Starfield, B, 2005, World Health Organisation, 2008.

14 Report to the Ministry of Health on Integrated Care Initiatives in selected New Zealand Health Networks – Baird, J & Smith, P:

Nov. 2011

National StrategyPolicy and service planning will support quality health and disability support programmes integrated around the needs of older people. Older people with high and complex health and disability support needs will have access to flexible, timely and co‐ordinated services and living options that take account of family and whanau carer needs. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

It is recognised that primary, community focused, fully integrated health systems improve health outcomes, access to and delivery of care and an improved quality of life, for patients.

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The Midland Health Network Older Person’s Service Level Alliance Team (SLAT) is piloting a number of initiatives across the continuum of care for older people. In the western BOP, Bay Navigator is being developed as an online access point for clinical staff across primary and secondary care, enabling them to follow evidence‐based clinical guidelines that deliver better outcomes for patients. For example, by following the new Bay Navigator TIA (transient ischaemic attack) Guideline, eight out of 10 strokes following a TIA can be prevented, with an approximate saving of $2.5 million per annum in the BOP alone. While the lessons and outcomes from these initiatives are still emerging, they are demonstrating a shift to a greater degree of primary care‐based proactive management. The reason why there is a significant opportunity for improvements in efficiency is that the patients being targeted by integrated care account for significant costs. If collaborative, targeted and intensive care of older people and those with long term conditions can be implemented (with the consequential reduction of avoidable hospital admissions, lower spend on medicines and rest‐home costs) then there will be significant benefits. Significant benefits can also be gained by improving the capacity and capability of general practice to be able to better identify, manage and support older people with long term conditions and avoid admissions to hospital. There is a range of ways that this can be achieved including:

Population screening for targeted groups, such as people over the age of 75 for early detection and intervention;

Carrying out needs assessments for long term supports for older people;

Promoting screening and self‐assessment;

Improving access to specialist advice via primary care. Primary care can also play a role in helping to support residential care and home and community providers through provision of training and education programmes, and developing better links with this sector. The Primary Nurse Liaison currently provides education available for staff of aged care providers to attend where appropriate. It is recommended that this is supported to continue.

More flexible care in the community

In the last five years, in line with Government policy, the BOPDHB has been investing in strategies that improve older people’s ability to remain independent and living in their own homes. As a result, there has been an increase in the percentage of the eligible population over 65 that access home and community support services and a decrease in the percentage of the population in more expensive rest home level care. However, there is much still to be done. While considerable advances have been made in implementing a restorative model of care in home and community support services by the BOPDHB, the traditional model of care for older people is a disability support model. Currently the majority

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of home based support services (HBSS) in the Bay of Plenty, both long and short term, are delivered using a traditional model of service delivery, generally a task orientated approach and delivered in hours of support, with the minimum allocation being one hour. This time is allocated in a structured way (weekly, fortnightly etc) and is not flexible to meet individual or changing needs. Funding is uncapped, the growth in demand exceeds demographic growth and is not sustainable within current funding availability. A new approach is required. Illness, or exacerbations of chronic disease, often has functional consequences in older people, but they do not necessarily need to be admitted to hospital if they can be assessed in their own home, treated, and temporary additional support put in place. The most common reasons for avoidable admission to hospital are:

Falls and minor injuries/fractures;

Mild exacerbations of a chronic disease;

Minor infections;

Gradual (and predictable) inability to cope at home – reaching a crisis point. Sometimes older people do need to be in hospital and they do have a right to a medical diagnosis. However, access to a General or Nurse Practitioner can be difficult, especially out of hours. The Ministry, in its Health of Older People Strategy, has committed to assessing options to reduce cost barriers for older people accessing primary health care. However, many older people are admitted to hospital unnecessarily because of the lack of alternatives. Currently HBSS contracts are not flexible enough to allow for intensive support periods when they are required without reassessment and sometimes lengthy delays. This often results in an unplanned admission to hospital via the Emergency Department. Rather than the traditional emphasis on household tasks and personal care, a more tailored response using a restorative approach and endorsing a wider variety of interventions/services that support a return to independence is both valued by service users and has benefits longer term across the health system. HBSS can also play a vital role in supporting people to remain living in their own homes rather than moving to an Aged Care facility, thus alleviating some of the shortfall in residential care/nursing home beds. National and regional work in line with this thinking includes the development of a new national service specification by the Ministry of Health that promotes a restorative approach across the board. Alongside this, Auckland University has developed a system to determine “case mix” which can be used to set eligibility and the service delivery approach. The case mix model is useful for tailoring the response to different client groups and early outcomes are that there are opportunities for improved efficiencies by providers. The temporary nature and urgent requirement to provide intensive services to some older people would appear to sit well within the restorative bulk funded model of

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care, but in reality it does not. Older people requiring additional support have the propensity to dominate service provision/resources from the providers – who understandably wish to reduce their care (and therefore their on‐going costs) as soon as possible. This can lead to hospital admission/re‐admission, over utilisation of allied health services or admission to a residential care facility, compounding the problem and wasting resources. In reality intensive services are better “ring fenced” within a small and uniquely funded contract with clear expectations, auditable outcomes and provider accountability. The Midland DHBs15 propose to align their activity in this area to achieve efficiencies and streamline service delivery through a collaborative redesign project. This project includes a review the findings of a number of concurrent activities happening nationally including the Auckland Case Mix model, and a recent redesign project occurring in Capital and Coast DHB and changes recently implemented by the Accident Compensation Corporation in this area. The Midland project is in its early days, however the aligned regional approach is based on the following recommendations:

Services are delivered with a restorative approach across the board and are flexible and able to be delivered in smaller time slots;

Support workers are able to administer and supervise medications, deliver advanced personal care and supervise exercise programmes;

There is a focus on services that aim to prevent admissions to hospital and aged residential care;

There are incentives for providers to work proactively with people to restore function and independence and thereby reduce services over time where appropriate;

There is less provision of low need household management tasks except where necessary for health and hygiene reasons;

Increased training requirements for support workers;

Services are bulk funded within a capped budget based on a package of care approach.

The national service specification developed by the Ministry of Health aligns with this approach. The redesign project has been included in the 2012/13 Regional Services Plan. Additional resource or a dedicated project manager may be required to ensure project deliverables are achieved within a time frame that meets individual DHB requirements.

Needs assessment and service co‐ordination

Eligibility for and access to all long term funded support services (both home based and in aged residential care) is through a needs assessment carried out by the DHB Needs Assessment and Service Co‐ordination Agency, Support Net. Effective and

15 The Midland DHBs comprise the BOPDHB, Lakes, Waikato, Taranaki and Tairawhiti.

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standardised needs assessment and service co‐ordination services are crucial for ensuring people have good information, equity of access to services and receive the right care at the right time. InterRAI is an internationally developed, standardised and validated needs assessment process that gives a consistent objective measure of a person’s needs and enables information to be shared on patient assessment and care requirements. InterRAI is a comprehensive, multidimensional needs assessment which leads to provision of services that improve the health and well‐being of older people and their carers. The implementation of InterRAI is being rolled out throughout the country. Assessors are required to be clinically trained when using the comprehensive tool. While some DHBs have only recently commenced using InterRAI this year, BOPDHB was an early adopter of InterRAI and the Home Care Tool and Contact Tools have been in use for approximately six years in the Bay of Plenty, giving us considerable experience in the use and potential of the tools. There are a number of developments which may impact on NASC services in the future including: 1. An InterRAI tool specifically designed for use in long term aged residential care

(the InterRAI Long Term Care Tool) is currently being rolled out in aged residential care nationally as part of a national business case developed collaboratively between DHBs and the New Zealand Aged Care Association. InterRAI LTC Tool is designed to improve assessment and care planning, thereby improving quality in aged care. It can also be used by providers to determine changes in levels of care and consequent approvals for changes in funding levels, although this has yet to be approved by DHBs, given the potential financial impacts.

2. As the number of people requiring assessment increases and the focus shifts to

supporting people with complex needs in the home, there is a need to consider the most effective way to carry out needs assessments. Auckland DHB Case Mix model reallocates needs assessment and allocation of service responsibilities to providers where people’s needs are considered to be non‐complex, while needs assessments for people with complex needs are carried out by the NASC. This enables resources to be used more effectively and incentivises providers to work proactively with people, to reduce reliance on funded services over time where appropriate. Quality requirements and monitoring can be included through the contractual terms of the agreement to reduce risk of inappropriate service reduction or gaming.

3. Assessments for short term support services following a discharge from

hospital do not use InterRAI. Currently assessments are carried out by district nursing services in accordance with historical practice. However the Short Term Support Services Review for BOPDHB carried out in 2007 recommended that InterRAI be used for all assessments for older people, for both short term and long term care to improve equity of access to services and continuity of care, but this has not been able to be progressed. It is recommended that this

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process is reviewed alongside any reviews of NASC services generally arising from activity outlined above.

4. Not all assessments carried out in secondary services use InterRAI, leading to

inconsistent access to long term residential care following discharge from hospital. There is now a national requirement for all assessments in secondary services to be using InterRAI by 30 June 2012. BOPDHB is currently implementing this.

5. The current NASC criteria (disability lasting six months or more) can create

artificial barriers to co‐ordinating and integrating services and inequities of access to services. Alongside moves towards seamless and integrated service provision, it is appropriate to review the eligibility criteria.

Impacts on the contracting and funding model for NASC service will need consideration resulting from the activity outlined above. However, Support Net is well positioned to adapt to changes. For example, a number of assessments are currently carried out through a sub‐contract process, including in kaupapa Maori services and primary care. Information technology and management is a key enabler to progressing person‐centred integrated models of care. The potential of InterRAI has not been fully realised. For example, making the information available to service providers can streamline the way in which support services are accessed and delivered and reduce the need for multiple assessments. Work is currently under way with home and community providers to make InterRAI assessments available electronically.

Recommendations

1. Progress integrated models of care. Evaluate outcomes of activity focusing on integrated care and chronic disease management (including Eastern Bay PHA Te Whiringa Ora Service and the Midland Health Network Service Level Alliance Team (SLAT) pilot on stratified assessment in primary care) to inform recommendations for further structural changes to primary care.

2. Develop specific Bay Navigator pathways that are relevant to older people e.g. falls prevention, osteoporosis, dementia and TIA.

3. Improve access to specialist advice via primary care 4. Promote and support education for aged residential care and home and

community support providers by primary care. 5. Implement a redesign of HBSS in conjunction with the Midland Region DHBs as

part of a regional project to a restorative model of care. Consider changes to the current funding model from an uncapped demand driven model to a capped bulk funding model with adjustments for demographic growth in future years where appropriate.

6. Implement use of InterRAI for all needs assessments for long term support services which are carried out in secondary care across all specialties when planning a discharge.

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7. Consider implications arising from amending the current criteria for access to service assessed and co‐ordinated by Support Net by removing the requirement for a disability lasting longer than six months.

8. Review NASC functions carried out by district nursing for short term support services.

9. Fund and support roll out of InterRAI Long Term Care Tool in Aged Residential Care in accordance with national business case and implementation plan.

10. Review funding and contracts for provision of NASC Services in light of recommendations above.

11. Reduce the need for duplication and multiple assessments for people and recording errors of patient information by providing read‐only access to InterRAI to home and community support providers.

12. Develop a seamless user‐friendly referral and triage process for access to health services for older people, potentially utilising Bay Navigator as the mechanism.

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D. Hospital Care

Once in hospital, older people are at highest risk of acquired disability, cognitive decline or admission to residential care, either as a consequence of illness or as a consequence of treatment following hospital admission. Older people’s health needs are more complex, usually with co‐existing medical, functional, psychological and social needs that are often misunderstood and require a different approach to care while in hospital and after discharge. Acute illness in older people often has functional consequences, and patients may require a period of rehabilitation to regain function and independence. Rehabilitation is a specific health intervention with a strong evidence base. This need not take place in hospital if a patient is medically stable, and in many regions it does not (e.g. the United Kingdom, Australia and parts of New Zealand). However, the BOP lacks community‐based alternatives to hospital in‐patient rehabilitation after an acute illness. Comprehensive geriatric assessment (CGA) is the assessment of a patient by a specialist team that is led by a doctor trained in Geriatric Medicine, followed by interventions and goal setting agreed with the patient and carers. It is a form of specialist organised geriatric care. It covers the following areas:

Medical diagnoses;

Review of medicines and concordance with drug therapy;

Social circumstances;

Assessment of cognitive function and mood;

Functional ability (ie ability to perform activities of daily living);

Environment;

Economic circumstances. CGA should inform discharge planning and the InterRAI needs assessment process (see Section C). Meta‐analysis of randomised controlled trials shows that patients who undergo CGA after emergency admission to hospital are more likely to be discharged to their own home, less likely to need residential care, less likely to experience deterioration and more likely to have better cognition compared with

National Strategy Policy and service planning will support quality health and disability support programmes integrated around the needs of older people. Admission to general hospital services will be integrated with any community‐based care and support that an older person requires.

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those who receive general medical care.16 Outcomes are most improved when hospital care is delivered in specialist geriatric wards rather than by mobile teams. In studies, “comprehensive assessment” that does not include a doctor trained in Geriatric Medicine does not have the same positive outcomes. The reasons for this are that older people tend to be medically complex. The Royal College of Physicians of London and British Geriatric Society stated in 2001:

“At the core of Geriatric Medicine as a specialty is the recognition that older people with serious medical problems do not present in a textbook fashion, but with falls, confusion, immobility, incontinence, yet are perceived as a failure to cope or in need of social care. This misconception that an older person’s health needs are social leads to a prosthetic approach, replacing those tasks they cannot do themselves rather than making a medical diagnosis. Thus the opportunity for treatment and rehabilitation is lost, a major criticism of some current services for older people. Old age medicine is complex and a failure to attempt to assess people’s problems as medical are unacceptable.”

Comprehensive Geriatric Assessment can be delivered in a range of acute hospital settings:

In the ED: For example, NHS Lanarkshire demonstrated a reduction in admissions by 6% for older people through an “Acute Care of the Elderly” (ACE) team based in the Emergency Department.17

In surgical wards: The sub‐specialty of Orthogeriatrics involves a specialist geriatrician sharing care with orthopaedic consultants. This means older people admitted with fractures receive a multi‐factorial falls assessment and treatment for osteoporosis when they otherwise would not. “Proactive Care of Older People undergoing Surgery (POPS) and “Systematic Care of Older People in Elective Surgery (SCOPES) are other programmes developed in the UK that demonstrate reduced complication rates, reduced length of stay and better functional outcomes on discharge for older people undergoing surgery.18

In dedicated Acute Stroke Units: Specialist stroke unit care means that patients are more likely to be independent and living at home following a stroke.19 Stroke unit care means complications are identified and treated earlier, and combined with early supported discharge (eg via Intermediate Care), this results in reduced length of stay.20

16 Ellis G, Whitehead MA, Robinson D et al. Comprehensive Geriatric Assessment for older adults admitted to hospital: met‐

analysis of randomised controlled trials. BMJ 2011; 343: d6553]. 17 Dr Graham Ellis, Consultant Geriatrician, NHS Lanarkshire, UK.

18 British Geriatric Society www.bgs.org.uk POPS special interest group and SCOPES: [email protected]].

19 Stroke Unit Trialists Collaboration. Organised in‐patient (stroke unit) care for stroke. Cochrane Database Syst Review 2007,

issue 4. CD000197. 20 Fjaertoft H, Rohweder G and Indredavik B. Stroke unit care combined with early supported discharge improves 5 year

outcome. Stroke 2011; 42: 1707‐11.

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In acute geriatric wards: Acute geriatric unit care significantly reduces length of stay, hospital costs, leads to improved function on discharge and increases the likelihood of returning home, compared to usual hospital care. 21

Demand on hospital services will continue to grow with an ageing population, particularly for specialist services for older people. The Government’s Guidelines for Specialist services for Older People were developed in 2004. The Guidelines provide DHBs with a framework for progressively developing specialist health services for older people that provide an expert service, build on initiatives in other parts of the health system (such as primary care), disseminate knowledge and develop collaborative partnerships that deliver integrated services to vulnerable older people, their whanau and carers. Access to Comprehensive Geriatric Assessment by community home based support providers can improve quality, effectiveness and timeliness of service provision and reduce unnecessary errors, duplication and admissions to hospital. The majority of medical admissions to secondary services are for people aged over 65 (63% in BOP in 2010). However, the vast majority of older people admitted to hospital in the BOP do not receive specialist care. There is a Health in Ageing (HIA) service in Tauranga Hospital (but not in Whakatane). This consists of a 39‐bed rehabilitation focussed unit, with limited “in‐reach” services. The current number of specialists in geriatric medicine is below what is nationally recommended for our population to deliver a basic service. In 2011, the number of geriatricians was increased to three, however a recent independent review by Dr Fred Hirst indicated a minimum of five full time equivalent (FTE) geriatricians is required to deliver proper specialist services and provide input to Whakatane, with one FTE being a community geriatrician. The current specialists in Geriatric Medicine have recommended a way forward to expand numbers to a recommended minimum level of six within existing FTE for physicians. This would allow the conversion of an existing general medical ward to an acute geriatric ward in addition to the existing 39‐bed HIA unit, a plan this Strategy supports. The acute geriatric ward would incorporate Comprehensive Geriatric Assessment for frail older people admitted to hospital as an emergency, specialist care for older people with delirium (a condition with significant mortality and morbidity), and potentially enable co‐location of stroke patients in an organised stroke service (refer to section G). An expanded geriatric service and workforce would also allow essential specialist services to be provided to Whakatane, and expand existing community work, education, “in‐reach” services, increased specialist advice to primary care, service and pathway development and outpatient capacity. In the redevelopment of Tauranga and Whakatane hospitals, provision has been made for an increased number of beds for HIA in line with national benchmarks for

21 Baztan J, Suarez‐Garcia FM, Lopez‐Arrieta J et al. Efficiency of acute geriatric units: a meta‐analysis of controlled studies. Rev

Esp Geriatr Gerontol 2011; 46 (4): 186‐92].

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the proportion of bed numbers to the population aged over 65. However, increases have been deferred until 2017 and will require significant funding. In the meantime, without the ability to fund any increased capacity, our focus will be on improving the care of acute admissions for older people, managing patients better to reduce length of stay, and developing new models of care that are better suited to older people as well as being more cost effective, such as proper acute geriatric unit care and community‐based rehabilitation or “Intermediate Care”.

Intermediate Care

In 2011, a team of specialists in geriatric medicine performed a snapshot audit of in‐patients aged over 65 in Tauranga Hospital. It found that just over 10% of hospital beds were occupied unnecessarily due to a lack of (cheaper) community rehabilitation services. Intermediate Care offers a co‐ordinated service that links acute hospital care, community health services and social care to make more effective use of hospital capacity by providing Comprehensive Geriatric Assessment and rehabilitation in alternative settings. Evaluation of Intermediate Care services elsewhere has demonstrated reduced length of stay in hospital and higher patient satisfaction. Outcomes are as least as good as traditional acute hospital care. “Intermediate Care” describes services that meet all the following criteria:

Targeted at people who would otherwise have had an unnecessary, prolonged hospital stay, or inappropriate admission to acute inpatient care, or long term residential care;

Provided on the basis of a comprehensive geriatric assessment (that includes a geriatrician) resulting in a structured care plan that involves active rehabilitation and opportunity for recovery;

Has a planned outcome of maximising independence and typically enabling patients to resume living at home;

Is time limited, typically no longer than 6 weeks, and often as little as 1‐2 weeks;

Involves multi‐disciplinary working, with a single assessment framework, single professional records and shared protocols.

Intermediate Care is geared towards both admission avoidance, and early discharge; and encompasses rehabilitation at home, as well as in a community Intermediate Care facility (see diagram in Supporting Information section). Examples of Intermediate Care services in New Zealand include the Community Rehabilitation, Enablement and Support Team (CREST) service in Canterbury and the Supported

Our focus will be on improving the care of acute admissions for older people, managing patients better to reduce length of stay, and developing new models of care that are better suited to older people.

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Transfer and Rehabilitation Teams (START) service in the Waikato. These services feature community based rehabilitative supported discharge service (either in the person’s home or in a residential facility), a rapid response service, and a multidisciplinary team (general practice, community service providers and older person health specialist services). Elements of these services currently exist in the BOP that can be incorporated as part of any future Intermediate Care service. The western BOP has two “transitional care” beds in an aged residential care facility targeted towards older people who have been admitted to hospital following a fracture and are not yet ready for rehabilitation, and a Community Response Team (CRT) that focuses on admission avoidance. Community Primary Options (CPO) funding for general practice provides for the ability for GPs to admit a patient to residential care for a few days to avoid an admission to hospital or after a discharge. However, if patients require more support that can be provided at home or through CPO funding, there are limited options for GPs or the CRT to refer or admit patients to more appropriate cheaper care in the community such as an Intermediate Care facility or increased temporary support in the home. The introduction of an Intermediate Care service would reduce length of stay for older people across all hospital specialties. It would allow the HIA in‐patient service to focus on older patients with more complex medical and rehabilitation needs (e.g. acute stroke) and also mitigate the projected increased need for HIA beds in the future.

Allied Health

With a focus on a comprehensive geriatric assessment, rehabilitation and restoration of function and independence are key elements to the success of a number of the services for older people recommended in this Strategy. Examples include the Intermediate Care Service, acute geriatric ward, organised stroke service and the redesign of home based support services including assessment and treatment by allied health professionals (particularly physiotherapy and occupational therapy). Currently there is limited access to both hospital and community allied health across the BOP, but particularly in the western BOP. There are no foreseeable plans to address this shortage. In developing this Strategy, consistent messages were received from hospital and community based services and older people themselves about the importance of access to allied health professionals as a fundamental enabler to many of the recommendations in the Strategy. Many people described difficulties with accessing sufficient (even basic) allied health treatment and advice due to insufficient staffing levels. It is strongly recommended that options to address increased access to allied health professionals is addressed as an essential part of the implementation plan.

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Recommendations

1. Specialist services for older people are developed in line with the Government’s Guidelines for Specialist Services for Older People (Ministry of Health, 2004).

2. Expand the specialist geriatric workforce to recommended levels (including geriatricians, registrars and junior doctors, nursing and allied health professionals) to encompass the patient journey from acute admission to discharge and community based care. This will require increased capacity and capability for specialist health services for older people to work within acute medical, surgical and orthopaedic services.

3. A particular focus is recommended to address ways to increase allied health input across the range of services, both hospital and community based, as a key enabler to implement a number of recommendations in this Strategy.

4. Develop an acute geriatric ward in addition to the existing 39‐bed HIA unit, which would incorporate a comprehensive geriatric assessment for frail older people admitted to hospital as an emergency and specialist care for older people with delirium (a condition with significant mortality and morbidity). This is also an enabler to develop an organised stoke service (refer to section G).

5. Through the provision of an expanded geriatric workforce, provide essential specialist services to Whakatane and expand existing community work, education, “in‐reach” services, advice and education to support primary and community care, service and pathway development and outpatient capacity.

6. Provide education and support to build the ability for all services that treat older people acutely in the hospital to deliver a comprehensive geriatric assessment in the future.

7. Make better use of existing resources by developing different, cost effective, evidence‐based models of care such as increased community rehabilitation or “Intermediate Care”.

8. Make funding provisions to increase the numbers of beds for specialist geriatric medicine services in line with national recommendations for the proportion of beds to the population of the BOP and the planned redevelopment of Tauranga Hospital by 2017.

9. Implement better communication between secondary and primary care on discharge from hospital, so that any comprehensive geriatric assessment can inform the InterRAI assessment process and community care as well as the patient’s GP.

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E. Aged Residential Care

Aged residential care (ARC) is a scarce, high cost resource. People are entering residential care at an older age and with higher support needs. The number of people requiring residential care, particularly at hospital and dementia levels of care is predicted to grow. Currently, there are insufficient “Stage 3” secure dementia care and psychogeriatric beds available in the BOP which can lead to hospital stays lasting several months for some patients. A comprehensive review of the future needs for residential care carried out by Grant Thornton in 2010 sets out the predicted increase in bed numbers over the next 20 years. 22 ARC is a demand driven service purchased by DHBs for people over 65 who have health and disability related needs and are assessed as needing ARC. BOPDHB purchases capacity in ARC facilities throughout the BOP. ARC providers are private organisations following legislative and contract changes made in 2006, DHBs no longer have the ability to control the number of beds purchased in ARC providers facilities. Availability of beds is market driven and there is no guarantee of any level of occupancy by the DHB and providers accept this level of commercial risk. Access to residential care is through the Needs Assessment and Service Coordination (NASC) process. Only those people who have been assessed as eligible and needing full time residential care will be able to access a funded bed. The assessment process used is InterRAI (refer to Section C). Thresholds for entry to access are reviewed and all other options for community care are explored before the BOPDHB agrees to grant access to an ARC bed. Contracts for services and the price paid for ARC beds are negotiated and set nationally through DHBs and the providers’ representative body, the majority of whom belong to the New Zealand Aged Care Association. All DHBs sign up to this process, which then prohibits the development of local funding models or options. Price increases negotiated for ARC through this process in the last few years have exceeded the level of cost pressure funding generally received by DHBs through the funding envelope. Funding for ARC is a mixture of DHB funding (for fully subsidised residents who meet eligibility criteria through a financial means test), private payments, and client contributions through their national superannuation. People who do not qualify for a DHB subsidy (they have assets higher than the required threshold) are required to pay for the cost of their care, but this is no more than the maximum contribution

22 Grant Thornton. Aged Residential Care Service Review. Sep 2010. wwwgrantthornton.co.nz.

National Strategy Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

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each week. The maximum contribution is the same for all residents, regardless of the level of care they are assessed as requiring. It is an amount set by legislation each year and is equal to the weekly cost of rest home level care (the lowest level of care). The difference between the maximum contribution and the cost of higher levels of care if required, eg hospital level care, is topped up by the DHB. Approximately 5.2% of people aged over 65 in the Bay of Plenty live in an ARC facility. This compares to a range of approximately 5‐7% nationally. The proportion has been declining overall, but particularly at rest home level, as the BOPDHB has invested more in home support services that enable “ageing in place”. However, the proportion of people in higher levels of ARC has been increasing due to higher acuity and complexity of care. A range of factors influence the proportion of people who access ARC including availability of community services eg medication supervision, respite care, day programmes and home support; where people live, what family or whanau support they have, and the health and wellbeing of a primary carer. The utilisation rate by Maori of residential care is low in comparison to non‐Maori, largely due to culture and whanau structures encouraging and enabling support and care to be provided at home. However, this is changing as family structures change and younger Maori are moving away from home, often in search of employment. In the western BOP, many older people do not have family nearby and many live on their own. The average age of people accessing ARC is currently 84 years 11 months. This has implications for growth in demand for ARC as the growth rate for people over age 85 is increasing at the rate of approximately 6% per annum. Hospital level care has steadily grown at the rate of between 5% and 9% each year for the last 5 years. This level of growth will continue with the influence of population ageing and higher levels of disability. This has inevitable cost implications for the DHB because of the funding mechanism set out above and the DHB needs to plan and budget for this appropriately. To ensure we will have sufficient ARC capacity in the community, commercial commitment and an element of risk by private organisations based on forecast modelling and demand projections is required. Investment in new buildings requires time and money and therefore a long lead in time to develop new capacity. The funding and focus of ARC is currently on long‐term care and support. To better manage future demand and maximise this high cost specialised resource, much more focus could be directed to preventative and rehabilitative care, with development of short‐term service options. Currently, services are stand‐alone with little community services integration. The ARC contract does not allow for flexibility. There are few incentives for restorative care (i.e. reversal of functional loss). Yet

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there is considerable expertise in ARC, and investment in facilities in central community locations that could be better utilised. More flexible services could provide:

Residential care (medium and high needs care);

Intermediate care beds (temporary care‐home based rehabilitation – (refer to Section D);

Palliative care;

Day, night and weekend care;

A community electronic monitoring base (for falls prevention, medication management, diabetes etc);

Co‐ordination of aged care education and access to available services;

A base for primary care and community allied health providers (aligned with the integrated family health centre model);

Social meeting points for older people and their families. The current ARC access and funding regulations make it difficult to re‐enter community based care due to income/asset testing (assets, usually the family home, often have been sold when entering ARC to pay for the cost of care). In the current environment where funding follows eligible residents, there is little opportunity to manage the growing demand for ARC. Furthermore, the cost component of providing accommodation and catering services in ARC is high and alternative models could be considered. For example, accommodation and catering could be provided by specialist private sector providers with the health care component provided by health care providers.

Recommendations

1. Plan and budget appropriately for the forecast growth in demand in aged residential care.

2. Manage demand on scarce high cost resources by developing new flexible, integrated and restorative models of care with ARC e.g. short term care, Intermediate Care, integrated community facilities.

3. Improve access to education, specialist advice and support by residential care providers to improve their quality and capacity to access primary healthcare and thereby avoid or reduce unnecessary admissions to hospital and improve resident outcomes (refer to Section D)

4. Fund and support roll‐out of the InterRAI Long Term Care Tool (refer to Section C) in ARC in accordance with the national business case.

5. Consider and recommend what opportunities might be feasible by splitting the accommodation and care service provision eg the asset/income testing could be managed under Housing New Zealand while the care component could be a full or partial government funded service.

6. Streamline contracts and auditing processes to reduce compliance costs.

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7. Consider ways in which Primary Care and Aged Residential Care can identify those nearing the end of their lives and offer/implement Advanced Care Planning.

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F. Dementia and Mental Health in Older People

The number of older people with dementia is rising rapidly. Nationally, dementia affects 40,746 people. By 2050 it is estimated there will be 146,699 people living with dementia. The prevalence of Alzheimer’s Dementia (AD) strongly correlates with age (see the table below). Of all the patients under mental health services for older people in the BOP, approximately 80% have dementia and 20% have other mental health disorders. Prevalence of Alzheimer’s Dementia (AD), 2006:

Age 65‐69 75‐79 85‐89 90‐95

Prevalence (%) 1.1% 4.7% 15.2% 26%

AD represents 60‐70% of all dementia in New Zealand (this figure does not include “mild cognitive impairment” or early dementia which carries a significant risk of progressing to AD). Mental health problems among older people exact a large social and economic toll on patients, their families and carers, as well as the statutory agencies. Under‐detection of mental illness in older people is widespread due to the nature of symptoms and the fact that many older people live alone. Depression in people aged 65+ is especially under diagnosed, and this is particularly true of residents in care homes. Mental health problems may be perceived by older people and their families, as well as by professionals, as an inevitable consequence of “old age” and not as health problems which can respond to treatment.

Promoting good mental health

Promoting mental health is as important in older people as in younger people. Interventions at a population level to promote good mental health include educational activities, and creative and social pursuits. Specific additional interventions which promote good mental health in older people include tackling

National StrategyPopulation‐based health initiatives and programmes will promote health and wellbeing in older age. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

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social isolation and providing bereavement support. Older people in residential care and nursing homes and those receiving day care should be able to participate in a range of stimulating group or one‐to‐one activities. These can include reminiscence, art therapy, news‐based discussions, aromatherapy, games and quizzes, adult education and drama. Older people should be offered a choice of activities matched to their needs and preferences. An appropriate environment can also aid orientation and help to avoid visual and sensory confusion. Continued engagement for older people in valued roles in the community, including flexible options for older people to continue working should they choose, also promotes good mental health (see the wider determinants of health in Section A).

Early identification and treatment

Most people with mental health problems will be diagnosed and cared for in primary care with the support of social services, but specialist mental health services should be available to develop care pathways with primary care and be consulted when needed. A range of specialist services should be available, from diagnosing and treating more complex problems, to providing community and in‐patient services for those with a clinical need. The emphasis should be on promoting the independence of older people with mental health problems and supporting them and their carers in the community whenever possible. The BOPDHB has a specialist mental health service for older people. However, services that focus on early identification of dementia, support and preventative interventions are very limited. Early identification of people with dementia enables support to be put in place earlier to prevent further loss of function and to support primary carers to take a break. Flexible options in the community for supporting people with dementia are required to reduce carer strain and delay entry to residential care for as long as possible. There few services in the BOP that focus on people in the early stages of dementia. A report to the Disability Issues Directorate of the Ministry of Health recommends “Memory Assessment Centres” for quality improvement in the diagnosis of dementia. International research has shown services that focus on the early stages of cognitive impairment can significantly improve health and social care outcomes, delay admission to residential care, improve well‐being of full time carers, prevent unnecessary admission to hospital and reduce health care costs in the long term. A memory pilot undertaken by mental health services for older people (MHSOP) in the BOP in 2011 demonstrated a significant demand for early intervention services for people with dementia. Currently in the BOP, specialist assessment for dementia is spread across three services including MHSOP, HIA and neurology. While all services have contact in various ways, there is no co‐ordinated or targeted service delivery, and there is little coordination or integration with primary care. A coordinated approach, with greater

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integration with primary care is recommended. A business case is currently under development for the establishment of a coordinated dementia service, incorporating an early intervention service.

Secure residential facilities

Specialist residential facilities (secure dementia facilities and psychogeriatric level care) throughout the BOP operate at close to 100% occupancy, making placement in the community difficult and increasing length of stay in hospital. There is a need to expand psychogeriatric level capacity in the community, particularly in the geographical areas at either end of the BOP, namely the west of western BOP and the eastern Bay of Plenty. The acuity of older people who present to specialist mental health services is increasing. When there is a shortage of suitable options in the community to enable a safe and well supported discharge, this impacts negatively on average length of stay in hospital. To further manage the growth in demand for psychogeriatric level care, careful management of access to this high cost scarce resource is required to ensure those most in need have access to this level of care when required. The assessment process and access criteria differs across different DHBs and impacts on capacity. This is a national issue and there is a need for a standardised assessment process and access criteria. Locally, bed availability can be actively managed by ensuring people in psychogeriatric facilities are appropriately assessed and re‐assessed regularly for changes in their care needs. New models of care and knowledge about the importance of the environment of secure dementia units are being developed locally and internationally. Quality facilities and care in line with best practice has been shown to reduce admission to hospital, improve resident outcomes, reduce the need for psychotropic medication and give confidence to family members when residential care is required. Residential providers need support to be the best they can and develop innovative facilities and models of care for people with dementia as well as access to specialist assessment and advice when required. A set of best practice guidelines is recommended to support provider care and development.

Recommendations

1. Promote recognition and assessment of mental health status of the older people by all health care providers as central to supporting healthy ageing. This includes depression, underlying mental illnesses or dementia.

2. Provide greater accessibility and seamless clinical service delivery for people with dementia through establishment of a coordinated, integrated dementia service including an early detection and management service for people with dementia in all settings, including acute inpatient services, community and residential care facilities.

3. Improve access to specialist advice and support for community providers.

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4. Improve support to primary carers of people with dementia through education and training and a range of flexible respite, day and home based support options.

5. Introduce training requirements in service specifications for home based support services where staff work with people with dementia.

6. Develop a dementia pathway for people with behavioural support needs through Midland Region Dementia Advisory Service, specialist health services for the older person, MHSOP and Bay Navigator.

7. Develop a future bed forecast for Stage 3 dementia and psychogeriatric level residential care for the next five years and make appropriate budget provision for increased numbers of beds as per the forecast. Identify and actively seek suitable psychogeriatric level providers in the west of the western BOP and eastern BOP.

8. Better manage access to and utilisation of psychogeriatric level beds by requesting regular re‐assessments of people to identify changes in levels of need.

9. Advocate at a national level for a standardised needs assessment process for access to psychogeriatric and Stage 3 dementia level care.

10. Support best practice in residential care by developing a set of best practice guidelines to support approvals of applications for new Stage 3 dementia and psychogeriatric units and support existing providers to improve quality of care and environment.

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11. G. Stroke and Transient Ischaemic Attack (TIA)

The Ministry of Health and New Zealand Stroke Foundation published the national Guidelines for Stroke Management Implementation Plan in 2011. A national acute stroke audit commissioned by the Ministry in 2009 found that:

New Zealanders currently do not have sufficient access to organised acute stroke services.

Only eight out of 21 DHBs at the time provided stroke services that are consistent with international best practice, and only 39% of patients in the audit received care in a stroke unit.

The Implementation Plan is clear that all DHBs should provide an “organised stroke service”, and all people admitted to hospital with a stroke should expect to be managed in a stroke unit by a team of health professionals with expertise in stroke and rehabilitation. DHBs are also expected to develop organised stroke services as signalled in the DHB annual planning guidelines for 2012/13 and to develop regional stroke services within existing resources. Key objectives for large (population greater than 200,000) DHBs are:

They should provide an acute TIA service;

They should provide an acute thrombolysis service or a pathway to access one;

Inter‐disciplinary teams should utilise current stroke protocols for stroke management;

They should provide organised stroke care in a designated geographical area under the care of a designated stroke physician;

They should provide rehabilitation in a dedicated area (i.e. a stroke rehabilitation unit) under the coordinated care of a team experienced in stroke rehabilitation including a designated stroke physician;

They should implement ongoing education for staff, patients and families/caregivers;

National StrategyPopulation‐based health initiatives and programmes will promote health and wellbeing in older age. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

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Preventing stroke

The Ministry of Health has recently produced best practice guidelines on better prevention of cardiovascular diseases – including a toolkit for DHBs. The risk factors for cardiovascular (heart) disease and stroke are the same. Heart disease occurs because of disease in the arteries supplying the heart; stroke occurs because of disease in the arteries supplying the brain. Stroke is the third leading cause of death in New Zealand after heart disease and all cancers combined. It is also a major cause of neurological disability. There is a large volume of evidence to show that early detection and management of risk factors for stroke can prevent stroke from happening. It is only in recent years that the risk of stroke after a transient ischaemic attack (TIA) has been appreciated. A TIA is defined as stroke symptoms and signs that resolve completely within 24 hours. TIAs are sometimes referred to as “mini‐strokes” but there is nothing minor about a TIA. A person’s risk of a disabling stroke after a TIA can be as high as 12% in the next seven days and 80% of all strokes following a TIA can be prevented. There are at least 540 TIAs each year in the Bay of Plenty DHB. By treating TIA as an emergency, and following the evidence‐based New Zealand TIA guidelines, we could prevent around 52 disabling strokes and save over $2.5 million each year in stroke‐related care. Stroke is a health gain priority area for Maori. Maori develop risk factors for stroke earlier. Prevalence, morbidity, and mortality from stroke are all higher in Maori than in people of European origin. Healthcare providers must recognise the cultural values and beliefs that influence the effectiveness of services for Maori people with TIA and stroke. Maori may be less likely to present to hospital with symptoms of a TIA or stroke, particularly in more rural areas. A TIA pathway is currently being developed through Bay Navigator to promote best practice but disparity in services between the western and eastern BOP is evident (and being addressed).

Organised stroke services

In Tauranga Hospital at the moment, patients with high risk TIAs are admitted to hospital and seen by a specialist stroke physician and nurse. All outpatient referrals from the ED or GPs are seen in a TIA clinic within one week. Many patients with “low‐disability strokes” who only require admission to hospital for a few days are managed by general physicians with the advice of the stroke physician and nurse who then follow patients up in clinic. For patients with a major disability following stroke, randomised controlled trial evidence shows that outcomes are significantly improved if care is provided on a geographically defined stroke unit run by a specialist team of nurses, therapists and stroke physician(s). The best outcomes are found in units that are co‐located with the stroke rehabilitation unit. Specialist stroke unit care means that patients are

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more likely to be independent and living at home following a stroke.23 There is no such unit in the BOP. Recent Ministerial emphasis on the importance of stroke units supports the development of an acute stroke unit. It is recognised that this will need to be achieved within current funding resources. However, in line with the rest of this Strategy, provision of community‐based rehabilitation (eg Intermediate Care), would free up beds currently being used in hospital for slow‐stream rehabilitation so that an acute stroke unit could be created in the most appropriate area (refer to recommendations in Section D). An organised stroke service is also dependent on an appropriate workforce, as outlined in Section D.

Recommendations

1. Complete the development of a TIA pathway through Bay Navigator . 2. Establish an organised stroke service ‐ Refer also to Section D on the

development of an acute geriatric ward. 3. Increase the number of specialist geriatric medicine workforce to provide

appropriate treatment of TIAs and Stroke ‐ refer to Section D. 4. Continue with on‐going specific thrombolysis training for ED and general

medical Registrars/Consultants in accordance with international best practice. 5. Develop a BOPDHB Stroke Guideline that sets out how the national NZ Clinical

Guidelines for Stroke will be implemented locally.

23 Stroke Unit Trialists Collaboration. Organised in‐patient (stroke unit) care for stroke. Cochrane Database Syst Review 2007,

issue 4. CD000197.

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H. Falls and Bone Health

Falls are a major cause of disability and the leading cause of mortality due to injury in older people aged over 75. It is estimated that one‐third of community‐dwelling over 65s fall each year, usually in their own home with no obvious hazard. There is good evidence that interventions to prevent falls reduce an older person’s risk of falling in the future. The national Health of Older People Strategy specifically highlights falls as an area for action. One in three women and one in twelve men over 50 are affected by osteoporosis, which increases the risk of fracture following a fall. Osteoporosis is called the silent epidemic because of its symptomless development and the lack of public awareness. Osteoporosis is not just an "old people's disease". Young people with low bone density can get osteoporosis too.

More than 3,000 New Zealanders break a hip each year. This figure is expected to rise to 4,800 in ten years time, as our population ages.

About a quarter of people who fracture a hip die within a year from related complications. One third never return home, and those that do lose their mobility and independence.

More women are hospitalised with a hip fracture due to osteoporosis than through breast cancer.

The prevalence of osteoporosis is predicted to increase by 30% from 2007 to 2020 due to population ageing.24 The total health cost of osteoporosis through fractures in New Zealand in 2007 was more than $1.15 billion or $3 million per day. Problems with both falls and osteoporosis can be detected early and treated successfully, preventing injuries, fractures and disability. What is little understood by the public, and many health professionals, is that falls in older people are not accidents, but are the result of medical problems, many of which are treatable. In one study of older people presenting to the ED with a fall,

24 Osteoporosis NZ Independent Research Report 2007

National StrategyPopulation‐based health initiatives and programmes will promote health and wellbeing in older age. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning. Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

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patients had an average of five risk factors for falls – the most common being disorders of gait and balance, inappropriate medications, problems with blood pressure, visual impairment and cardiovascular disorders. Falls in a later life are also a common symptom of previously unidentified health problems which need to be managed. A fall can precipitate admission to long‐term care. After an osteoporotic fracture, 50% of people can no longer live independently. Hip fractures are the most common serious injury related to falls in older people, costing on average of $24,000 per person for acute treatment and rehabilitation, resulting in an annual cost to New Zealand of around $18 million per year.25 Of this, around half is for acute hospital care and half for long term disability services or aged residential care.

Preventing falls

Previously, the Accident Compensation Corporation (ACC) was the lead agency for funding falls prevention programmes for people aged over 65. However, in 2010 ACC discontinued funding for falls prevention programmes for older people, but retained promotion of Vitamin D use in older people to prevent falls. There is currently no falls prevention strategy or service in the BOPDHB. There are three levels of approach to falls prevention: A population‐based strategy

Including the promotion of exercise and activities that promote muscle strength and balance (eg Tai Chi classes).

An increased intake of calcium and vitamin D in the diet for older people.

Ensuring that pavements are kept clear and in good repair, and there is adequate street lighting .

Making property safer – many falls in older people are related to “home hazards”.

Preventing falls in individuals

Better identification of those at risk of falling – ie those with gait and balance disorders (eg an old stroke or Parkinson’s Disease); visually impaired; taking four or more medications; those with home hazards.

Referring older people who have fallen to a health professional for a “falls assessment” and interventions as necessary.

Implementing measures in aged residential care and hospitals to prevent falls in older people.

Specialist falls service

Older people with recurrent falls, “unexplained falls” or dizziness benefit from a specialist multi‐factorial falls assessment that involves a specialist geriatrician and therapy team.

25 Osteoporosis New Zealand Inc. “The Burden of Osteoporosis in New Zealand 2007 to 2020”.

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Interventions for falls usually include:

Diagnosis and treatment of underlying medical problems such as eye diseases/visual impairment, diseases causing abnormal gait and balance, correction of postural hypotension or cardiac rhythm abnormalities, discontinuing inappropriate medication, treating bladder problems etc;

Rehabilitation, including physiotherapy to improve confidence in mobility, and occupational therapy to identify home and environmental hazards;

Equipment to improve the safety of an older person at home;

Social care support if required. Individually tailored exercise programmes administered by a qualified professional can reduce the incidence of subsequent falls in older people or as part of a multiple intervention approach in those at risk. Falls prevention programmes for individuals should contain more than one intervention and focus on the individual’s particular risk factors.26 The redesign of HBSS recommended in Section C supports this approach.

Treating osteoporosis

Any person who has had a fragility fracture (ie a fracture that occurred when falling from standing height or less) should be flagged for an osteoporosis assessment. Risk factors for osteoporosis include:

Previous fragility fracture;

Prolonged corticosteroid therapy;

Premature menopause or history of amenorrhoea (not treated to reduce risk of osteoporosis);

The presence of eg liver or thyroid disease, malabsorption, alcoholism, rheumatoid arthritis;

A family history of osteoporosis (including maternal hip fracture);

Low body mass;

Smoking. Osteoporosis may also be identified through:

DXA (Dual Energy X‐ray Absorptiometer) bone mineral scan;

Radiographic evidence of vertebral fracture and/or loss of height associated with vertebral fracture.

In women aged over 75, a DXA scan is not required to diagnose osteoporosis, if there is a history of previous fragility fracture and other metabolic bone diseases are excluded by an x‐ray of the fracture and blood tests. 27

26 National Institute for Health and Clinical Excellence (NICE). The assessment and prevention of falls in older people. Clinical

Guideline 21, 2004. 27 Royal College of Physicians and Bone and Tooth Society of Great Britain. Osteoporosis: clinical guidelines for prevention and

treatment. RCP, London, 2000 / and Osteoporosis New Zealand www.bones.org.nz.

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There is no routine assessment and treatment for falls and osteoporosis in older people who attend ED each year in the BOPDHB with fragility fractures. The opportunity for health promotion and prevention, potentially saving millions of dollars in hip fracture care alone, is lost. The HIA department in Tauranga Hospital currently provides an orthogeriatric service for older people with fractured hips. However, the problem of falls and bone health needs to be tackled far earlier in order to make a difference.

Recommendations:

1. Assess the impact of Accident Compensation Corporation’s withdrawal of funding for falls prevention programmes for older people.

2. Promote a population‐based falls prevention strategy for older people, including the identification of those at risk of falls living in their own home or in care homes.

3. Develop an education strategy for patients, carers and health professionals around falls and osteoporosis.

4. Develop a specialist falls service for people with recurrent falls, “unexplained falls” or dizziness. Assess how this could work across the BOP, working with GPs in more rural areas.

5. Implement a Falls Pathway through Bay Navigator that facilitates the evidence‐based assessment and treatment of older people who have fallen in both Primary Care and Secondary Care.

6. Implement an Osteoporosis Pathway through Bay Navigator that links with the Falls Pathway, facilitating the evidence‐based assessment and treatment of older people with risk factors for osteoporosis or a previous fragility fracture.

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I. Medications Management

Older people are high users of medications, particularly those in Aged Residential Care. Two‐thirds of people over the age of 60 are taking regular medication, and over half of those with repeat prescriptions are taking more than four drugs. Medications are a valuable therapeutic tool but they can cause significant problems, particularly if they are not reviewed regularly: 1. Many health problems in older people are a direct result of unrecognised side

effects of their medication. Up to 30% of admissions to hospital in older people may be associated with problems related to medication.28

2. As many as 50% of older people may not be taking their medicines as

intended. Campaigns for people to return unwanted medicines to pharmacies confirm that large amounts of medicines are never taken. “Inequivalence” in quantities on repeat prescriptions mean that patients have to order different items at different times, and may unintentionally receive the same medicine on separate prescriptions. The wastage that results from this has been estimated to account for 6‐10% of total prescribing costs.

3. Following discharge from hospital, changes to medication are frequently made

both intentionally and unintentionally. Communication between Secondary and Primary Care is often poor. For example, the HIA stroke follow‐up clinic regularly sees patients who are taking dangerous combinations of powerful blood‐thinning drugs which were accidentally prescribed on discharge from hospital, a recurring theme that has recently been flagged as a clinical risk.

4. Elderly people have a higher prevalence of polypharmacy, which is associated

with more adverse drug events. The risk of an adverse drug event has been estimated at 13% for two drugs, 58% for five drugs and 82% for seven or more.29 As we get older, our bodies change and handle medications differently – older people are more sensitive to side effects of medications due to age‐related physiological changes. As well as causing side‐effects, many medicines are no longer required as we age and can be successfully withdrawn. Two large

28 Hanlon JT, Schmader KE, Kornkowski MJ, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc.

1997;45:945‐948. 29 Fulton MM, Allen ER. Polypharmacy in the elderly: A Literature Review. J Amer Acad Nurse Pract. 2005;17(4):123‐131.

National StrategyPopulation‐based health initiatives and programmes will promote health and wellbeing in older age. Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

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studies have shown that approximately 21% of medicines used in older people may be inappropriate.30 31

Other issues for older people and medicines are that their carers’ potential contribution and needs are often not recognised or addressed. Formal carers (eg home care) are discouraged from assisting older people to take their medicine, even though this could be of benefit. Family members, who could be more involved in treatment decisions and practicalities, including administration and the recognition of possible side‐effects, are often under‐utilised. The redesign of HBSS outlined in Section C supports the increased ability for support workers to supervise medication adherence. DHBs, PHARMAC and the pharmacy sector agents are planning significant changes in 2012/13 to the way medicines are dispensed and managed in the community. These changes seek to improve the safety, quality and effectiveness of pharmaceutical dispensing and encourage the development of a patient‐centred service model that utilises the skills and competencies of community pharmacists. Pharmacists will have the flexibility to provide medicines education and adherence support for certain patient groups including people who are “frail, infirm or unable to manage their medicines”. This includes the ability to tailor the way they dispense medicines according to individual patient need and should benefit older people through the use of compliance packaging to improve medication adherence.

Medicines reconciliation

A high proportion of medication errors occur when patients are admitted to and discharged from hospital. Issues with medication errors on admission and discharge can be addressed using “medicines reconciliation”. Medicines reconciliation by pharmacists ensures that patients receive all intended medications and no unintended medications following transitions in care and significantly reduces medication errors. In the BOPDHB, there is no formal provision of medicines reconciliation in hospital. There is a pharmacist discharge support service for high‐risk patients that includes medicines reconciliation on discharge, but there is no assessment process to identify high‐risk patients and consequently many are not identified.

Regular review of older people’s medicines

Medication reviews ensure that patients are obtaining the maximum benefit from their medicines. This results in better disease management, fewer exacerbations of chronic conditions, reduced need for acute interventions such as GP visits and hospital admissions, improved medication adherence and fewer medication errors. Studies in general practices and aged residential care in the United Kingdom have

30 Zahn C, Sangl J, Bierman AS, et al. Potentially inappropriate medicine use in the community‐dwelling elderly. JAMA

2001;286(22):2823‐9. 31 Curtis LH, Ostbye T, Sendersky V, et al. Inappropriate prescribing for elderly Americans in a large outpatient population. Arch

Int Med 2004;164(15):1621‐5.

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shown that every £1 spent on employing pharmacists to review patients’ medication resulted in a £2 cost saving. Currently, medication reviews in primary care are funded through a primary health organisation (PHO) contract which does not cover medication review in aged residential care. Studies have shown that people in residential care are more likely to be on a greater number of medications than a similar aged population living in the community. Compared with residential aged care facilities around the world, New Zealand facilities have a 42% higher drug use.32

Recommendations

1. Adopt HQSC (Health Quality and Safety Commission) national medication safety programme for identification of high risk patient populations and provide Medicines Reconciliation for all patients identified as high risk on admission to hospital in BOPDHB.

2. Develop the role of a clinical pharmacist to support safe medication management for high risk patients across inpatient, primary and community care, including aged residential care. This will include medication reconciliation for complex patients on transfer of care or discharge.

3. Develop resources to support patients and families health literacy in relation to medication self management on discharge (including better information and the involvement of family and carers).

4. Participate in the development of medication management processes which support the safe transfer of medication information between care environments, e.g. secondary, primary and community services. This will include national HQSC projects such as electronic prescribing, medication reconciliation and health information transfer.

32 Grant Thornton, Aged Residential Care Services Review 2010.

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9. Delivery _____________________________________________________________________ Delivering the recommendations of this Strategy will depend on a review of our existing workforce, a successful implementation plan, and the highest support at Board level. We recommend that a separate implementation plan is developed following approval of this Strategy and re‐presented to key stakeholders. Funding provision, contracts and purchasing methods will need to be reviewed across most portfolios including health of older people, primary care, chronic conditions, secondary services, mental health and pharmacy to enable the recommendations to be achieved.

Workforce

The impacts of an ageing population will place significant stresses on workforce demands. Strategies for increasing and diversifying the workforce are not well developed or focused. The workforce itself is ageing. The average age of nurses in the BOPDHB is now 52 and the average support worker is 50. Pay rates for unskilled labour are at minimum wage level or marginally above as rates for home based support services have not been able to keep up with increases in cost of living. The skill level required by support workers is increasing to keep up with increasing complexity of older people’s support needs. The industry is not an attractive option for younger people. Working in aged care is generally low skilled, untrained and low‐paid, and not highly valued by younger people. Unpaid caregivers are also undervalued. It is recognised throughout the care industry that in New Zealand we pay people less to look after our vulnerable kaumatua and kuia, and our mothers and fathers, than we pay other low‐skilled workers (eg those who stack supermarket shelves). If we are to attract the right people to meet the demands that an ageing population will have on the workforce, considerable work needs to be done to change this culture. Considerable investment and multi‐agency collaboration is required to attract and train the workforce of the future, particularly tailored to younger Maori school leavers. Recent research published by the Department of Labour in 2009: Workforce 2020 – The Future Demand for Paid Caregivers in a Rapidly Ageing Society outlined the actual and projected number of paid caregivers needed for New Zealanders aged 65 years and above from 2006‐2036. It estimated that in 2006 there were around 54,700 people over the age of 65 requiring care in New Zealand, and approximately 17,900 paid caregivers. The report projects that by 2036 there will be approximately 147,700 people over the age of 65 requiring care, and there will be a requirement for 48,200 paid care workers. The report notes the projections are based on current models of care. It further notes that the average age of paid care workers is currently 50 years old. The research makes a number of recommendations to address projected workforce

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shortages. The recommendations in this document align with the recommendations in the research. In the year to December 2011, the unemployment rate for Maori flat‐lined at 13.4% in comparison to the general unemployment rate of 6.3%. The latest update from Statistics New Zealand’s Household Labour Force Survey shows the jobless rate of 15 to 19 year old group in the Eastern Bay of Plenty’s Rangatahi Iwi is at 24.2%. Some whanau and mokopuna are capable of finding employment or going in search of educational opportunities outside of eastern Bay of Plenty. However, the whanau who remain, many of whom are unemployed, and young Rangitahi who have left school with little or no educational achievement will be the main caregivers or whanau support for what will become vulnerable kaumatua. There is a need for any Health of Older People Strategy to allow inter‐sectorial approaches, including Whanau ora, integrated service provision and extended whanau members to be employed to provide care. The Organisation for Economic Co‐operation and Development (OECD) has examined the potential contribution to efficient use of the health workforce and recommends skill mix changes and the development of new roles, including enhancing skills among particular groups of staff as ways to address future workforce demands. Allied health professionals play a significant role in rehabilitation, treatment and long term support for the health and wellbeing of older people and can help alleviate projected medical and other specialist workforce shortages. However, access to community allied health therapists is limited, particularly in the western BOP and there are no major structural changes planned to increase the numbers or level of service. This will require a rethink about how these issues can be addressed within existing resources. Workforce planning for an ageing population is also the subject of specific strategic work both nationally and locally. Health Workforce New Zealand has developed forecasts of what the future health workforce in New Zealand will look like in 11 specialties including aged care. Some clear themes have emerged from the forecasts. They recommend:

Making better use of the existing health workforce, from untrained workers to highly specialist, by developing new roles and extending existing roles to make best use of the skills of all members of the health care team.

A focus on prevention, rehabilitation and self care to underpin a shift of resources from hospital to community.

Better use of the potential of information technology, including telemedicine.

Development of regional clinical networks to make the best of resources and ensure provision of services to all communities.

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Recommendations

1. Support the implementation of the recommendations from Health Workforce

New Zealand Aged Care Workforce Service Review. 2. Promote a transformational “cascade of knowledge” to mitigate the shortage

of specialists and the sparse workforce for the most efficient and best clinical effect. Focus on the clinical presentations and treatment of older people, management of dementia and delirium, restorative and rehabilitation approaches.

3. Review current level of education and advice by specialist services and develop a work plan to increase education by and access to specialists in older people’s health to other sub‐specialties, community agencies, Primary Care and aged residential care.

4. Support the development of changed roles eg rehabilitation assistant, advanced specialty nursing, clinical advisers, care navigators (people with a sophisticated understanding of the services available and threaded links for referrals).

5. Increase the current level of service provision for community allied health to recommended levels.

6. Recognise the value of the unpaid/volunteer workforce, family and whanau by providing specific training and development opportunities for these groups.

7. Maximise opportunities through the BOP Clinical School to support the above. 8. Develop policies to increase workforce participation and retention of older

workers within BOPDHB. 9. Review contractual requirements for staff training in provider contracts and

introduce where necessary minimum standards and levels of attainment against nationally relevant unit standards.

10. Collaborate with and make submissions to other government agencies such as the Department of Labour to influence long term planning approaches to encourage participation in the workforce by older workers.

11. Provide incentives for community providers to include volunteers and primary carers in training programmes.

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10. Implementation Plan and Next Steps _____________________________________________________________________ A detailed implementation plan will be developed following a prioritisation process for the recommendations. It is envisaged that a number of work streams will be necessary to implement the recommendations in a staged process. Prioritisation of recommendations and resulting work streams will take into account Government and Board priorities, annual and regional planning commitments and funding availability and priorities. A prioritisation process will be developed and recommended by the Executive Council of the DHB and approved by the Board. The Strategy Steering Group has now been disbanded following development of the Strategy. It is recommended that an implementation committee be formed to prioritise the recommendations and resulting work streams (in accordance with the prioritisation process) and oversee implementation. Membership of the implementation committee will be agreed by the DHB Executive Council. Details of shifts in current funding, investments required and where appropriate, expected savings, costs avoided or reductions in forecast growth will outlined with each work stream. Approvals for contracts, funding and service reconfiguration will be subject to the current BOPDHB approval process through the Funding Management Committee.

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11. Supporting Information _____________________________________________________________________

Development of the Strategy

The development of this Strategy has included:

Review of overarching Government strategies and priorities for health of older people.

Review of international trends and priorities in health services for older people.

Review of previous local strategic work and service reviews carried out for BOPDHB and a stocktake of progress.

Review of work being carried out by other DHBs and throughout the Midland Region and consideration of what can be applied to the BOP setting.

Future demand analysis and implications from the population projections for the BOP and what we know about demand on current service provision.

Collection of base line data by the BOPDHB Planning and Funding team to measure our success and track performance.

Discussion and consultation over a period of time with BOPDHB staff, clinicians, Planning and Funding Portfolio Managers in the BOPDHB and around the country but particularly in the Midland Region, and local stakeholders groups including the Population Ageing Technical Advisory Group, about the current model of care, identified gaps and identifying solutions for the future.

Formation of a Steering Group to provide direction and develop the Strategy. The Steering Group has broad representation from the sector and includes local specialists in geriatric medicine, providers of aged care and community services, Maori Health services, needs assessment and service co‐ordination, and DHB Planning and Funding. Members are also represented on or have links with broader groups including the Population Ageing Technical Advisory Group, Positive Ageing Tauranga, Age Concern, Alzheimers Tauranga, western Bay of Plenty PHO and eastern Bay of Plenty Alliance Leadership Team, Disability Services and various community non Government organisations (NGOs).

Forums with Midland Region Health of Older People Portfolio Managers on potential regional activity and areas of alignment.

Formation of a draft strategy document to inform further discussions and stakeholder consultation.

Consultation and input from key stakeholder groups including older people themselves and NGO providers that advocate for older people, Primary Care, all providers of community based aged care services, Cluster Leaders in Tauranga and Whakatane Hospitals.

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Background Documents

The following documents have been considered in the development of this Strategy:

The New Zealand Health Strategy The New Zealand Disability Strategy The New Zealand Health of Older People Strategy Health of Older People Strategy, 2001 Positive Ageing Strategy The Carers’ Strategy Guidelines for Specialist Health Services for Older People Mental Health and Addiction Services for Older People Dementia Services

Guideline Diabetes and CVD Guidelines Better Sooner More Convenient Health Policy Health Needs Analysis for the Bay of Plenty Maori Health Plans for BOPDHB BOPDHB Programme of Care for Older People, 2003 Redesign of Specialist Services for Older People, 2005 Short Term Support Services Review for BOPDHB, 2007 PATAG Strategic Recommendations for Health, 2010 BOPDHB Annual Plan 2011/12 and 2012/13 Midland Regional Clinical Services Plan 2011/12 and Regional Plan 2012/13 Ministers Letter of Expectations for DHB for 2011/12 and for 2012/13 Midland Health Network Older Person’s Service Level Alliance Team

Recommendations National Service Framework for Older People, NHS (UK), 2000 New Zealand Clinical Guidelines for Stroke: Implementation Plan, 2011

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12. Appendices _____________________________________________________________________

Appendix 1: Terms and Abbreviations Appendix 2: Intermediate Care Service Proposed Model Appendix 3: Measures of Success Appendix 4: Acknowledgements

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Appendix 1: Terms and Abbreviations

Abbreviation Definition

ARC Aged Residential Care

BOPDHB Bay of Plenty District Health Board

HBSS Home Based Support Services, generally home help and personal care.

HIA

Health in Ageing, the secondary specialist geriatric service in Tauranga Hospital.

HQSC Health Quality and Safety Commission

NASC Needs assessment and service co‐ordination. Access to funded long term support services requires a needs assessment be carried out by a DHB approved needs assessor. In the Bay of Plenty, the DHB NASC service is Support Net.

MHSOP Mental Health Services for Older People, the secondary specialist mental health service for older people in Tauranga and Whakatane hospitals.

SHSOP Specialist Health Services for Older People. This is the combined services of HIA and MHSOP.

STSS Short Term Support Services, generally home help and personal care provided for people after an admission to hospital.

TIA Transient Ischaemic Attack

WHO World Health Organisation

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Appendix 2: Intermediate Care Service ‐ Proposed Model

Key: CRT = Community Response Team AHP = Allied Health Professionals

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Appendix 3: Measures of Success

The following table outlines indicators or measures of improved performance that we can expect to see as implementation of the recommendations progresses. These measures have been selected based on availability of current data (either through our own data base or reported to us by providers through Performance Monitoring Returns). The implementation plan may identify gaps in current data collection which may require changes to our current data collection systems, service specifications or provider contracts. The implementation plan will provide detail on targets for performance improvement associated with each work stream. Where indicated, some measures are expected to be monitored and reported on in the DHB Annual Plan 2012/13.

Standards Measure of Success

2012/13 Annual plan

measure

A. Community Health Prevention and Information

Older people, their carers, family and whanau are informed about their choices. Government agencies and local government develop policies that are age‐friendly and responsive and reflect opportunities and impacts of population ageing. Increase percentage of people in age residential care facilities are prescribed Vitamin D. Increased percentage of the population of people age over 65 receive influenza vaccine.

√ √

B. Person Centred Care Increased proportion of the population who identify as Maori are accessing services. Increased awareness and identification of elder abuse Increase in number of people diagnosed with a terminal illness have an Advance Care Plan

C. Integrated Care and Community Services

Bay Navigator pathways that are relevant to older people are developed. Reduction in the rate of growth of acute or unplanned admissions to hospital for people over the age of 65 Reduction in the rate of growth of readmissions to hospital for people over the age of 75 The proportion of the population over the age of 65 that is supported in long term aged residential care

√ √ √

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2012/13 Annual plan

measure

is reduced. The number of people that are assessed as requiring long term age residential care following an acute admission to hospital is reduced. There is an increase in utilization rates for respite care and carer support

D. Hospital Care An increase in the proportion of patients over 65 admitted acutely to hospital return to live independently in their own homes The number of people that are assessed as requiring long term age residential care following an acute admission to hospital is reduced. The proportion of the population over the age of 65 that is supported in long term aged residential care is reduced. Reduced average length of stay in hospital for all patients over 65. Increased access by primary and community providers to specialist geriatric advice and education.

√

E. Aged Residential Care The proportion of the population over the age of 65 that is supported in long term aged residential care is reduced. The average length of stay in residential care is reduced. An increase in the number of residents in long term residential care who have a comprehensive clinical assessment and care plan developed using InterRAI Long Term Care Tool. Reduced unplanned admissions to hospital from residents in aged residential care An increase in the number of providers certified with the Ministry of Health who are certified for a three year period or more. A reduction in the number of formal complaints received by the DHB

√

F. Dementia Reduced average length of stay for patients in MHSOP

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2012/13 Annual plan

measure

Reduction in the number of acute admissions to MHSOP A pathway for dementia care is developed through Bay Navigator. The rate of expected growth in the proportion of the population with dementia admitted to long term residential care is reduced.

√

G. Mental Health on Older People

Reduced average length of stay for patients in MHSOP Reduction in the number of acute admissions to MHSOP

H. Stroke and TIA A pathway for TIA is developed through Bay Navigator Increase in percentage of patients presenting with a TIA that are treated within recommended time frames as set out in the NZ Stroke Guidelines. Reduction in the percentage of people with a TIA who develop a disabling stroke. An increase in the percentage of people who have a stroke who return to live independently and in their own homes.

I. Falls and Bone Health Reduction in the number of people over 65 who present to the Emergency Department with a fracture following a fall. Decrease in prevalence of osteoporosis

J. Medications Management To be developed.

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Appendix 4: Acknowledgements

There were a range of people, including members of the community, hospital clinicians and business leaders, service providers and primary care providers who have all provided valuable input, advice and expertise in the development of this Strategy. BOPDHB thanks you all for your contributions. In particular we acknowledge the following people:

Bronwen Foxx, CEO Disability Resource Centre, Whakatane, Member CPHAC/DSAC Dorothy Stewart, Community Member, Age Concern, Elder Forum Trevor Deane, Regional Manager, Access Tony Lawson, Nurse Practitioner, Health in Ageing Dr Elizabeth Spellacy, Clinical Director, Health in Ageing Dr Nicola Cooper, Senior Medical Officer, Health in Ageing Rosemarie Webb, Regional Team Leader over 65 Team, Support Net Sharon Linwood, Clinical Co‐ordinator, Mental Health Services for Older People Sandra Fielding, Nurse Leader, Medical Cluster, BOPDHB Joop Wieringa, Manager, Hodgson House, ARC Provider, Secretary BOP branch NZACA Judi Harpur, Manager Ngati Kahu Hauora Enid Ratahi‐Pryor, CEO Ngati Awa Social and Health Services, eastern BOP Alison Wieringa, Service Manager, Enliven, Presbyterian Support Northern Philippa Jones, Primary Nurse Liaison, Western BOP PHO and Planning and Funding BOPDHB. Kiri Peita, Senior Portfolio Manager, Maori Health Planning and Funding, BOPDHB Sarah Davey, Portfolio Manager, Health of Older People, Planning and Funding, BOPDHB

Kia Momoho Te Hapori Oranga – Healthy, Thriving Communities

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Measuring our success Some of our key measures which will demonstrate our success

and contribute to national, regional and local objectives are:

5‐10 year outcomes:

People take greater responsibility for their health

People stay well in their homes and communities

People receive timely and appropriate care

3‐5 year impacts:

1. Older people, their carers, family and whanau are supported and informed about their choices.

2. Government agencies and local government develop policies that are age‐friendly and reflect opportunities and impacts of population ageing.

3. The growth rate of acute or unplanned admissions to hospital for people over the age of 75 is reduced.

4. The proportion of people over 65 admitted acutely to hospital, who then return to live independently in their own homes, increases.

5. The proportion of eligible people over 65 that are supported in their own homes increases.

6. The proportion of eligible people over 65 living in long term residential care reduces.

7. More older Maori are supported to live independently in their own homes for longer.

8. More people with dementia are able to live in the community.

Funding The BOPDHB will receive a total of $622M during 2012/3 to fund

its activities, including services for older people:

The full document is available on the Bay of Plenty District Health Board website:

www.bopdhb.govt.nz

Published in July 2012 by the

Bay of Plenty District Health Board P O Box 12024, Tauranga, 3143

See also our Annual Plan 2012/13, Maori Health Plan and the Midland Regional Services Plan.

Our vision: Healthy, independent and dignified ageing

Our Objectives: To provide quality health and disability services for our growing older population that:

Promote, improve, and support healthy, independent and dignified ageing;

Have an integrated approach across the continuum of care;

Reduce the demand on related high cost service expenditure to levels that can be sustained within current financial constraints;

Reduce duplication in the health system;

Are simple, streamlined and efficient.

BOPDHB Health of Older People Strategic Plan 2012 ‐ 2017

“The current economic climate is seen by many as a crisis. We see an opportunity, as a DHB, to pursue new and better ways of doing things.”

Phil Cammish, Chief Executive Officer

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About older people in the Bay The Bay of Plenty’s warm sunny climate and pleasant coastal geography have provided an attractive retirement destination for many decades. The district experiences one of the highest proportions of older people in New Zealand. Our population of people aged over 65 is projected to grow by 84% in the 20 years between 2006 and 2026, the majority in the western BOP. However, the populations of rural or smaller towns in the Bay of Plenty, particularly the eastern BOP, while declining are also ageing. Most older people are well, independent and living in their own homes. However, as a group they have a much greater need for health and disability services than the young, so a significant proportion of health and social care resources are directed at their needs. Older Maori have low access rates of health and support services in comparison to non‐Maori and this contributes to health inequalities. Better quality health and disability care for older people can result in improved health outcomes and reduced projected costs in the future. It is preferable to maintain older people independent and living in their own homes for as long as possible.

Our 5 year focus

Our Strategy identifies nine standards that encompass the Government’s Health of Older People Strategy (2002) and includes:

promotion of health and wellbeing through education, information, prevention and restoring function;

a stronger focus on service integration with community services and primary care;

development of services that aim to address health problems that are particularly significant for older people, such as

o stroke; o falls and bone health; o dementia and mental health in older people;

and o medications management.

Recommendations in brief:

Promote active ageing

Promote risk assessment and targeted interventions for all people over the age of 75 and at highest risk

Enhance access to services for older Maori

Redesign home based support services to a restorative model of care

Develop clinical pathways that are relevant to older people.

Enhance specialist health services for older in our hospitals.

Improve access to education and advice from specialist services to residential care and primary care.

Implement an organised stroke service.

Develop flexible, integrated community services such as Intermediate Care

Support quality improvements for aged residential care.

Establish a coordinated, integrated dementia service.

Improve support to primary carers of people with dementia.

Educate patients, carers and health professionals around falls prevention and osteoporosis.

Promote education on advance care planning

Support the safe transfer of medication information between care environments.

Promote use of medication reconciliation for high risk patients.

Plan for workforce changes necessary to support these recommendations.

We will achieve our goals by working in partnership with

older people, families and whanau, local government

and other agencies, DHBs in the Midland region, Primary

Health Organisations, Aged Residential Care and

Community Providers.

A new approach is recommended that integrates health

and welfare services, connects families and communities,

and develops programmes that delay the onset of

disability, ameliorate its trajectory and enhance older

people’s capacity to take better care of themselves.

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BOPDHB Adult Palliative Care Services Plan 2011-2016 SUBMITTED TO: Board Meeting: 18 July 2012 Prepared by: Sarah Davey, Portfolio Manager, Health of Older People, Planning and

Funding Kiri Peita, Senior Portfolio Manager, Maori Health Planning and Funding Endorsed by: Helen Mason, General Manager, Planning and Funding Janet McLean, General Manager, Maori Health Planning and Funding Submitted by: Helen Mason, Acting Chief Executive RECOMMENDED RESOLUTION: That the Board:

1. Endorses the BOPDHB Adult Palliative Care Services Plan 2011-2016 (“the Services Plan”) a copy of which is attached.

2. Notes that the Services Plan has been endorsed by CPHAC/DSAC and the Clinical Board. 3. Notes the proposal for the implementation and next steps outlined below. 4. Notes that the full version of the Services Plan is to be prepared for publishing by the

Communications team in conjunction with the Midland Cancer Network. The published version may include photographs and incorporate some minor formatting and style changes.

5. Notes that a ‘”light” version of the Services Plan will be developed by the Midland Cancer Network in conjunction with the Communications Team.

ATTACHMENTS: BOPDHB Adult Palliative Care Services Plan 2011-2016

BACKGROUND: The purpose of BOPDHB Adult Palliative Care Services Plan (“Services Plan”) is to review the current progress of palliative care service development in Bay of Plenty District Health Board and to identify actions for local palliative care services for the period 2011 to 2016, and to inform our Annual Plan. It is intended be a living document and will be reviewed and updated as required, particularly when current national palliative care projects are completed and require implementation. Support for and development of the draft document for consultation has been provided by the Midland Cancer Network. The Services Plan has been developed over the past 12 months or so, in collaboration with palliative care service providers in the Bay of Plenty including specialist and generalist providers of palliative care and secondary services. The Plan aligns with work being undertaken by the Midland Palliative Care Network.

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The focus of the Services Plan is adult palliative care services inclusive of malignant and non-malignant life threatening disease. Currently work is happening at a national level to develop the model of care for paediatric palliative care in New Zealand. A separate paediatric palliative care plan for Midland region and local networks will be prepared once the national guidance document is received. It has been assumed that funding will be limited during this period and it is unlikely there will be any new funding for existing palliative care services from the Ministry of Health. The focus of the plan is to better manage the forecast growth in demand in palliative care within existing resources. The process to develop this document has included: High level review of overarching government palliative care strategies and objectives High level review of international trends and priorities in developing palliative care services Review of previous local palliative service plans or similar Review of the recommendations from the Gap Analysis of Specialist Palliative Care in New

Zealand Analysis of hospice patient demographics and trends from the palliative care monitoring returns Estimation of some future demand implications from the population projections and what we

know about current services Discussion and consultation with stakeholders about the current model of care and services

delivered. Specific sessions were held to focus on: o Eastern Bay of Plenty o Western Bay of Plenty o Māori (regional session although there was no Bay of Plenty Māori present at this

meeting and some discussion palliative care at a local hui with Māori providers) o Paediatric palliative care (including representatives from Starship Hospital)

Implementation and next steps It is intended that implementation of agreed actions contained in the Services Plan will be the responsibility of BOPDHB overseen by the BOPDHB Palliative Care Network with programme support from Midland Cancer Network. Implementation of the agreed regional activities and projects will be the responsibility of the Midland Palliative Care Workgroup. At its recent meeting in June, the BOPDHB Palliative Care Network identified the following priorities over the next 12 months:

1. Development of Hospital Palliative Care service Links to recommendations 8.2.1(a), 8.2.1 (k) and 8.2.4 (e)

2. Development of Community Support (home care & aged residential care) Links to recommendation 8.2.1.(j)

3. Education and training (inclusive of the wider sector) Links to recommendations 8.2.1 (c) (e) (f) (g) (i), 8.2.2 (h) 8.2.1 (d), 8.2.2 (d), 8.2.6 (a)

Endorsement The Services Plan has been endorsed by both CPHAC/DSAC and the Clinical Board. The final version presented to the Board includes some minor amendments following engagement with CPHAC/DSAC and the Clinical Board, formatting and numbering changes.

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Bay of Plenty Palliative Care Service Planning Page 1 of 94 FINAL V1.4

Bay of Plenty

Adult Palliative Care Service Plan

2011- 2016

Author: Sharon Hardaker, Midland Cancer Network

Last Updated: 3 June 2012

Document Name: Bay of Plenty Adult Palliative Care Service Plan

Version: V 1.4 FINAL

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Revision history

Date Author Summary of Changes Version

5/07/2011 Midland PC Work Group planning discussion and

discussions with national representatives on national

projects

7 /12/2011 S Hardaker Midland Palliative Care Work Group review of

Outcomes Framework and draft of Midland PC

priorities aligned to the framework.

19/09/2011 S Hardaker Draft sections of plan developed for discussion with

BOP Palliative Care Work Group

Oct - Feb S Hardaker Sections sent to ‘experts’ for review and completion

23/02/2012 S Hardaker Draft plan developed and presented for discussion

and review by BOP Palliative Care Work Group

V1.0

16/03/2012 S Hardaker Incorporating BOP Palliative Care Work Group

feedback (refer to minutes of 27 February), feedback

from stakeholders and general editing.

V1.3

4/06/2012 S Hardaker Incorporating feedback from Clinical Board. FINAL V1.4

Distribution

Name Title Issue Date Version

BOP Palliative Care Work Group Draft for discussion 21/02/2012 V1.0

BOP Planning & Funding

PHO CEOs Hospice CEOs Copy to BOP PC Work Group

Final draft for endorsement of

CPHAC/DSAC and Clinical Board

20/03/2012 V1.0

V1.3 (update)

DHB Planning & Funding for

BOP DHB Board

FINAL 4/06/2012 V1.4

Approvals

Approver Signature Issue Date Version

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Table of Contents

Executive summary .................................................................................................................. 5

1. Overview........................................................................................................................... 8

1.1. Introduction...........................................................................................................8

1.2. Service planning process......................................................................................8

2. Strategic Context ............................................................................................................ 10

2.1. Background documents ......................................................................................10

2.2. Treaty of Waitangi...............................................................................................10

2.3. What is palliative care?.......................................................................................11

2.4. Strategic vision ...................................................................................................11

2.5. Defining palliative care........................................................................................11

3. National palliative care work plan.................................................................................... 15

3.1 Specialist palliative care service specifications ...................................................15

3.2 National health needs assessment for palliative care..........................................15

3.3 Resource and capability framework (role delineation model) ..............................15

3.4 Health Workforce New Zealand palliative care workforce service review ............16

3.5 National specialist palliative care data definitions and business process ............16

3.6 Measuring What Matters: Palliative Care ............................................................16

3.7 Liverpool Care Pathway (LCP)............................................................................17

3.8 Advance care planning for adults........................................................................17

3.9 The Gold Standards Framework (GSF) ..............................................................17

3.10 Palliative care education and standards..............................................................18

4. Midland region context.................................................................................................... 19

5. Local Bay Of Plenty DHB palliative care ......................................................................... 20

5.1. Bay of Plenty District Health Board strategies.....................................................20

5.2. Bay of Plenty palliative care strategy 2003..........................................................21

5.3. Bay of Plenty DHB geographic and population demographics ............................22

5.4. Health needs of specific population groups.........................................................24

5.5. Current Palliative Care Services .........................................................................27

5.6. Specific Bay of Plenty initiatives..........................................................................36

5.7. Funding ..............................................................................................................40

6. The future ....................................................................................................................... 43

6.1. Increasing need for palliative care.......................................................................43

6.2. Capacity to meet future demand. ........................................................................50

6.3. Specialist palliative care workforce development ................................................52

6.4. Hospital based specialist palliative care..............................................................56

7. Summary of key strengths and issues ............................................................................ 57

7.1. Strengths ............................................................................................................57

7.2. Issues and gaps..................................................................................................57

8. Vision and recommendations.......................................................................................... 59

8.1 Vision..................................................................................................................59

8.2 Recommendations..............................................................................................59

List of appendices 1. National documents/reviews – additional detail 2. Outcomes Framework 3. Bay of Plenty population trends 4. Service description for Waipuna Hospice 5. Service description for Hospice Eastern Bay of Plenty 6 Illness trajectories and palliative care 7. Palliative care in acute general hospitals: international examples 8. Western Bay of Plenty: Stakeholder summary 9. Eastern Bay of Plenty: Stakeholder summary

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List of Figures Figure 1: The palliative care “system”.................................................................................... 14

Figure 2: Diagnosis of hospice patients – Hospice Eastern Bay of Plenty ............................. 45

Figure 3: Diagnosis of hospice patients – Waipuna Hospice ................................................. 46

Figure 4: Hospice EBOP patients – place of death ................................................................ 47

Figure 5: Waipuna Hospice Patients - Place of Death ........................................................... 48

Figure 6: Number of deaths by territorial authority – actual and projected ............................. 48

List of Tables Table 1: Characteristics of the BOP DHB by territorial authority ............................................. 23

Table 2: Overview of providers of palliative care.................................................................... 27

Table 3: PHOs in Bay of Plenty and enrolled population as at Quarter 1, 2012 ..................... 28

Table 4: Bay of Plenty Residential Care Beds ....................................................................... 31

Table 5: Residential care contracted beds for palliative care ................................................. 32

Table 6: Diagnosis hospice patients 2008-2010 .................................................................... 45

Table 7: Ratio of deaths in hospital – BOP 2007-2010 .......................................................... 47

Table 8: Place of death of hospice patients - 2010 ................................................................ 47

Table 9: Mid range estimate of the number of adults who would benefit from palliative care . 49

Table 10: Waipuna Hospice referrals..................................................................................... 50

Table 11: Hospice EBOP referrals......................................................................................... 50

Table 12: Required specialist inpatient beds per 100,000 population / benchmarks ............. 51

Table 13: BOP palliative care staff requirements.................................................................... 53

List of commonly used abbreviations

BOP Bay of Plenty

BOP DHB Bay of Plenty District Health Board

DHB District Health Board

EBOP Eastern Bay of Plenty

EN Enrolled nurse

GP General practitioner

LCP Liverpool Care Pathway

MOH Ministry of Health

NASC Needs Assessment and Service Coordination

NGO Non-government organisation

PHA Primary Health Association

PHO Primary Health Organisation

P&F Planning and Funding

RMO Resident medical officer

RN Registered nurse

WBOP Western Bay of Plenty

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Executive summary Palliative care is a concept of care which focuses on relieving suffering and achieving the best possible quality of life for patients with a life limiting illness and their family/whānau caregivers. It provides coordinated medical, nursing and allied health services including pastoral care services, delivered where possible in the environment of the person’s choice. It includes the provision of grief and bereavement support for families, whānau and carers during the life of the patient and following his or her death. The New Zealand Palliative Care Strategy was launched in February 2001 with the aim of setting in place a systemic and informed approach to the future provision and funding of palliative care services and to ensure that all people who are dying and their family/whānau have access to palliative care services, provided in a co-ordinated and culturally appropriate way. The purpose of this plan is to review the current progress of palliative care service development in Bay of Plenty District Health Board (DHB) and to identify actions for local palliative care services for the period 2011 to 2016. This will be a living document and will be reviewed and updated as required, particularly when current national palliative care projects are completed and require implementation. As the Bay of Plenty DHB population grows and ages, with an increasing incidence of cancer, a growth in chronic life-threatening disease and people with multiple co-morbidities, and changing family support structures there will be increasing demand for all levels of palliative care services and an increase in the complexity of care. There has been considerable additional investment by the Ministry of Health in palliative care services (particularly hospices) in the past few years and so it is assumed there is unlikely to be any significant increases (if any) in funding for specialist palliative care services in the foreseeable future. In a financially constrained environment there will be challenges meeting the increasing service demands. The focus for the recommendations in this plan is on service improvement, improved relationships and building capacity and capability within the generalist level enabling the specialist services to focus on providing education and support for generalists and direct care for patients with the most complex needs. A key focus must be on prioritising the allocation of resources and how to organise or deliver services differently to live within the service’s means. The Bay of Plenty has a well developed community based model of palliative care. Specialist palliative care services receive strong community support and recognition. There are service gaps and access issues to some essential services and a collaborative approach between the PHOs, specialist palliative care services, Māori health providers and the DHB is required to find sustainable solutions. The need to develop in-hospital palliative care has been recognised as a gap and should form a major focus for the next phase of development of palliative care services in Bay of Plenty. It is not seen as being necessary to make any major changes to the current model of care operating in Bay of Plenty DHB. However, it is acknowledged that the national project to develop a Resource and Capability Framework for delivery of palliative care services in New Zealand may require changes to be planned and implemented. This will be considered during 2012 when the outcome of the current national project is known. There are opportunities identified to work with other palliative care services in Midland to share resources and knowledge, reduce duplication and create consistency across the Midland region. This will form the basis of the regional palliative care workplan. The palliative care strategic vision is that all people who have a life limiting illness and their family/ whānau who could benefit from palliative care have timely access to quality palliative care that is culturally appropriate and provided in a coordinated way. Three long term outcomes are considered necessary to achieve the vision. • Access to palliative care regardless of setting • All palliative care providers are configured to ensure a seamless care pathway • Palliative care provision is high quality. Each of the long term outcomes have supporting objectives and actions recommended for implementation over the next five years. These have been summarised as:

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1. Access to palliative care regardless of setting 1.1 Ensure sufficient capacity within primary and specialist palliative care

- sufficient workforce and appropriate services and infrastructure (a) Scope and implement (using a phased approach) a district wide hospital specialist

palliative care team/service. Consider the model of care required to improve access to palliative care medical specialist in Eastern Bay of Plenty

(b) Investigate opportunities to implement virtual medical services e.g. video conference (c) Consider strengthening the palliative medicine workforce through regional co-operation (d) Develop a workforce plan to address identified areas of skill shortage (e) Implement the Hospice NZ education programme ‘Fundamentals of Palliative Care’ (f) Implement cultural competency education for health professionals in specialist palliative

care services where required (g) Develop and implement topic specific education sessions for palliative care health

professionals (h) Ensure access to clinical supervision (i) PHOs to integrate palliative care into education and training plans of primary practices (j) Improve consistency of access to NACS funding and other supportive care services (k) Explore opportunities to enable hospice medical specialist’s access to diagnostic and

treatment services in Tauranga Hospital (l) PHOs to develop and implement sustainable solutions for 24/7 access to a general

practitioner (m) Improve patient access to primary palliative care services (n) Review access to grief and bereavement services in Bay of Plenty particularly for those

people who are not referred to specialist palliative care services (o) Improve access to emergency/out of hours medication related to palliative care (p) Develop consistent criteria, guidelines and other resources (q) Develop community strategies to manage patients in their home and minimise inpatient

demand (r) EBOP district nursing and Hospice EBOP review current nursing arrangement and look at

opportunities to improve. 1.2 Ensure appropriate referrals to specialist palliative care services

- awareness of palliative care referral processes and understanding of palliative care principles.

(a) Document access criteria and referral processes (b) Develop a Bay of Plenty palliative care service directory (c) Review and strengthen website content of Bay of Plenty DHB, hospices, Māori Health

providers, PHOs and other relevant NGOs (d) Develop and implement a communication plan for palliative care health promotion (e) Develop a Bay Navigator project for palliative care (f) Review and standardise palliative care patient/family/whānau information (g) Ensure hospitals and other PHO and NGO services have policies and protocols reflecting

the palliative care approach (h) Educate providers in the palliative care approach through the development of orientation

and/or education sessions.

1.3 Support and align with national work programme priorities

(a) Apply Resource and Capability Framework to the Midland region (b) Implement other national work programme initiatives as they become available i.e. service

specifications and any new funding models. (c) Consider Ministry of Health EOI for the development and evaluation of a managed clinical

network and submit proposal, if appropriate, for the Midland region. (d) Implement the HISO National Specialist Palliative Care Data and Business Process

Standard when finalised.

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2. All palliative care providers are configured to ensure a seamless care pathway 2.1 Ensure there is continuity and coordination of care

o appropriate links between services o appropriate role delineation between providers o shared strategic vision across the region o appropriate information sharing.

(a) Refresh the Bay of Plenty Palliative Care Work Group to lead implementation of this plan (b) Develop service level agreements between specialist palliative care services and others (c) Develop a process to ensure every palliative patient has a nominated care coordinator

and there is a plan for continuity of care after hours (d) Complete the implementation of PalCare into hospices, scope system integration with (or

access by) primary, hospital and other specialist services (e) Bay of Plenty DHB to consider hospice staff access to relevant patient information (f) Scope requirements to capture national minimum palliative care dataset (g) Scope and understand how NGOs can contribute to the national initiative of shared care

record.

3. Palliative care provision is high quality 3.1 Best practice is followed in delivering palliative care

- standards for palliative care services are met; there is an interdisciplinary team approach to palliative care, and patient pathways are followed.

(a) Implement the Hospice New Zealand Standards

(b) Complete implementation of Liverpool Care Pathway (LCP) and monitor utilisation (c) Implement the LCP reflective data cycle (d) Encourage and promote research opportunities (e) Support the implementation of Advanced Care Planning with primary and specialist

services.

3.2 Palliative care meets the needs of patients, their families and whānau

- culturally appropriate care, meeting the needs of specific population groups and effective treatments and support.

(a) Understand education and support needs for Māori health providers to inform palliative

care education planning and service development (b) Support specialist palliative care services to carry out cultural audits of services (c) Participate in the development of national or regional clinical guidelines and standards (d) Develop relationships with other services for support with care of people with non

malignant conditions, multiple co-morbidities and/or dementia (e) Explore strategies to improve patient transport between providers (f) Develop a Kaupapa Māori palliative care approach.

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1. Overview

1.1. Introduction

The New Zealand Palliative Care Strategy1 was launched in February 2001 with the aim of setting in

place a systemic and informed approach to the future provision and funding of palliative care services. The focus of the strategy was on the setting up of services in New Zealand and had a 5 to 10 year vision. Since the strategy was launched considerable progress has been made in the establishment and development of the palliative care services and workforce in New Zealand. The Ministry of Health (MOH) has provided additional funding to support the implementation of the national strategy. A number of national projects are currently underway that demonstrate progress in achieving the vision and provide clarity in areas identified as requiring further development. The purpose of this service plan is to review the current progress of palliative care service development in Bay of Plenty DHB (BOP DHB) and to identify priorities and actions for local palliative care services for the period 2011 to 2016. This will be a living document and will be reviewed and updated as required, particularly as the national palliative care projects are completed and require local implementation. There has been considerable additional investment by the Ministry of Health in palliative care services (particularly hospices) in the past few years and so it is assumed there is unlikely to be any significant increases (if any) in funding for specialist palliative care services in the foreseeable future. Due to increasing population and demand we expect there will be increased pressure on services. Therefore, a key focus must be on prioritising the allocation of resources and how to organise or deliver services differently to live within the service’s means. The DHB works with other Midland DHBs to advance palliative care services for both the Bay of Plenty area and the Midland region as a whole. Activities that can be facilitated by regional cooperation and are of benefit to all DHBs in Midland have been identified and will be included in a regional palliative care overview (separate to this plan).

1.2. Service planning process

This process has included: • high level review of overarching government palliative care strategies and objectives • high level review of international trends and priorities in developing palliative care services • review of previous local palliative service plans or similar • review of the recommendations from the Gap Analysis of Specialist Palliative Care in New Zealand

2

• analysis of hospice patient demographics and trends from the palliative care monitoring returns • estimation of some future demand implications from the population projections and what we know

about current services • discussion and consultation with stakeholders about the current model of care and services

delivered. Specific sessions were held within: o Eastern Bay of Plenty (EBOP) o Western Bay of Plenty (WBOP) o Māori (regional session although there were no Bay of Plenty Māori present at this

meeting as well as some discussion on palliative care at a local hui with Māori providers)

o Paediatric palliative care (including representatives from Starship Hospital).

The focus of this service plan is adult palliative care services inclusive of malignant and nonmalignant life threatening disease. Currently work is happening at a national level to develop the model of care for

1 Ministry of Health: The New Zealand Palliative Care Strategy, Wellington NZ, February 2001

2 Ministry of Health: Gap Analysis of Specialist Palliative Care in New Zealand – Providing a national overview of hospice and hospital-based services, Wellington, December 2009.

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paediatric palliative care in New Zealand. A separate paediatric palliative care plan for the Midland region and local networks will be prepared once the national guidance document is received. It has been assumed that funding will be limited during this period and it is unlikely there will be any new funding for existing palliative care services from the MOH. Implementation of agreed actions contained in the local DHB plans will be the responsibility of the DHBs using their local cancer and/or palliative care forums with programme support from Midland Cancer Network. Implementation of the agreed regional activities and projects will be the responsibility of the Midland Palliative Care Work Group.

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2. Strategic Context

2.1. Background documents

The following key documents have been considered alongside the New Zealand Palliative Care Strategy: • New Zealand Cancer Control Strategy (2003) • New Zealand Cancer Control Strategy Action Plan 2005-2010 (March 2005) • Primary Health Care Strategy, February (2001) • He Korowai Oranga: Māori Health Strategy (2002) • Health of Older Persons Strategy (2002) • Report of the Palliative Care Expert Working Group to the Cancer Control Steering Group (February

2003) • Specialist Palliative Care Service Specifications (Draft 2008) • Gap Analysis of Specialist Palliative Care in New Zealand (December 2009) • Positioning Palliative Care in New Zealand (February 2010) • National Health Needs Assessment for Palliative Care: Phase 1 Report (June 2011) • Bay of Plenty District Health Board District Strategic Plan 2005-2015 • Bay of Plenty Maori Health Strategic Plan 2001-2010 • Bay of Plenty DHB Health Needs Analysis (September 2008) • Palliative Care Health Workforce Service Review, Health Workforce NZ (April 2011) • Resource and Capability Framework for Adult Palliative Care Services in New Zealand (Draft Nov

2011) • Measuring What Matters – Palliative Care (Draft November 2011)

2.2. Treaty of Waitangi

The Government and district health boards recognise the Treaty of Waitangi as the founding document of New Zealand and acknowledge the special relationship between Māori and the Crown under the Treaty. Central to the treaty relationship and the acknowledgement of the treaty principles is a common understanding that Māori will have an important role in developing and implementing health strategies for Māori. The relationship must be based on the following principles: • partnership - Working together with iwi, hapū, whānau and Māori communities to develop strategies

for improving the health status of Māori. • participation - Involving Māori at all levels of the sector, in decision-making, planning, development

and delivery of health and disability services that are put in place to improve the health status of Māori.

• protection – Ensuring Māori wellbeing is protected and improved as well as safeguarding Māori cultural concepts, values and practices.

He Korowai Oranga: Māori Health Strategy

3 sets the direction for Māori health development in the health

and disability sector. The strategy provides a framework for the public sector to take responsibility for the part it plays in supporting the health status of whānau. The overall aim of He Korowai Oranga is Whānau Ora - Māori families supported to achieve their maximum health and wellbeing. This is an inclusive approach to providing services and opportunities to families across New Zealand. It empowers families as a whole, rather than focusing separately on individual family members and their problems. It requires multiple Government agencies to work together with families rather than separately with individual family members.

3 Ministry of Health. 2002. He Korowai Oranga: Māori Health Strategy. Wellington: Ministry of Health http://www.health.govt.nz/publication/he-korowai-oranga-maori-health-strategy

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2.3. What is palliative care?

Palliative care is a concept of care, rather than a particular mode of treatment. It is not a specialty in isolation and does not take exclusive ownership of palliative care. It is a philosophy of care to be owned by the healthcare community as a whole and delivered in all clinical settings. Palliative care focuses on relieving suffering and achieving the best possible quality of life for patients and their family/whānau caregivers. It provides coordinated medical, nursing and allied health services including pastoral care services, delivered where possible in the environment of the person’s choice. It includes the provision of grief and bereavement support for families, whānau and carers during the life of the patient and following his or her death. Palliative care is often not well understood. In some cases it is believed to be just terminal care or end-of-life care, that it is the alternative to life-prolonging or curative care, that it is hospice care, or that it is only available for those that have cancer. Historically the majority of people accessing specialist palliative care services have had a cancer diagnosis however there is now an increasing recognition of the value of palliative care for people with progressive nonmalignant diseases (such as cardiovascular and cerebrovascular diseases, diseases of the respiratory system, advanced organ failure and degenerative neurological diseases). We are now seeing an increasing trend of patients with this wider range of non-malignant diseases also accessing palliative care services. There is now greater understanding that inclusion of a palliative approach should not be delayed until the end stages of an illness. There is value in a palliative approach alongside curative treatment, particularly to support people with chronic progressive illnesses over many years.

2.4. Strategic vision

The national vision for provision of palliative care services as described in the New Zealand Palliative Care Strategy is that: All people who are dying and their family/whanau who could benefit from palliative care services have timely access to quality palliative care services that are culturally appropriate and are provided in a coordinated way. Underpinning this vision is a community-based model of palliative care services. Palliative care services are described as providing holistic care – that all aspects of people's needs, physical, psychosocial, spiritual and cultural be taken into account and seen as a whole. From a Māori perspective this is encapsulated in the philosophy ‘Te Whare Tapa Wha’ (four sided house). This model for wellbeing includes the components Te Taha Hinengaro (psychological health), Te Taha Wairua (spiritual health), Te Taha Tinana (physical health) and Te Taha Whānau (family health).

2.5. Defining palliative care

In 2001, the New Zealand Palliative Care Strategy defined palliative care as:

‘the total care of people who are dying from active, progressive diseases or other conditions when curative or disease modifying treatment has come to an end. Palliative care services are generally provided by a multidisciplinary team that works with the person who is dying and their family/whānau.” In 2002, the World Health Organisation (WHO) redefined palliative care for adults as:

‘an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’ (World Health Organisation, 2002)

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This WHO definition reflects a fundamental shift internationally in recognising that the provision of

palliative care is applicable at any stage after diagnosis of a life limiting illness4, wherever there is a

need and wherever the patient is, and not just at the very end of life (terminal phase). In 2007, the Palliative Care Subcommittee of the New Zealand Cancer Treatment Working Party further developed the definition resulting in the current working definition of palliative care. This took into consideration the fundamental place of the Treaty of Waitangi, the evolving practice of palliative care, the diversity of cultures, the importance of primary care and the need to integrate specialist and generalist palliative care. The New Zealand definition of palliative care that is now widely referred to is

Care for people of all ages with a life limiting illness which aims to: 1. Optimise an individual’s quality of life until death by addressing the person’s physical,

psychosocial, spiritual and cultural needs. 2. Support the individuals family, whānau and other caregivers where needed, through the

illness and after death.

Palliative care is provided according to an individual’s need, and may be suitable whether death is days, weeks, months or occasionally even years away. It may be suitable when treatments are being given aimed at improving quantity of life.

It should be available wherever the person may be.

It should be provided by all healthcare professionals, supported where necessary, by specialist palliative care services.

Palliative care should be provided in such a way as to meet the unique needs of individuals from particular communities or groups. These include Māori, children and young people, immigrants, refugees, and those in isolated communities.

5

The definition identifies both generalist and specialist levels of palliative care, which should be part of an integrated framework of care provision. This may be facilitated through local and regional networks with defined formal linkages to key services including community primary care, local acute hospitals, regional cancer centres and other regional palliative providers.

Generalist palliative care is palliative care provided for those affected by life-limiting illness as an integral part of routine standard clinical practice by any healthcare professional who is not part of a specialist palliative care team. This is also sometimes referred to as primary palliative care. Generalist palliative care is provided in the community by general practice teams, Māori health providers, allied health teams, district nurses, and aged residential care staff etc. It is provided in hospitals by general ward staff, as well as disease specific teams – for instance oncology, respiratory, renal and cardiac teams. Not all patients who have a life limiting illness will need specialist care. Primary health practitioners (usually GPs, practice nurses and district nurses) appropriately care for many patients with palliative care needs. These practitioners need to be able to refer and/or seek advice from specialist palliative care services when necessary. For the majority of patients this will be for assessment or periodic review with the responsibility for ongoing care remaining with the primary health care provider. For patients with more complex care needs, care will involve a specialist palliative care service in conjunction with the primary health care service. 24 hour/7 day access to specialist palliative care advice, support and consultation is essential to ensure quality care and to build the skills and confidence of the primary health services.

4 Life limiting illness is used to describe ‘illnesses that can be reasonably expected to cause the death of the patient

within the foreseeable future. This is inclusive of malignant and non-malignant illness. This differs from chronic illnesses where, even though there may be significant impact on the patients abilities and quality of life, there is less likely to be a less direct relationship between the illness and the person’s death’. Palliative Care Australia. (2005). A Guide to Palliative Care Service Development – a population based approach. 5 NZ Cancer Treatment Working Party. The New Zealand Definition of Palliative Care,: Wellington 2007

www.health.govt.nz/system/files/.../nz-palliative-care-definition-oct07.pdf

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Specialist palliative care is palliative care provided by those who have undergone specific training and/or accreditation in palliative care/medicine, working in the context of an expert interdisciplinary team of palliative care health professionals. Specialist palliative care is provided through accredited services (or organisations) that work exclusively in palliative care and meet specific palliative care standards as they are developed nationally. This is usually by a hospice or hospital-based palliative care team where patients have access to at least medical and nursing palliative care specialists. Specialist palliative care practice builds on the palliative care provided by generalist providers and reflects a higher level of expertise in complex symptom management, psychosocial support, grief and bereavement support. Specialist palliative care provision works in two ways.

1. Directly – to provide direct management and support to patients and families/ whānau where more complex palliative care need exceeds the resources of the generalist provider. Specialist palliative care involvement with any patient and the family/whānau can be continuous or episodic depending on the changing need. Complex need in this context is defined as a level of need that exceeds the resources of the generalist team. This may be in any of the domains of care: physical, psychological, spiritual, etc.

2. Indirectly – to provide advice, support, education and training of other health professionals and

volunteers to support the generalist provision of palliative care.

Palliative Care is best delivered through an integrated approach that focuses on the needs of the patient and family/whānau. Such an approach recognises and defines the respective roles of all parties, both specialist and generalist, within a collaborative framework across a given geographical area. An integrated approach can occur in two ways:

Generalist/specialist integration – Specialist palliative care services should link with generalist services e.g. general practice, aged residential care, district nursing, Māori providers and hospital teams to ensure that palliative care need is met within a collaborative model that recognises and supports roles and responsibilities of the respective services.

Specialist/specialist integration – Depending on the complexity of palliative care need, smaller specialist palliative care services will at times require input from a more comprehensive service with greater specialist resources which may be geographically distant. This could occur on a regional basis with specialist services linking with other DHB specialist services utilising defined linkages and processes.

Strategies To support the national vision for provision of palliative care services nine strategies were developed with the aim of building a palliative care culture.

1. Ensure access to essential palliative care services.

2. Each DHB to have at least one local palliative care service.

3. Develop specialist palliative care services.

4. Implement hospital palliative care teams.

5. Develop quality requirements for palliative care services.

6. Inform the public about palliative care services.

7. Develop the palliative care workforce and training.

8. Ensure that recommendations from the Paediatric Review are implemented.

9. Address issues of income support.

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Essential services Palliative care incorporates a wide range of different services and providers. Care is provided in a variety of settings and requires a case management approach to enable an appropriate combination of interventions by the right providers in the right place, at the right time and based on the needs for each individual and their family/whānau. A full range of essential services ensures access for people to choose the option of dying at home with access to a range of community based services and access to specialist services when required.

Essential services: • Assessment – initial and ongoing multidisciplinary team assessment to identify needs early and

establish an individualised care plan. General practice services must be included in the multidisciplinary team to ensure continuity of care to the person.

• Care coordination – each person should be allocated a care coordinator. This coordinator is responsible for appropriate information regarding options and services available to the person dying and family/whānau. Patients need to experience a seamless service with smooth and timely transition from one service to another. Timely referral to palliative care service is essential (preferably not in crisis) with smooth access to inpatient care (respite, symptom control) when required. Rapid and straight forward discharge planning and transfer from acute care to palliative care services is also required.

• Clinical care – access to medical services (primary care and specialist), nursing services and equipment to provide symptom control, 24 hours a day, seven days per week in the community. Access to inpatient care for respite and/or control of symptoms (if required or preferred), bereavement counselling and spiritual care before and after death.

• Support care – support in the home and long term residential care in an appropriate setting for people who are unable to be cared for in the home. Older people currently undergo income and asset testing to access residential care.

To ensure people and their family/whānau have access to the essential palliative care services, a service framework is required with a network of two inter-linked levels of care. The two levels of palliative care services will be local and specialist palliative care services. It is important that where there is more than one provider, services are well coordinated to ensure that the dying person and their family/whānau receive seamless care.

The palliative care “system” Cancer Control New Zealand and the Palliative Care Council have developed the following diagram which demonstrates the range of providers of palliative care services and the links between them that tie each together. Figure 1: The palliative care “system”

Source: Measuring What Matters Palliative Care (Draft): Cancer Control New Zealand, as yet unpublished.

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3. National palliative care work plan

In the last ten years, since the development of the New Zealand Palliative Care Strategy, additional Ministry of Health funding has been made available to support the development of both existing and new palliative services. A number of reviews have been conducted to establish the progress made in implementing the Palliative Care Strategy and identifying gaps and areas requiring further work. A summary of these reviews is included in Appendix 1. A number of national palliative care service development projects are currently under way which are intended to address the gaps and issues identified in previous reviews and to guide sustainable service provision in the future in the face of increasing demand for palliative care services. As these projects are completed, implications for the DHBs in Midland will be considered and this service plan will be reviewed and updated as appropriate. The current projects are outlined below:

3.1 Specialist palliative care service specifications

In February 2008 the Ministry of Health released a draft service specification for specialist palliative care along with $2M ongoing funding to help DHBs and hospices implement new components of the service specifications (end of life care, 24/7 telephone advice, education to generalists). After wide consultation it was recognised that further service development work was required before submitting the specifications for final approval. The following work is being undertaken: • development of a resource and capability framework (role delineation model) for palliative care • development of a national funding approach.

Based on the need to first complete the above work it is anticipated that the completion of the specialist palliative care service specifications will be delayed until mid 2012. It has been indicated that these might be in a more generic form rather than highly itemised.

3.2 National health needs assessment for palliative care

The Palliative Care Council of New Zealand recognised the need for a National Health Needs Assessment to determine the need for palliative care in New Zealand on a population basis for all people who would benefit from palliative care. The Phase 1 report: Assessment of Palliative Care Need published by Cancer Control New Zealand in June 2011 establishes the number of people who might benefit from palliative care in New Zealand, on both a national and regional basis. Further work will follow which will make an assessment of the services required to meet the identified need and to determine how this compares with current service provision.

3.3 Resource and capability framework (role delineation model)

It has been recognised that there are currently variations in palliative care structures and levels of service across New Zealand, with access to palliative care services being described as inequitable and inconsistent. The Ministry of Health initiated a project to develop a resource and capability framework for New Zealand which maps out a structure for palliative care services based on the patients assessed need rather than their diagnosis or locality. It is expected to provide clarity for District Health Board funders to determine the level of services they want to purchase to meet the needs of their region, so palliative care providers can plan their service development with guidance on the appropriate workforce and facilities required. After consultation within the palliative care sector, a draft framework based on a hub and spoke approach has been proposed for final consultation in the early part of 2012. The draft framework emphasises the targeting of specialist palliative care services to support both those patients and family/whānau with the most complex need and generalist/primary providers. This means it is likely there will be an increase in the acuity of patients seen by specialist palliative care services, with less complex patients cared for by primary care providers.

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The framework is expected to be finalised by mid 2012. Once the final framework is known, the impact for Midland will be assessed and a plan for implementation of any agreed changes within Midland will be developed. Throughout this document we have included (in shaded boxes) some of the key actions recommended in the draft Resource and Capability Framework where they relate to particular issues or needs identified in the Bay of Plenty.

3.4 Health Workforce New Zealand palliative care workforce service review

Health Workforce New Zealand has recently published the results of a workforce service review to develop a vision and model of palliative care service and workforce for 2020 in a context of increasing demand and limited funding. A key recommendation of the review is the development of eight regional palliative care managed clinical networks, which are linked nationally, to manage palliative care in New Zealand. Recommendations include: • development of a funding model for community palliative care • utilisation of advanced nursing roles • development of the roles of allied health professionals in palliative care.

While it is recommended that one of the eight clinical networks would align with the current Midland DHB grouping of Lakes Bay of Plenty and Waikato DHBs there could be future implications for service alignment based on the Midland five DHB model (inclusive of Taranaki and Tairawhiti DHBs) and the recommended eight clinical network groupings. The recommendations of the workforce service review have not yet been endorsed. It is proposed to test the concept with a demonstration pilot/s in 2012.

3.5 National specialist palliative care data definitions and business process

The specialist palliative care community in New Zealand has identified the need for nationally endorsed data standards to provide a basis of a common language for discussions between stakeholders and for understanding palliative care in New Zealand. A draft Business Process Standard and associated Data Definition document were made available for comment during the early part of 2011. These documents are intended to ensure that minimum agreed palliative care data is collected and stored in a consistent manner whenever it is collected and stored. The finalised documents are awaiting approval and release by the Ministry of Health.

3.6 Measuring What Matters: Palliative Care

The report by Cancer Control New Zealand in 2010 identified a lack of monitoring and evaluation of the Palliative Care Strategy. The Palliative Care Council, in consultation with the Ministry of Health, Hospice New Zealand and with input from other stakeholders, has been working on developing a framework for palliative care that will generate information to inform strategic decision making across all health settings in New Zealand. A draft document from the Palliative Care Council presents a palliative care outcomes framework using an intervention logic approach (Appendix 2). This has been developed to articulate the desired outcomes and impact of activities across the palliative care sector. Although this work is not yet complete we have used the outcomes framework to present the recommendations and actions of this service plan.

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3.7 Liverpool Care Pathway (LCP)

The Liverpool Care Pathway for the Dying Patient is an evidence-based, integrated care pathway developed in the UK for the last days and hours of life. The LCP guides health care professionals to deliver best practice care to dying patients and their families/whānau in the last days and hours of life, irrespective of diagnosis or care setting. The eighteen 'goals of care' in the LCP are measurable and facilitate audit and benchmarking of end-of-life care.

The LCP has been implemented into hospitals, residential care facilities, in the individual's own home/community and into hospices in NZ. It is recognised as a best practice model for care of the dying by the Ministry of Health.

In 2008, additional funding was made available for district health boards to implement 'last days of life care programmes' which has resulted in a significant increase in the use of LCP nationally.

The National LCP Office NZ was established in November 2008 and is funded by the Ministry of Health to coordinate the sustainable implementation of the LCP in NZ. It aims to make significant improvements in the quality and consistency of LCP provision in NZ, including the development of a national database to facilitate benchmarking.

3.8 Advance care planning for adults

Advance care planning (ACP) is a process of discussion and shared planning for future care. It is patient- focussed and includes the health professionals involved in the person’s care. A National Advance Care Planning Cooperative has been formed to facilitate the development and deployment of ACP services in New Zealand. The vision of the cooperative is that “All people in New Zealand will have access to comprehensive, structured and effective advance care planning.” A guidance document on ACP in the New Zealand context and a number of supporting publications have been published by the Ministry of Health. While ACP is not palliative care specific, it is not included elsewhere in DHB plans in the Midland region. There is an opportunity with this planning process to consider the implementation of ACP within primary care, aged care, hospice and hospital services. A roll-out plan similar to that implemented for LCP could be considered as a collaborative project within Midland. Elsewhere in New Zealand (Auckland, Counties Manukau and Wanganui) ACP projects have commenced and will provide additional information to inform an implementation project within Midland.

3.9 The Gold Standards Framework (GSF)

The GSF in use in the UK National Health Service is simply a way of pulling together all the good things that occur in the primary care setting in a way that supports and encourages evidence based best practice. It is concerned with helping people to live well until the end of life and includes care in the final years of life for people with any end stage illness in any setting. GSF improves the quality, coordination and organisation of care in primary care, care homes and acute hospitals. This enables more patients to receive the type of care they want, in their preferred place, with greater cost efficiency through reduced hospitalisation. The key goals of the framework are to improve: • teamwork and continuity of care • advanced planning, including out of hours • symptom control • patient, carer and staff support • benefits identified from implementation of the framework are: • better assessment and control of symptoms • more patients dying in preferred place of choice

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• better planning and fewer crisis calls and admissions through more proactive care • improved carer support and information • improved staff confidence, communication and co-working with hospital and specialists

The model has a community palliative care compass that has seven points aiming for better care for patients at home in the last years of life. • Communication • Coordination of care – nominated co-ordinator • Control of symptoms • Continuity - out of hours and between services • Continued learning • Carer support (emotional, practical, bereavement and staff support) • Care of the dying phase – LCP. Currently in New Zealand, there is some varied use of concepts of the GSF. While the value of the framework is generally acknowledged there is no widespread implementation into care settings.

3.10 Palliative care education and standards

In 2009, the Ministry of Health and Hospice New Zealand considered the results of the national stock-take into service provision. Nationally, there were two areas of need that required focus. • The need for nationally consistent education programmes that support generalist palliative care

providers. • The need for revised palliative care standards and an ongoing implementation programme to ensure

consistency in the quality of service regardless of locality.

Hospice New Zealand coordinated two projects to address the identified needs. Results of the projects were piloted in 2011 and implementation has commenced as follows. Education A Fundamentals of Palliative Care learning package has been developed is now released for use by hospices as a part of their education programmes offered to generalists. The initial focus for implementation is gerontology services and residential aged care; however the learning packages will be adapted over the next two years for other settings where a palliative approach is required e.g. general practice, hospital/acute care and district nursing. The Hospice New Zealand Caregiver Assistant package will be revised and brought into alignment with the Fundamentals programme. Standards New standards for hospice care “Hospice NZ Standards for providing Palliative Care” have been developed and are being implemented across New Zealand hospices. It is anticipated that the standards will be mandatory for member hospices of Hospice New Zealand and will be supported by an audit tool developed by Hospice New Zealand. It is not clear yet how the standards will link with district health board contracts and audit processes and whether the standards should apply to other palliative care providers such as hospitals and residential care.

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4. Midland region context

The Midland region includes the Bay of Plenty, Lakes, Taranaki, Tairawhiti and Waikato DHBs. For many years collaborative activity has occurred amongst the DHBs. To meet service and financial needs and ministerial expectations the DHB chairs and chief executives recognised the need for a more structured and coordinated regional approach to planning and delivery of services. In March 2011 the Midland Regional Cooperation Project commenced with priority given to the implementation of the Regional Clinical Services Plan, coordinating regional clinical networks (including the Midland Cancer Network) and assessing back office and support functions that could be advanced regionally. The cancer networks are accountable to the DHBs. The geographical boundaries of the regional cancer networks in New Zealand were established on the historical non-surgical cancer treatment flow. Based on this Tairawhiti and Taranaki currently aligns with the Central Cancer Network, but have an open invitation to the Midland Cancer Network when required. As of 1 August 2011 the Midland Cancer Network now operates from HealthShare, the regional vehicle to drive regionalisation requirements. A Midland Palliative Care Work Group comprising Lakes, Bay of Plenty and Waikato stakeholders was established in December 2007 as a service specific work group under the umbrella of the Midland Cancer Network

6. The purpose of the work group is to:

• take a proactive leadership role to oversee the implementation of agreed regional palliative care

initiatives for the Midland region

• support and advise the participating organisations about issues, activities and priorities related to the delivery of palliative care services across the Midland region.

The work group membership now has wide representation including primary care, PHOs, hospices, secondary and tertiary hospital service managers, hospital based specialist palliative care, planning and funding and regional Māori Health services. This region wide, all of sector approach has worked successfully to develop palliative care services through the sharing of resources and expertise as well as by using a collaborative approach to address common issues and activities. It was agreed in December 2009 that a co-ordinated approach to palliative care service planning would be taken and would incorporate district plans with a regional view.

6 Palliative Care (malignant and non-malignant) is part of the Midland Cancer Network work programme.

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5. Local Bay Of Plenty DHB palliative care

5.1. Bay of Plenty District Health Board strategies

The Bay of Plenty District Strategic Plan 2005-2015 outlines the priorities for the DHB over the ten year period to 2015. The DHB is committed to working with it’s communities to achieve greater health, remain healthy and care for people when they need care. Meeting the Government imperatives including implementing the New Zealand Cancer Control Strategy which incorporates palliative care, are a priority. The DHB has one of the fastest growing populations of over-65 year olds in New Zealand. A key outcome in the plan which has particular relevance for palliative care is for healthy, independent and dignified ageing and recognises the need to:

• modify community norms and perceptions relating to ageing and death • strengthen community capacity to provide resources to support older people • develop appropriate services for older people with end-stage chronic conditions to support dying with

dignity • work with communities to develop safe environments for older people particularly those with

dementia. The DHB has recognised a number of key capacity and capability issues. These include the rurality of large portions of the DHB population, difficulty developing and maintaining consistent levels of key competencies for delivering quality services across the care continuum and coping with an increasing rate of complex and multiple chronic conditions. Each of these is applicable for the delivery of palliative care where a key focus is to provide support for people to die in their place of choice which, for most people, is at home.

In order to achieve health for Māori and act consistently with the direction set in He Korowai Oranga, the New Zealand Māori Health Strategy, BOP DHB has identified the following priorities.

• Consistent with rangatiratanga, Māori will maximise their health. • To increase the capacity of Māori providers and communities to meet their own health and

independence needs. • To ensure responsiveness of mainstream services to Māori. The DHB is working towards achieving by Māori for Māori services and has developed a strong participation framework for Māori throughout the DHB’s governance and service provider structures. The DHB has a commitment to invest and support the following: • Māori provider assistance • accelerated workforce development initiatives, by Māori for Māori • service developments that promote integration and coordination • identification of best practice and procedure models that promote cultural values and tikanga

practices.

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5.2. Bay of Plenty palliative care strategy 2003

In 2003, a palliative care strategy was developed which is outlined in the document Palliative Care in the Bay of Plenty District Health Board – Evaluation of Need and Proposed new Directions.

7

This strategy focussed on: • developing a consistent palliative care approach • establishing a district palliative care network • organising a single point of co-ordination • building provider capacity and capability • developing a comprehensive continuum of care. In 2007, an exercise was undertaken to review progress of the implementation of the 2003 strategy and recommendations contained therein. A draft report was prepared titled Evaluation of the Implementation and Impact of the Bay of Plenty District Health Board Palliative Care Strategy November 2007. There is acknowledgement that the 2007 implementation review was a less than optimal process and it is understood the document remained in draft and was not endorsed. For the purpose of this palliative care service planning process the recommendations contained in the draft 2007 report have had a high level review to determine those that still have relevance today and to ensure these are considered in the current discussions. There has not been a detailed review against the 2007 draft report. Areas that are considered still relevant today and where progress is required. • Refresh the Bay of Plenty Palliative Care Network (completed 2011/12). • The establishment of hospital palliative care services for Tauranga and Whakatane hospitals

(discussions in progress, refer to section 6.4). • Ongoing need to educate generalists on the role of palliative care, to increase their ability to provide

care using a palliative approach for their patients and to promote timely referral to specialist palliative care services where required (In progress, refer to section 5.5 subtitle Education).

• Development of the palliative care concepts for supporting non-malignant conditions. • Building mainstream service responsiveness to the needs of Māori and strengthening relationships

with Māori health providers (BOP Maori palliative care hui held 2011 to start the process, refer to section 5.4).

7 Palliative Care in the Bay of Plenty District Health Board – Evaluation of Need and Proposed new Directions. Produced by the Planning and Service Development, Bay of Plenty DHB, draft report May 2003.

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5.3. Bay of Plenty DHB geographic and population demographics

The BOP DHB is made up of five territorial authorities (TAs) which, in total, cover an area of 9,666 square kilometres. These TAs are grouped into Eastern and Western Bay of Plenty and the DHB services are generally aligned to these groupings with Tauranga Hospital in the WBOP and Whakatane Hospital in the EBOP. The palliative care specialist services also align to these groupings The BOP DHB population at the 2006 census was 200,750. In terms of population size, the DHB is 8th largest out of 20 district health boards in New Zealand. However, the DHB has the second fastest growth rate of all DHBs

8.

In the five year period of this planning document (2011 to 2016) the population is predicted to grow by 5.6% (12,000). This rate of growth is higher than that for New Zealand as a whole (+4%). The majority of the growth is expected to be in the WBOP (particularly Tauranga City) with the EBOP expected to experience a static or declining population. The characteristics of the Eastern and Western Bay of Plenty areas are considerably different. These are summarised in Table 1. Detailed demographics and graphs are provided in Appendix 3

8 Bay of Plenty District Health Board Annual Plan 2011/21 Statement of Intent 2012/13, pg 7

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Much of the population in the EBOP is dispersed into small rural communities many of which are isolated in terms of distance and many of these areas are of high deprivation. In the WBOP the population is more concentrated on the larger urban area of Tauranga.

Table 1: Characteristics of the BOP DHB by territorial authority

Eastern Bay of Plenty Western Bay of Plenty

Territorial Authorities

• Whakatane • Kawerau • Opotiki

• Western Bay of Plenty • Tauranga city

Population at 2006 census % of BOPDHB region

50,850 25%

149,900 75%

Estimated population at 2011 Estimated population at 2016 Predicated population change between 2011 & 2016

50,740 50,160 -1.1% (decline of 580)

163,200 175,800 +7.7% (increase of 12,600)

Māori population

25,000 (approx 50% of the EBOP population )

25,000 (approx 17% of the WBOP population)

Population characteristics

• Young population • High proportion of Māori • Slow population growth • Lower life expectancy • More lower socio-economic

communities many rurally isolated

• Older population • Lower proportion of Māori • One of the fastest population

growth rates • Higher life expectancy • Non Māori in these areas tend

to have less family support

% aged 65 years and over 2006 2011 (estimated) 2016 (estimated)

13% 14% 17%

17% 18% 20%

Number of deaths 2006 2011 (estimated) 2016 (estimated)

360 428(+18%) 457 (+6%)

1220 1290 (+5%) 1450 (+12%)

Population ageing Of relevance to the palliative care services is the ageing population. In general about 70% of patients who access specialist palliative care services are over 65 years so the increasing proportion of those in this age group will increase demand for both generalist and specialist palliative care services. In 2006, 16% of the population were aged 65 yrs and over which is higher that the national rate of 12%. By 2016 this is expected to be 19% in the region and will continue to increase as the large baby boom generation begins to enter this age group. The number of people aged 65 and over is projected to increase in each of the areas with the most significant increase occurring in Tauranga which is a popular retirement destination. The number of deaths is estimated to increase by 11% between 2011 and 2016 (189 additional deaths). The greatest increases are estimated to occur in the territorial authority areas of WBOP growth of 15% (n = 50) and Tauranga city growth of 11% (n = 110).

Ethnicity In 2006, 25% of the population identified as Māori, 1% Pacific people and 74% European/Other. Nationally Māori make up about 15% of the population. However, within the DHB a much higher proportion of Māori live in the EBOP area. In 2006, 50% of the people living in EBOP were Māori compared with 17% in WBOP. The Māori population is predicted to increase by 8% (n=4,300) between 2011 and 2016.

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Socioeconomic measures New Zealand research has shown that there is a strong association between socioeconomic deprivation and health outcomes. This is measured by the New Zealand Index of Deprivation 2006 (NZDep06). Areas with high NZDep06 scores are associated with poorer health. In the DHB about one quarter of the population (50,000 people) live in areas with high deprivation scores. About one in seven live in areas with low scores (associated with better health). Socioeconomic deprivation is much greater in EBOP than in WBOP. In Kawerau and Opotiki districts nearly 70% of the population lives in areas of high scores (quintile 5) and 40% in Whakatane district, compared to 20% in WBOP district and Tauranga city. The areas with the highest proportions of Māori tend to correlate to the areas with high socioeconomic deprivation. Nearly 60 percent of Māori live in areas of high scores (quintile 5) compared to 20 percent of non-Māori.

5.4. Health needs of specific population groups

The DHB takes a population approach to building healthy, thriving communities. Different population groups have varying palliative care needs, which require unique interventions to enable appropriate care. This section combines the analysis of the key population characteristics and recommendations from the New Zealand Palliative Care Strategy to consider the requirements for specific groups within Bay of Plenty.

Māori As a population group, Māori have on average the poorest health status of any ethnic group in New Zealand. Māori aged 50 and over have higher rates across many health conditions and chronic diseases than non-Māori of the same age group. This includes rates of cancer, diabetes and cardiovascular disease. Of particular concern is that the overall cancer mortality rate for Māori is considerably higher than that of non-Māori. This is not acceptable, and the Government and the MOH have made it a key priority to reduce the health inequalities that affect Māori. The New Zealand Palliative Care Strategy emphasised the following. • Palliative care services are to have policies in place that recognise the specific needs of Māori. • There are linkages between palliative care providers and Māori development organisations and that

a plan for services for local Māori is developed to assist in meeting the specific needs of Māori. • At a local level, where appropriate, each provider should employ one or more care coordinators who

could meet the special needs of Māori, particularly in areas with a high Māori population. The care coordinator would coordinate services and work with the whānau to ensure that the needs of the dying person are met in a culturally appropriate way. The care coordinator could be employed in conjunction with local Māori health providers. It is important that the principles of cultural safety are recognised in the employment of Māori.

2006 Census data shows: • BOP has a Maori population higher than the national average (Bay of Plenty 25%, national average

15%) • within the DHB a much higher proportion of Māori live in the Eastern Bay of Plenty area (of all the

Māori living in BOP, 50% are in EBOP; and 47% of the people living in EBOP are Māori compared with 17 percent in WBOP)

• the highest proportion of Māori reside in the EBOP where the socioeconomic deprivation is greatest. In addition: • eighteen iwi are located within the DHB area • the DHB has the highest number of Māori providers of any DHB (50).

These unique characteristics provide both opportunities and challenges in the development and delivery of services.

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Specific hui held with Māori throughout Midland identified some particular common priorities for Māori. These are summarised as the need for:

• appropriate information available for Māori to raise awareness of palliative care services • education in palliative care for Māori health providers • awareness and education sessions targeting specific parts of the community e.g. kaumātua,

whānau as carers • the development of Māori into palliative care careers • specialist palliative care services to include an understanding of Whānau Ora and Tikanga in

relation to palliative and end of life care in their staff orientation and education programmes • non-Māori palliative care staff to be taught basic Te reo to enhance communication and

understanding between them and their Māori patients and their family/whānau (especially in the absence of any Māori palliative care staff)

• strategies to support whānau carers to care for their relative in the community.

People with disabilities and nonmalignant diseases People with disabilities will often require more support care and resources such as equipment and flexible packages of care to maintain them in their home and support their family. Traditionally specialist palliative care services have focussed on improving conditions of people who are dying from cancer. Emerging needs of people with other life limiting nonmalignant diseases can benefit from palliative care services. These include: • heart failure • end stage renal failure • chronic obstructive airways disease • liver failure • motor neurone disease • multiple sclerosis • HIV/AIDS. These illnesses are often longer in duration than a disease such as cancer and often require a higher complexity of support care. Literature indicates that people with nonmalignant diseases can have improved quality of life through access to palliative care services when required. According to the New Zealand Palliative Care Strategy, 90% of people cared for by hospices in 1998/99 had cancer and 10% had nonmalignant diseases. It was predicted that more people with non-malignant diseases would access palliative care and hospice services. More recent data from the hospices in Bay of Plenty shows a changing proportion of their patients with a non-cancer diagnosis. Information for 2010

9 shows:

EBOP: 72 percent had cancer and 28 percent had other nonmalignant diseases WBOP: 88 percent had cancer and 12 percent nonmalignant diseases. The WBOP is experiencing a slower shift in the make-up of patient diagnoses due to the higher proportion of the very elderly residing in Western Bay of Plenty and cancer is more often associated with this age group. Detailed analysis of the reasons has not been carried out but factors contributing to the change could include: • an increasing prevalence of non-cancer conditions • greater awareness of the role and value of palliative care and hospice services for those with non-

malignant diseases leading to more referrals of these types of patients by GPs and hospital specialists etc

• an increased public awareness that hospice services are not just for those with cancer.

9 Measured across all patients who died or were transferred in the calendar year.

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People in rural Bay of Plenty According to the 2006 Census, 79% of the Bay of Plenty population lives in urban

10 areas compared to

86% nationally, and 21% live in rural areas compared to 14% nationally. Most of the geographical area that is rural and remote falls into the EBOP district, with many isolated from basic primary health services and required to travel long distances to access specialist secondary or tertiary care. This rural isolation impacts on health providers and professionals servicing these populations. In addition, just under half the population in the EBOP live in areas of high deprivation (48%). Financial hardship is common amongst residents in rural EBOP. Many do not have personal transport or cannot afford the cost of petrol to attend doctors appointments, have no access to public transport, cannot afford telephones and in some areas there is no cellphone coverage to be able to communicate easily, some cannot afford medications from the pharmacy especially when sourced on a public holiday (some pharmacies add surcharges). For many it is simply too hard or too expensive to access health services. Patients living in rural areas face significant personal costs when needing to be transported to and/or from their home and residential care especially if ambulance transport is required due to the person’s condition. The patient is charged the full cost of the ambulance transfer which can in some cases be several hundred dollars. From time to time the families choose to use alternative means of transport which can cause significant discomfort for the patient and can be particularly unsafe. Issues also arise for palliative care service delivery to patients in remote rural areas. With long distances to travel, few patients can be seen in a day requiring more nurses to support a model of home based care for rural areas. When there is no out of hours GP in an area the ability for hospice nurses to respond to patient needs out of hours becomes complex, expensive and can be delayed if a visit is required rather than support by phone. Shared care arrangements with district nurses have been one way to minimise some of these factors. However, district nurses who do not provide palliative care as a part of their normal case load generally lack the skills to provide out of hours care for palliative patients e.g. they cannot change subcutaneous syringe drivers.

10 Urban and rural areas are determined by Statistics New Zealand. Urban areas are centred on a major city and include neighbouring areas which are regarded as suburban and belonging to that city. Rural areas are those areas not specifically designated as ‘urban’ they include towns of fewer than 1000 population.

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5.5. Current Palliative Care Services

People who are dying can receive services from a wide range of providers as described in Table 2. Access is dependent on the availability of services in each area. Table 2: Overview of providers of palliative care Level of Care Provider Type of care

Primary care practices - GPs and practice nurses

Primary care in the community

Residential care facilities Private hospital and rest home care

District nursing services

Community (home based) care

Public hospital services (e.g. ED, renal, cardiology, oncology)

Inpatient and outpatient palliative care (non-specialist)

DHB allied health staff (e.g. occupational therapists, physiotherapists, social workers)

Assessment for equipment etc, therapy, access to support services

Generalist*

NGOs and volunteer organisations e.g. home support agencies, carer support agencies, Kaitiaki Nursing Services, Cancer Society, support groups such as Alzheimer’s, Multiple Sclerosis

Support care

Waipuna Hospice Specialist inpatient care Day care Community care Specialist*

Hospice Eastern Bay of Plenty Day care Community care

*Generalist palliative care providers are any health professionals involved in the care of someone with a life threatening illness, often with no formal training in palliative care. Palliative care is not their primary role or function. *Specialist palliative care providers are health professionals trained specifically in palliative care working within a multidisciplinary specialist palliative care team.

Settings Palliative care occurs in a range of settings and requires a case management approach to enable the appropriate combination of interventions by the right providers in the right place, at the right time and based on the needs for each individual and their family /whānau. These settings include: • patient’s home (the home of their choosing e.g. own home or family/whānau home) • residential care facilities • primary care

o General practice rooms o General practice home visits o General practice after hours care facilities

• Tauranga and Whakatane hospitals o Emergency department o Inpatient wards o Outpatient services

• Waipuna Hospice inpatient unit, outpatient clinics and day programme facilities • Māori health provider and marae based services • other volunteer and supportive care services such as Cancer Society in their facilities or through

home visits.

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Generalist palliative care in Bay of Plenty

• Primary health care /general practice teams For people with a health need the general practice is usually the first and most frequent point of contact with the health service. All palliative patients are encouraged to have a general practitioner (GP) and the GP remains responsible for their overall care even though they may receive intermittent or episodic care from a palliative care specialist service. Most, if not all, GPs will have a number of patients requiring palliative care each year. Many patients and family/whānau need for palliative care will be appropriately met by the general practice team and will not require the input of specialist palliative care services. Others may have more complex needs that cannot be met by the GP alone and would benefit from the additional expertise and/or wider support services of the specialist services. In most cases the need for specialist services is likely to be episodic rather than ongoing. Primary Health Organisations (PHOs) are responsible for organising and delivering primary health care services to meet the needs of their enrolled population. They are funded by the Ministry of Health via DHBs based on the number and characteristics of their enrolled population. There are three PHOs in the Bay of Plenty area and approximately 95% of the Bay of Plenty population is enrolled with a PHO – see Table 3. The percentage split between Māori and non Māori enrolled patients is very similar to the makeup of the general population. i.e. 25% of the BOP population is Māori and approximately 24% of the enrolled PHO population is Māori. Table 3: PHOs in Bay of Plenty and enrolled population as at Quarter 1, 2012

PHO PHO Enrolled Population

Total

enrolled Māori % Non Māori %

Eastern Bay Primary Health Alliance (EBPHA)

11 45,928 21,203 46% 24,725 54%

Western Bay of Plenty PHO12

142,974 18,793 13% 124,181 87%

Nga Mataapuna Oranga Kaupapa Māori PHO

13

10,906 8,348 77% 2,558 23%

TOTAL 199,808 48,344 24% 151,464 76%

Source: Ministry of Health PHO Enrolment Demographics 2012 Qtr1 (Jan – March 2012) http://www.health.govt.nz/our-work/primary-health-care/about-primary-health-organisations/enrolment-primary-health-organisation Accessed 20.01.2012 There is no specific categorisation or reporting of palliative care work undertaken by PHOs or general practices and therefore this component of work of primary practice cannot be quantified. There is a mixed level of engagement of GPs in providing palliative care. Many GPs consider it to be an integral and valuable part of their work. Some prefer not to provide palliative care or end of life care. The varied level of commitment by GPs to providing comprehensive palliative care, including being available after hours, and willingness to do home visits or visits to patients in residential care is of significant concern. Often there is inadequate handover to GP colleagues. Some after hours cover arrangements such as the use of A&E centres do not suit the requirements of palliative patients as many patients are not ambulatory and cannot attend an out of hours clinic. Concern is also expressed at the increased use of locums where locums may not have adequate palliative care experience and lack an understanding of the patient’s care plan and local support services and processes. There is anecdotal evidence that the variable access to suitable GP services after-hours results in additional demand on

11 Formed on 1 October 2010 from the amalgamation of the three PHO's of the Eastern Bay Of Plenty - Eastern Bay of Plenty PHO, Kawerau PHO, Te Ao Hou PHO 12

Joint venture partnership between Ngati Ranginui and Ngaiterangi Iwi and the WBOP Care Providers Inc (Provider Inc). 13

The majority of the enrolled population is Māori. The PHO practices Māori values and philosophy of Te Reo, Rangatiratanga, Whakapapa and Whanaungatanga with Māori governance and management. The services are described as “By Māori for Māori but not exclusive to Māori.”

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emergency services such as the ambulance service and results in avoidable presentation at emergency departments and acute admissions to hospital. In some cases, it also results in palliative care medical specialist being required to provide care after hours which should be provided by the patient’s GP. Residential care facilities report that some residents die in pain unnecessarily due to the difficulty in getting GPs to prescribe after-hours or in the weekend. There is difficulty maintaining up-to-date knowledge and skills in caring for palliative patients when GPs may only care for a few palliative patients each year. The need for specialist palliative care services to give advice and support to GPs, to provide on-going education opportunities and to develop tools, clinical guidelines and quick reference information for GPs is a critical role for the specialist services. Some GPs choose to develop a special interest in palliative care but the ability for them to access funded palliative care diploma training placements is limited. In general, the method of funding general practice visits is not conducive to providing palliative care. The length of time given for a routine GP appointment is insufficient for providing a quality palliative care service which requires considerably more time to be spent talking with the patient and family/whānau. Many GPs are reluctant to charge the patient for the cost of the extended consultation and, in many cases, the patient could not afford to pay the actual cost. Alternative palliative care funding schemes are being used elsewhere in New Zealand such as the MidCentral DHB Palliative Care Partnership. This is an example of palliative care primary and secondary integration which provides an alternative funding scheme which aims to reduce the barriers to primary health care for palliative patients. The Ministry of Health Services to Improve Access (SIA) funding is available in some areas although it is not universally available or applied to reduce the cost barriers for palliative patients. The Eastern Bay PHA is currently looking at developing a scheme using SIA funding for this purpose.

• Community (home based) care Nursing care Good home based care is required for people to be able to choose to die at home and for the patient and family/whānau to be well supported during this time. There are two main primary palliative care nursing service delivery models in Bay of Plenty. WBOP is resourced by hospice nurses. EBOP includes district nurses in some areas but is not a full shared care model. These models have developed to address the different characteristics of Eastern and Western Bay of Plenty.

1. In WBOP, Waipuna Hospice provides care co-ordination and 24/7 nursing care to enable

palliative patients to be cared for at home. Patients may be cared for in the community by the DHB district nursing service until they are considered to have reached a palliative stage at which time they are transferred to the care of Waipuna Hospice who work in conjunction with the patient’s GP and other service providers. The hospice employs a team of registered nurses and health care assistants to provide home based care.

The hospice works closely with the Kaitiaki cancer support nurses who provide services and home visits for Māori patients and their whānau affected by cancer.

2. In EBOP the population is spread over a wide geographic area with small remote settlements. Economies of scale preclude a full hospice community palliative care nursing service in all parts of the district. Hospice Eastern Bay of Plenty provides palliative care coordination and 24/7 palliative nursing care in people’s homes for most of the district however, in the more remote areas of Te Kaha and Murupara a shared care model with district nurses is used. With distances to travel and patient numbers it is not possible for the hospice nurse to visit every day. In these areas the hospice works closely with district nurses and GPs to provide specialist input when required.

There is also a shared care type arrangement within the hospice team. A district nursing oncology/palliative care role sits within the hospice and works as part of the hospice nursing team

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with the oncology/palliative district nurses employed and funded as part of the DHB Community Services. There are two part time nurses in this role with a total of 0.6 FTE allocated for palliative care patients. During the consultation phase this arrangement was highlighted as an issue by some stakeholders. In a mixed model of care it is difficult to develop and maintain up to date knowledge and skills in palliative care when there are small patient numbers and/or patients on an intermittent basis. While it might seem easier for palliative nurses to do all the palliative patient work it also de-skills the district nurses and takes away some flexibility in rural areas where district nurses are located throughout the community. If increasing shared care arrangements is promoted as a way of coping with increased demand for community based palliative care then issues of skill level of district nurses will need to be addressed.

The hospice works closely with Māori health providers in EBOP and works directly with family and whānau as carers to educate them on the role they have as the in-home carer and support.

Home help and personal care services In the WBOP this service is provided through Waipuna Hospice using health care assistants for patients that have a diagnosis of cancer or end stage renal failure and who have a prognosis of less than six months. The hospice provides up to three personal care and one home help visit per week. This is designed to facilitate patients remaining at home for as long as possible and focuses on those patients who have no carer support or carers who themselves are too frail to cope. However, three visits a week are inadequate to meet the needs of many of the frail patients and because of this there is a tendency for the most frail and most vulnerable patients to be transferred from home to aged residential palliative care beds (which are funded by the DHB) when they would otherwise be able to reside at home if a seven day service was available. In EBOP palliative care home help needs are assessed by Hospice EBOP. The services are coordinated by hospice but provided by other agencies including Disability Resource Centre and Te Puna Ora O Mataatua Health Care NZ. Funding is provided via Support Net

14. During the stakeholder

consultation there were no issues reported with the provision of this service. However, the need was stressed for carers employed by the home care provider organisations to have appropriate palliative care education which requires the support of their employer e.g. release time to attend education sessions. The level of service that is provided for palliative patients under Waipuna Hospice care is inequitable when compared to the services provided by Support Net and district nursing for other patients who do not come under the Waipuna palliative contract (which covers only those that have a diagnosis of cancer or end stage renal failure). The entitlement under Support Net and district nursing is based on assessed needs for individuals and can be for up to seven days per week home help/personal care. The New Zealand Palliative Care Strategy defines the set of essential services that dying people and their families/whānau should have access to including ‘Support Care based on need’. Support care includes support in the home. The draft Resource and Capability Framework states as one of the principles underpinning the framework “Palliative care services will be provided according to need in a seamless manner, regardless of setting, diagnosis or location”.

14

Support Net provides Needs Assessment and Service Co-ordination (NASC) services for people in the Bay of Plenty. A NASC helps people with disabilities or difficulties carrying out daily activities due to age, get the support they need to be as independent as possible in their home or community.

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• Residential care Residential care is provided by rest homes and private hospitals and a small number have specialised services to cater for dementia and other mental health needs. There are total of 32 residential care facilities in Bay of Plenty providing services of different levels that are funded and contracted by the DHB. Table 4 shows the number of beds and number of facilities where these are available. Table 4: Bay of Plenty Residential Care Beds

Bed level Number of beds Number of facilities with each bed type

Rest home 731 32 Private hospital 768 20 Dementia 113 9 Psychogeriatric 36 1 1648

Source: BOP DHB Planning and Funding

At present the occupancy rate in these facilities in Bay of Plenty is high – 92% overall in WBOP and 97% overall in EBOP. Hospital level beds in EBOP are frequently all full. Information on the total number of deaths in these facilities has not been made available. Rest homes generally provide care for frail, elderly people using health care assistants. A private hospital cares for the elderly who need nursing due to illness and disability and these facilities employ a mix of registered nurses and health care assistants. Residential care facilities carry much of the burden of caring for dying patients. For many people the residential care facility is their home – they are essentially there until they die. Many die in a rest home or private hospital without the need for specialist palliative care input. The Australian Productivity Commission’s report

15 suggests palliative and end of life care should be core

business for aged care services yet in practice the quality of care is variable and residents are transferred to hospital when the needs are beyond the resources of residential care staff. The specialist palliative care services have an important role to play in supporting staff who are predominantly caregivers rather than registered or enrolled nurses, to deliver effective palliative care.

16 High staff

turnover which is a longstanding and common characteristic of this sector, increases the need for regular education to be available. The Liverpool Care Pathway for care of the dying patient is being implemented in many of the residential care facilities in Bay of Plenty. Patients under the care of the hospices may require short-term respite care in a residential care home or long term residential placement when they are unable to be cared for at home or where the caregiver at home requires a break. To support this need, the Bay of Plenty DHB purchases nine hospital level rest home beds for palliative care as detailed in Table 5. These are dedicated beds, purchased directly by the DHB on a block basis irrespective of occupancy. There is also some flexibility to purchase additional beds in other locations if required. Access to the funded beds in Western Bay of Plenty is prioritised to patients with cancer or end stage renal failure.

15 http://www.pm.gov.au/press-office/productivity-commissions-final-report-disability-care-and-support 16

Hall B. Resource and Capability Framework for Adult Palliative Care Services in New Zealand – Draft for consultation, November 2011.

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Table 5: Residential care contracted beds for palliative care

Name of facility Location No. of beds

Western Bay of Plenty

Althorp Private Hospital

Tauranga 4 beds

Hodgson House

Tauranga 3 beds

Eastern Bay of Plenty

Golden Pond Private Hospital

Whakatane 2 beds

A flexible fund (via SupportNet) exists for people in residential beds when the 9 beds are full or the patient and family are located in geographical area such as Katikati, Te Puke, Opotiki, Kawerau or Murupara. This fund equates to approximately 3 additional beds at any one time per annum.

Beds are fully funded for the first three months. If a patient survives beyond three months, they are transferred to long term aged residential care funding (or if under 65 then access Long Term Conditions for People with Chronic Health Conditions funding). The occupancy rate in palliative care beds varies between 85-95%. As the population and the proportion of those aged 65+ increases, there will be additional demand for residential care beds and for beds contracted for palliative care patients. No analysis of likely increased bed numbers has been done. Suitability of beds, demand and utilisation should be regularly reviewed by the DHB to ensure there is appropriate access to sufficient beds. Accessing suitable long term inpatient/residential care is an issue for palliative patients under 65 years of age. Placement in a residential care facility is not always suitable because of location (distance from family support) or because of the environment and skill level of the staff (most facilities are aged care with very elderly residents). This is not unique to the Bay of Plenty.

• Local hospitals The acute general hospitals in BOP DHB are:

• Tauranga Hospital (WBOP) - A secondary hospital of level 4-5 services with 324 beds

• Whakatane Hospital (EBOP). A secondary hospital of level 3-4 services with 101 beds.

In addition there are Project Hope Cancer Centres based at both Whakatane and Tauranga Hospitals. These provide an oncology base for Bay of Plenty specialists and Waikato visiting medical specialists.

Generalist palliative care is provided in hospitals by general ward staff, as well as disease specific teams for instance oncology, respiratory, renal and cardiac teams who provide care for patients who are dying as a result of their illness. An identified gap is the lack of a hospital based specialist palliative care team for the BOP DHB hospitals. Hospital based teams act to enhance the capability and capacity of the various hospital based generalist services to be responsive to patients’ palliative care needs and to facilitate timely access to specialist palliative care services. Hospital based palliative care is covered more in section 6.4. Under the current model Waipuna Hospice employs a hospital liaison nurse to assist with referrals and discharges from Tauranga Hospital. This supports the transition of patients from hospital into the hospice community care. Hospice EBOP does not have a similar role and stakeholders identified discharges of palliative patients from Whakatane Hospital are often a problem. These sometimes occur with little planning or communication with hospice; and they frequently occur late on a Friday afternoon or Saturday with no prior warning. From time to time there will be urgent discharges where a patient wishes to return home to die and prior warning is not possible. The hospice nurse out of hours can facilitate this. However, while hospice provides a 24/7 service this is minimally resourced out of hours (usually only one nurse). Using hospice nurses out of hours to cover work that can be carried out in a more planned way during normal work hours or days is expensive. Patient/s being discharged in the weekend significantly increases the cost

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to the hospice when an additional nurse needs to be employed to coordinate care. In addition, late discharges reduce the opportunity to coordinate care with other support services and to make sure all other requirements such as equipment and medications are in place. A part time discharge liaison role under Hospice EBOP would improve this situation but would require new funding. It is suggested (but not quantified at this stage) that investment in a hospital discharge liaison position within hospice would save the hospital money through facilitating early discharge.

• Allied health services Allied health services including pharmacy, physiotherapy, occupational therapy, speech language therapy and social work provide valuable assessment and support for palliative patients. Waipuna Hospice employs social workers, counsellors, chaplains and (more recently) a physiotherapist/ lymphodema therapist; Hospice Eastern Bay of Plenty employs a part time counsellor; the remaining allied health services are provided by the DHB and access is by referral or liaison. An exception is pharmacy input which is gained by working with DHB pharmacists but also, more often, local community pharmacists. Allied health professions are commonly part of palliative care multi/interdisciplinary teams in other countries but their role in palliative care teams in New Zealand is under developed. In general in New Zealand they are part of DHB allied health pools with competing service demands. There are many allied health professionals who have a declared ‘passion’ for palliative care and have developed particular skills and knowledge in working with palliative patients even though this may form only a small part of their patient workload. However, there is a nationally recognised lack of formal training in palliative care for allied health professions, a lack of opportunities to specialise in palliative care and difficulty accessing funding for palliative care post graduate education by allied health professions.

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Specialist palliative care Specialist palliative care practice builds on the palliative care provided by generalist providers and reflects a higher level of expertise in complex symptom management, psychosocial support, grief and bereavement support. Bay of Plenty DHB contracts two hospices for the provision of specialist palliative care. • Waipuna Hospice for services in Western Bay of Plenty • Hospice Eastern Bay of Plenty for services in Eastern Bay of Plenty. The hospices provide a single point of entry for referrals for specialist palliative care in each of their districts and coordinate care to ensure their patients and family/whānau have access to the services they require. Detailed service profiles and patient demographics for Waipuna Hospice and Hospice Eastern Bay of Plenty are provided in Appendices 4 and 5. A summary of the hospice services is provided below. Waipuna Hospice based in Te Puna, provides services for the territorial authorities of Western Bay of Plenty and Tauranga City and has a population base of around 150,000 which is three quarters of the DHB population. The hospice operates a nine bed inpatient unit and has a total paid workforce of approximately 50 FTE (90 headcount) with around 450 volunteers contributing in excess of 42,000 hours per annum. Services offered by Waipuna Hospice interdisciplinary team include: • Care coordination and liaison with GPs, residential care and other services • 24/7 nursing support and care in the community • Hospital liaison for referrals and discharges from Tauranga Hospital • Inpatient care for symptom management, end of life care, respite care and bridging care • 24/7 on call specialist medical support for GPs and community palliative care nurses in the Bay of

Plenty region • On site clinics (medical and nursing) • Weekly day programme • Biography service • Equipment loan • Psychosocial care and family support during illness and bereavement (bereavement counselling,

bereavement groups, social work services and chaplaincy support) • Public and professional education • Home help and personal care services Care for palliative patients in their own home is provided by the hospice community nursing team and does not involve shared care with district nurses. The stakeholders view is that this model works well in WBOP. The hospice employs a medical director (palliative medicine specialist) and GPs with special interest to provide outpatient consultations, inpatient medical care and a 24/7 medical telephone support. The medical specialist undertakes home visits for assessments when required and specialist medical visits to patients in the palliative care contracted beds at Althorp private hospital. Waipuna Hospice has been increasing the specialist medical support provided to the EBOP however growth of this service is currently constrained by resource availability. The inpatient unit has nine beds commissioned in a 12 bed unit. There is increasing demand for additional beds however this is an unaffordable option for the hospice at this time. In response to this growth in demand the remaining three rooms are being used for an expanded day services programme including ambulatory clinics, day stay procedures and day respite care. It also provides an opportunity to work with families to educate them in caring for their family member at home. Waipuna Hospice is the lead organisation for implementation of the Liverpool Care Pathway in Bay of Plenty and is the lead hospice in implementation of the PalCare patient management system for the five hospices in Midland.

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From January to December 2010 Waipuna Hospice cared for 417 people who died during the year, provided 6192 domiciliary nursing visits and undertook 4330 nursing and medical assessments. The hospice cares for around 190 people at any one time. Around 90% of their patients have cancer. 85% of those who died during 2010 were European and 13% Māori. Hospice Eastern Bay of Plenty based in Whakatane, provides services for the territorial authorities of Whakatane, Kawerau and Opotiki and has a population base of about 50,000 which is one quarter of the DHB population. The hospice has a paid workforce of 8.6 FTE as at July 2010 with around 50 volunteers contributing in excess of 7,000 hours per annum. Services offered by Hospice Eastern Bay of Plenty include: • Care co-ordination and liaison with GPs, residential care, hospitals, pharmacists and other services • 24/7 palliative care community nursing service provided by hospice nurses and in conjunction with

district nurses for patients in Te Kaha and Murupara • Weekly day stay programme • Specialist equipment loan • Psychosocial care and family support during illness • Grief and bereavement counselling and support groups, access to social work services and

chaplaincy support • Public and professional education • Assessment for home help and personal care services • Coordination of palliative beds in local rest home for respite or end-stage care • Biography service

The hospice works closely with GPs, some district nurses, residential care facilities and Māori provider services. LCP is being implemented as a part of a Bay of Plenty wide project under the leadership of Waipuna Hospice. Access to a palliative medicine specialist is improving via links with Waipuna Hospice. One-off education sessions for generalists and patient consultations for some EBOP patients have been provided but this is not yet formalised in terms of the degree of regularity. On occasions Eastern Bay of Plenty patients have been admitted to the inpatient unit at Waipuna Hospice however given the distance to travel this presents problems for them. Many patients and/or their family/whānau lack access to reliable transport or cannot afford the cost of travel. Transfer by ambulance is a prohibitive cost for patients. Because of this, admission to the Waipuna Hospice inpatient unit is not seen as a widely acceptable option for Eastern Bay residents. From January to December 2010 Hospice Eastern Bay of Plenty cared for 160 people who died during the year, provided 1968 domiciliary nursing visits and undertook 2476 nursing assessments (including giving phone advice). The hospice cares for around 50 people at any one time. About 72% of their patients have cancer. The next most common are respiratory and cardiovascular diseases. 62% of those who died during 2010 were European and 35% Māori. The criteria for access and admission to the specialist services of both hospices are based on the Leeds eligibility criteria for specialist palliative care services which is needs based and not diagnosis based for patients with an extraordinary level of need (i.e. their needs exceed the resources of the primary care team). Acceptance of referral into the service is determined following a comprehensive assessment.

The draft Resource and Capability Framework recommends the development and adoption of national eligibility criteria for access to specialist palliative care services.

Representatives of Waipuna Hospice and Hospice Eastern Bay of Plenty actively participate in the Midland Palliative Care Workgroup and have developed relationships with hospices within Midland and in other parts of New Zealand. They are members of Hospice New Zealand and involved in national activities. The Hospices are accredited under EQuIP4 standards and undergo HealthShare audits against the Bay of Plenty DHB contract.

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5.6. Specific Bay of Plenty initiatives

End of life Liverpool Care Pathway for the dying patient It is widely quoted that most people, given a choice, would prefer to die at home. In order to support this it is essential to provide comprehensive palliative care services within the community. Considerable effort has been made to put resources in place to support palliative patients who are dying to remain at home or in residential care. This has been further enhanced by the introduction of the end of life Liverpool Care Pathway (LCP) to guide the care of patients in their last days of life. The LCP has been endorsed by the Ministry of Health as the End of Life Care Pathway for use in New Zealand. The LCP is an integrated care pathway that guides healthcare professionals to deliver evidence-based best practice care to dying patients and their families in the last days and hours of life, irrespective of diagnosis or care setting. Waipuna Hospice is the lead organisation for implementation of the LCP. An implementation programme commenced in the WBOP in 2008 and is 79% complete (as at December 2011). Implementation began in EBOP in 2010 and is 45% complete (as at December 2011). One of the aims of the LCP is to avoid unnecessary hospital admissions by anticipating and planning for the possible needs of palliative patients who are dying, usually resulting in them being able to remain at home. Clinical guidelines In Bay of Plenty, clinical guidelines are generally available within the hospices for the services they provide. There is a gap in the availability of documented best practice clinical guidelines and referral pathways for use by generalists and the hospices recognise the need for further work in this area. There should be consistency across Midland and therefore consideration given to developing region wide best practice guidelines supported by local referral pathways and service descriptions.

The draft Resource and Capability Framework recommends the adoption of national evidence based symptom management guidelines to reduce duplication and resource required for review.

Bay Navigator The DHB in association with the Western Bay of Plenty Primary Health Organisation, Nga Mataapuna Oranga and the Eastern Bay Primary Health Alliance, has embarked on a project to develop care pathways for the improvement of the patients overall journey. Care pathways look at the continuity of care across different disciplines and sectors, with the aim of reducing duplication and improving the efficiency of resources within a constrained financial setting and medical workforce. Bay Navigator provides online support to enable hospital clinicians and general practitioners to work together to improve the coordination of patient care from the community, into hospital and back into the community. A care pathway development approach brings together clinical staff from a range of disciplines to design and agree care processes. This has resulted in "boundary-crossing", and the strengthening of clinical networks to share knowledge, produce efficiencies and reduce errors. The four health groupings initially chosen are diabetes, respiratory, cardiology and child health. It is recommended that palliative care be considered as an option for development on the Bay Navigator.

Information management There are a range of services contributing to the care of palliative patients (hospital, hospice, GPs, district nursing etc). Each service maintains their own information and patient records and there is little, if any, integration of systems and limited sharing of information. Obtaining information for this plan has been difficult because the information is either manually held, fragmented or simply not available. The availability of complete patient information, quickly and accurately, is extremely important to the effective relationships between primary/generalist and specialist services, and it enhances seamless care between providers.

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The two hospices have historically used a combination of Medtech and other paper or spreadsheet based records. Medtech is a modular practice management solution used by many medical practices throughout both New Zealand and Australia. Although it enabled some improved communication and information sharing between hospices and primary practice, it did not provide an overall information solution for the hospices. Many of their other information management requirements remained very manual, labour intensive and prone to error. Waipuna Hospice has recently led a project with the Midland hospices

17 to purchase and implement

PalCare an electronic patient care information management solution for the delivery of palliative care and support services at the point of care. This has been made possible by community grant funding for both software licences and communications equipment.

In addition to the benefits of shared patient information PalCare makes a wide range of other business related activities of the hospices such as monitoring and reporting more accurate and efficient.

The implementation of PalCare in the Midland hospices is currently in progress and will follow a staged roll out. Phase one is implementation within the hospices (and for district nurses in some areas) with some capability for GPs to access information via web access. Phase two will expand access to a wider group such as primary, hospital and other specialist services and will explore the integration with other systems.

There will be a requirement for DHBs and hospices to implement the HISO National Specialist Palliative Care Data and Business Process Standards when finalised.

Consideration also needs to be given to PalCare’s relationship with the regional data repository which is a wider Midland DHB regional information systems project.

The draft Resource and Capability Framework identifies several enablers of care across all services to facilitate the integration of care. This includes an integrated electronic record shared across formal care providers (with patient consent).

Research

Very little palliative care research has been carried out in Bay of Plenty. Some projects associated with staff undertaking tertiary study have been completed but the results are not widely available. In 2010 Hospice Eastern Bay of Plenty was successful in gaining funding to support a research project with Māori recording patient journeys of isolated rural Maori palliative patients. The project report has not yet been finalised. When available there should be consideration of the report findings relative to service improvements for the Eastern Bay of Plenty and possibly could be applied to other areas in Midland.

Education

• Generalist level Palliative care education is provided for generalists by Waipuna Hospice and Hospice EBOP. In general, each hospice provides education within their districts although there are now some whole of BOP and wider Midland regional approaches e.g. a recent Māori Health provider hui on Palliative Care and a Midland Palliative Care Education work group to facilitate sharing of resources and to promote consistency of approach throughout Midland. There is no Bay of Plenty wide education plan. Each hospice delivers the range and number of programmes in response to perceived local need and within their available resources. The Midland Palliative Care Nurses and Carers Education Strategy provides a view of the programmes available to build palliative care understanding and knowledge within the nursing and

17 There are five hospices in the Midland area - Waipuna Hospice, Hospice Eastern Bay of Plenty, Hospice Waikato, Rotorua Community Hospice and Lake Taupo Hospice

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carer workforce. A Midland education calendar is made available via the hospices and the Midland Cancer Network website. Additional Ministry of Health funding to implement new services defined in the National Palliative Care Service Specifications (Draft, 2008) and ‘Access to Care’ pressure funding for Bay of Plenty hospices targeted (amongst other things) the improvement of education to generalists and implementation of end of life care which includes an education component. Both hospices increased their staffing to meet the requirement for increased education and for implementing LCP. This enabled a dedicated focus on education as opposed to an add-on amongst other competing demands. Hospice New Zealand is actively involved in education and workforce development and has developed a range of education packages that can be used by member hospices. This provides a cost effective approach to the development and delivery of consistent palliative care education programmes and resources throughout New Zealand and are used by the BOP hospices. Details of the range of education programmes and sessions offered within Bay of Plenty are listed in the individual hospice service outlines – Appendices 4 and 5. Traditionally, Bay of Plenty specialist palliative care services have not had any involvement in delivering palliative care education for medical students, RMOs or advanced trainees. This is changing with the appointment of a palliative medicine specialist at Waipuna Hospice which has enabled: • agreement with Waikato Palliative Care Service for registrars/advanced trainees in palliative

medicine to undertake part of their training at Waipuna Hospice • site accreditation of Waipuna Hospice by the Royal Australian College of Physicians for

trainees to undertake core components of advanced training. The benefits of Waipuna Hospice increasing involvement in formal education for palliative medicine trainees includes enhanced recruitment opportunities for BOP, growing the number of specialists in New Zealand and a resource to support the development of hospice services.

Medical education would be further enhanced by the development of a Midland regional medical education strategy to identify a whole of region approach to providing education and placement opportunities for doctors.

Particular gaps identified in education for generalists in BOP. • Education of acute hospital staff on palliative care. Suggest a formal understanding be

developed with hospitals for the hospices to: o have a regular slot on orientation programmes o deliver grand round session/s on palliative care o present palliative care topics in nursing study days o have undergraduate nurse placements with hospice services o have medical student and RMO rotations through Waipuna Hospice as part of their

training. • Palliative care education for allied health. Palliative care is not covered at undergraduate

level or in any allied health training and so some are underprepared in dealing with palliative patients. Some allied health staff find it difficult to develop skills in palliative care as an area of specialisation or special interest.

• Medical education for GPs. This is currently limited by the lack of availability of palliative medical resource to provide this throughout BOP and would be enhanced by the appointment of additional specialist palliative medicine resource.

The draft Resource and Capability Framework identifies several enablers of care across all services to facilitate the integration of care. Education and training for generalist providers, including practice based education to support a palliative approach, is identified as an enabler.

Included in the recommendations contained in the draft R&C Framework is: • the development of qualifications appropriate for the allied health workforce to maximise the

potential for the discipline specific skill they bring to the provision of palliative care services; and

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• work with university and other education providers to develop e-learning opportunities which will enable staff who live outside of main centres to access training and qualifications.

• Specialist level Education and development of specialist nurses and others in the hospices is generally achieved through a combination of comprehensive in service activities, access to learning resources, agreed individual development plans, and CME arrangements for medical staff. There are a number of postgraduate training programmes available through a range of providers in New Zealand. There is some access to Health Workforce New Zealand funding to support staff post graduate training/education in palliative care (mostly targeting nursing and medical staff) and BNI Palliative Care Scholarships through Hospice New Zealand (for hospice staff or Hospice NZ individual members). A priority gap identified for knowledge and skill development of the existing palliative care workforce is in caring for an increasing range of nonmalignant diseases and those with dementia. It was also identified that allied health professions lack access to funding to support their development of specialist knowledge and skills in palliative care. Waipuna Hospice has entered into an agreement with BOP DHB to enable Waipuna Hospice to utilise the Moodle

18 online learning platform. Initially this will be used to make the mandatory

training more accessible to staff e.g. fire safety, however it is intended to expand this over 2012/2013 to include other online palliative care learning packages. Waipuna Hospice is increasing the number of undergraduate nursing student clinical placements offered to include placements for transition students. All students will have the opportunity to experience inpatient, hospice at home and day services. These placements will be available to students with an interest in palliative care and it is anticipated that from 2013 Waipuna Hospice will be in a position to employ new graduates from amongst those students who have had a placement at Waipuna Hospice.

Volunteers Hospices rely on the significant input of volunteers to support many of the services and fundraising efforts of hospices. Formal induction and training programmes are required for volunteers and are delivered regularly by the hospices. Public Bay of Plenty does not have a specific strategy around raising public awareness of palliative care services. In general, public promotion of palliative care and hospices is achieved through: • national campaigns under the umbrella of Hospice New Zealand

• hospice newsletters, websites, information brochures

• local hospice promotion, events and fundraising

• speaking engagements

• word of mouth ‘marketing’.

18

Moodle is an Internet based system for delivering e-Learning programmes for educational and training organisations.

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5.7. Funding

Generalist palliative care services

• Primary Health Organisations (PHOs) PHOs are funded at a population level, based on the characteristics of a practice's enrolled population. Community palliative care services delivered through PHOs for their enrolled populations do not have defined funding streams or specified services. They are considered to be a component of essential primary health care services. The Ministry of Health has provided funding (via DHBs to PHOs) to develop specific programmes to improve the provision of primary care. Examples are services to improve access (SIA) funding, Coordinated Primary Options (CPO) services and CarePlus. PHOs have flexibility to decide how these programmes will be developed in their areas to meet the unique needs of their population. The BOP DHB doesn’t specifically fund any palliative care initiatives through SIA or CarePlus funding. However, the PHOs have developed programmes that are available to groups which might include palliative patients (but there is no specific recording of patient by type of care). Examples include:

o BOP DHB provides funds to the three PHOs for CPO services. The PHOs choose what

components are to be covered under the CPO service. The PHOs have a ‘Rest Home’ component which funds a temporary stay (maximum 3 nights) for a person over 65 years of age. The service is to cater for patients that are too ill to be discharged home. The PHOs do not record if the patient is palliative or otherwise.

o WBOP PHO funds the Kaitiaki Nursing Services through SIA funding. This includes a Whānau

Cancer Support nursing service for Māori clients and their whānau affected by cancer. Three Māori nurses carry out home visits and support extends through treatment and palliative/end of life stages. This service is available to the enrolled population of the PHO.

o WBOP PHO uses CPO funding for grief support arising from depression. There is a grief

support agency in Tauranga (Grief Support Inc). • Hospital based palliative care

Palliative care is considered a part of usual treatment and care across a range of specialties within the hospital environment. There is no identifiable funding within the hospital service specifically for palliative care.

• District nursing and allied health services District nursing and allied health services are funded as a part of the DHB community services. There was no information provided on the funding of these services or volumes of workload for palliative care patients. There is a DHB funded district nurse position with a 0.6 FTE palliative care component in EBOP. This role is positioned with the Hospice Eastern Bay of Plenty team.

• Residential care The DHB directly purchases nine hospital level residential care beds for palliative care as detailed previously. These are dedicated beds, purchased on a block basis irrespective of occupancy. There is also some flexibility to purchase additional beds in other locations if required. Waipuna Hospice provides a specialist medical visiting service to Althorpe private hospital for patients in the palliative care contracted beds.

• Home help and personal care In the WBOP Waipuna Hospice provides limited home help and personal care service in patient’s homes. The service was initially provided by the hospice with $67,500 of DHB funding in 2006. Currently the hospice tops up the funding by an additional $30,000 per annum to provide for up to three personal cares and one home help visit per week for those that require it. In EBOP, funding for home help and personal care is provided through Support Net.

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• Other NGOs including Māori health provider services, Cancer Society etc receive funding from the

DHB to provide a range of care and support services. None have identifiable components of palliative care although they may be providing care or support for people who are dying.

Specialist palliative care BOP DHB funds services through annual agreements between the hospice and the DHB. In the past these were multi-year agreements but have changed to annual contracts because the hospices are experiencing high growth. The contracts are based on a volume of referrals which is capped. Currently the volume cap is less than the expected actual volume for both hospices. The hospices received increases for demographic growth and a price adjustment in the 2011/12 contracts. National Palliative Care Service Specifications (NPCSS) were developed in 2001 by the Ministry of Health as part of the Nationwide Service Framework. Purchase units (PUCs) are allocated to them and DHBs use them to contract regional/local clinical services. These PUCs are still broadly used today by DHBs but PUC values and processes to determine volumes and annual changes are not consistent between DHBs. In 2006, a review of the NPCSS was initiated and resulted in the first draft of new service specifications being released on February 2008. These service specifications currently remain in draft. From time to time funding has been allocated by the Ministry of Health to the hospices for specific initiatives. In recent years these were: • 2008/09 - funding for the implementation of end of life care, education to generalists, 24/7 telephone

advice. These were new services defined in the National Palliative Care Service Specifications (draft, MOH 2008)

• 2009 - $60M boost hospice funding nationally over four financial years (2009/10 to 2012/13) to

expand care and services and to help hospices meet their current financial challenges. The amount each hospice receives was determined on national hospice and DHB surveys, and was expected to ensure 70% of hospice costs (based on 2008 calculations) are covered by MOH/DHB funding. Boost Hospice Funding is confirmed for 4 years from 1 July 2009.

• $1.3 million of the total ‘Boost Hospice’ funding was allocated to some selected hospices to help

address difficulties in accessing palliative care services. This ‘Access to Care Pressures’ funding was to be used to address key gaps in the hospice services as identified in the qualitative results of the national stocktake of specialist palliative care services

19. This allocation was provided for the

2009/2010 and 2010/2011 years and has been confirmed for the 2011/12 and 2012/13 years.

Both hospices received Access to Care Pressure funding targeted towards education for generalists and developing a ‘hub and spoke’ model within BOP. In particular this has enabled Waipuna Hospice to provide Hospice EBOP with some palliative care medical specialist support and some access to the Waipuna Hospice inpatient unit where appropriate. These aspects of service require further development.

‘Boost Hospice’ funding is paid to the hospices in 12 even monthly payments. This does not attract any volume or price increases because it is passed on directly from the amount received from the Ministry of Health. It is not yet known whether the Boost Hospice Funding will continue. Currently the additional funding is expected to cease on 30 June 2013. This poses specific challenges for hospices as this funding supports their current level of services. In 2009, after the ‘Boost Funding’ allocation, public funding was expected to cover 70% of hospice costs. However, with no adjustment for inflation this now represents approximately 63% contribution for Waipuna Hospice and remains at around 70% for Hospice EBOP. The shortfall of at least 30% is raised

19

Gap Analysis of Specialist Palliative Care in New Zealand – Providing a national overview of hospice and hospital-based services, Ministry of Health, December 2009.

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by hospices through hospice shops, community fundraising activities and from sponsorship, bequests and donations from individuals and organisations. Donations of services ‘in kind’ and unpaid volunteers make a significant contribution the running of hospice services. Hospices would not provide their current range and level of services without these contributions. Inter district flows There are patients who live on or close to the boundaries between different DHBs, and it may be more appropriate for them to receive service/s form an alternate DHB area. An example is the boundary between EBOP and Lakes DHB around the Murupara/Ruatahuna district. In this example Hospice EBOP provides services but the residents may prefer residential care in Rotorua. In the past there have been only a few instances of this so hospices have not tended to recharge for their services. Equipment is usually supplied by arrangement between the hospices and/or hospital service. Inter district flow agreements provide for transfer of costs in residential care facilities for these patients. A precise map or description or has not been able to be located to identify exactly where the boundaries between DHBs exist. This does cause some operational issues around who should provide services especially in remote rural locations where providing nurse visits is resource intensive and more expensive. A detailed map would provide clarification and reduce confusion for the services. For Bay of Plenty DHB this would involve defining and agreeing the precise boundaries between Lakes and Waikato DHBs. Governance The allocation of funding and performance against contract of palliative care service providers in BOP DHB is the responsibility of the Planning and Funding Portfolio Manager for Health of Older People and the Portfolio Manager for Cancer. Elements of funding for primary care fall under the Portfolio Manager for Primary. The hospices submit quarterly returns of patient and activity data in a format prescribed by the Ministry of Health (MoH monitoring returns) and any other reports required by Planning and Funding. Portfolio managers meet regularly with the hospice managers to review performance against contract and identify issues. Identified funding issues Currently the way that specialist palliative care services are funded by the Midland DHBs is different in each DHB and this is also the case throughout New Zealand. The funding is fragmented and in general, there is a high degree of funding services based on predicted costs from previous year’s activities. This approach supports the funding of services based on historical activities rather than assessed need and can perpetuate inequities. DHB Planning and Funding managers have identified the lack of national service specifications for palliative care as an issue. The need for a new national funding model for specialist palliative care has been highlighted in a number of the current national initiatives. Work on the new national specialist palliative care service specifications and associated documents has not proceeded as quickly as originally planned. These were intended to provide a greater level of clarity to the planning, provision and purchasing of palliative care services. Included in the MoH current national work plan for palliative care is work on a discussion document on the national funding model. It is expected that a new national funding model will be developed following completion of the Resource and Capability Framework and Service Specifications.

Included in the recommendations contained in the draft Resource and Capability Framework is the need to change the current funding models to incentivise effective palliative care outcomes (at both a patient and systems level) instead of on the basis of historical services delivery.

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6. The future

6.1. Increasing need for palliative care

The population’s need for palliative care is being driven by a range of factors which increase the need for care delivered by both specialists and generalists including: • population growth and a growth in the number of deaths.

• ageing population – a greater proportion of people in the older age group means more people will require palliative care

• people living longer – likely to see a rise in chronic diseases such as heart disease, cerebrovascular disease, respiratory disease and cancer

• increasing complexity of care – more people with co-morbid conditions including more with dementia

• increase in rates of cancer and deaths from cancer – cancer has had the biggest influence on need for palliative care because most cancer deaths involve a period when palliative care is required

Based on the New Zealand Cancer Registry and the MoH’s Mortality Collection data, cancer is the leading cause of death in New Zealand accounting for 29% of all deaths. While age-standardised cancer incidence rates are falling, the growth in the older population will increase overall cancer registrations substantially

• increase in referral of patients with nonmalignant diseases due to an increased awareness that people with nonmalignant diseases can benefit from palliative care services

• increase in referrals overall as result of improved awareness of the services available and the benefits

• increase in utilisation by Māori, Pacific People and other ethnic groups as a result of services being more responsive to cultural needs leading to greater acceptance by these groups.

In addition, the hospices report additional demands being placed on their services because of the changing family structures. They observe more patients living alone with little or no family support as families are smaller, more dispersed or are elderly themselves. This increases demand for supportive services such as home help and personal care and makes it more difficult for people to stay in their own home and to die at home. Changes in clinical practice and policy in other clinical specialties (e.g. aged care and oncology) will also influence patterns of referral and demand for services. New models of care are being developed for other specialties and palliative care is increasingly being included as a key component in patient pathways. There is a need to ensure both the availability of palliative care and good integration of palliative care with other services to support these new models. The Bay of Plenty specialist palliative care services recognise the need to strengthen relationships with other specialty services, in particular aged care services, to ensure palliative care is an accepted part of mainstream healthcare and that other specialties receive the education and support they require to meet the needs of their patients and family/whānau. Palliative care should be infused into other clinical specialties and all clinical settings. The Medical Oncology Cranleigh Report (2011)

20 concludes that “overall, the increase in numbers of

people with cancer, survivorship, treatment duration, the changing care complexity and funding pressures are likely to significantly impact workloads and service sustainability.” The Ministry of Health recognises that in implementing new models of care for medical oncology there will be impact on other services provided by district health boards and non-government organisations. The report outlines that service and capacity pressures in other cancer related services, particularly palliative care, are affecting medical oncology capacity. It states “the sector consensus is that 10-20% of patients occupying medical

20

Report to the Ministry of Health - New Models of Care for Medical Oncology, Cranleigh Health, 5 October 2011.

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oncology inpatient beds may not need specific medical oncology input and could be better managed in a specialist palliative care facility.” The New Zealand Lung Cancer Standards

21 released in August 2011 include the availability of palliative

care as a specific standard, i.e. Standard 12: Patients who cannot be offered curative treatment, as well as those with a significant symptom burden, should be offered early access to palliative care services. The key to caring well for people who will die in the (relatively) near future is to understand how they may die, and then plan appropriately. Since diseases affect individuals in different ways, prognosis is often difficult to estimate. None the less, it seems that patients with specific diseases and their carers often have common patterns of experiences, symptoms, and needs as the illness progresses

22. Three

typical trajectories have been developed so far and are increasingly used to conceptualise palliative care needs – refer to Appendix 6. Physical, social, psychological and spiritual needs of patients and their carers are likely to vary according to the trajectory they are following. Specialist palliative care services that traditionally have cared for those with cancer are being challenged to meet the varied needs of those with other chronic conditions and especially those with dementia.

Cancer and chronic disease Overall in New Zealand, cancer is now the leading cause of death in New Zealand accounting for 29% of deaths from all causes. Seventy-two percent of all deaths from cancer in 2008 occurred in people aged 65 and over. According to the Ministry of Health, for the period 2006-2008 Bay of Plenty had the highest age-standardised cancer registration rate of all DHBs (370 per 100,000) and was significantly higher than the national rate (344 per 100,000). Bay of Plenty age standardised death rate from cancer (140.4 per 100,000) is higher than the national average (132.3 per 100,000) and is the eighth highest across all DHBs. The Bay of Plenty DHB had the same leading causes of death for older people (65+) as those nationally (2005-07): • ischaemic heart disease • stroke • chronic obstructive pulmonary disease • diabetes • lung cancer The leading causes of death were similar across ethnic groups. The Bay of Plenty District Strategic Plan 2005-2015 recognises the increasing rates of chronic conditions, including multiple chronic conditions, as a key issue requiring new approaches to preventing, detecting and managing new outcomes. Recent data in Table 6 from the hospices in BOP shows a changing proportion of patients with a non-cancer diagnosis. This could be attributed to an increasing prevalence of non-cancer conditions, awareness of the role and value of palliative care and hospice services for those with nonmalignant diseases and an increased public awareness that hospice services are not just for those with cancer.

21 National Lung Cancer Working Group. 2011. Standards of Service Provision for Lung Cancer Patients in New Zealand. Wellington: Ministry of Health. http://www.MoH.govt.nz/MoH.nsf/Files/cancer/$file/lung-cancer-service-standards-aug11.pdf

22

Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ April 2005; vol 330, pp 1007-1011.

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Table 6: Diagnosis hospice patients 2008-2010

2008 2009 2010

Hospice EBOP 79% 80% 72% Cancer

Waipuna Hospice 91% 90% 88%

Hospice EBOP 21% 20% 28% Non Cancer

Waipuna Hospice 9% 10% 12%

Source: Hospice MoH monitoring returns Note this data is based on the primary diagnosis of the patient which may or may not be the exact cause of death i.e. a patient with cancer as a primary diagnosis may have died of another cause.

Figures 2 and 3 show a breakdown of the number of patients by diagnosis and shows the overall makeup of diagnosis groups for patients who died or were transferred within each calendar year. EBOP is experiencing a marked increase in the number of people with respiratory, neurological and cardiovascular disease. Key to the diagnosis groups in the charts: OT Other RE Respiratory NE Neurological CV Cardiovascular CA Cancer Figure 2: Diagnosis of hospice patients – Hospice Eastern Bay of Plenty

Hospice EBOP - Diagnosis as a proportion of total

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Number of patients

OT 8 16 8

RE 9 9 18

NE 8

CV 10 9 18

CA 99 135 135

2008 2009 2010

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Figure 3: Diagnosis of hospice patients – Waipuna Hospice

Waipuna Hospice - Diagnosis as a proportion of total 2008-2010

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Number of Patients

OT 17 17 22

RE 5 4 8

NE 6 7 8

CV 10 12 16

CA 376 366 410

2008 2009 2010

Deaths in Bay of Plenty Place of death In UK, despite most people (56-74%) expressing a preference to die at home, only 35% actually achieve this aim (National Audit Office NAO, 2008)

23. The majority of deaths in England occur in an acute

hospital setting following prolonged, chronic illness. In Australia only 16% of people die at home. Twenty percent of people die in hospices and 10% in nursing homes. The rest (around 54%) die in hospitals.

24

The National Health Needs Analysis for Palliative Care

25 indicates that on a national basis most deaths

in New Zealand occurred in a hospital setting (34%) followed by residential care (31%) and private residence (22%). A small number of deaths were in a hospice inpatient unit. In BOP, the proportion of those who die in hospital is less than Australia, UK and New Zealand as a whole. During the 4 year period 2007 to 2010, an average of 28% died in Tauranga or Whakatane Hospitals. See Table 7.

23

End of Life care, 2010, Vol 4 No 3 24

CareSearch Preferred Place of Death www.caesearch.com.au Accessed 24 August 2011. 25

National Health Needs Analysis for Palliative Care, Cancer Control Council, June 2011. A full copy of the National HNA for Palliative Care is available from the publications section on the Cancer Control New Zealand website http://www.cancercontrolnz.govt.nz/about-us/publications

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Table 7: Ratio of deaths in hospital – BOP 2007-2010

Whakatane Hospital deaths

Tauranga Hospital deaths

Total deaths in Hospital

All deaths in BOP

Deaths in hospital as a % of all

deaths 2007 107 345 452 1714 26% 2008 101 341 442 1669 26% 2009 105 428 533 1728 31% 2010 100 391 491 1723 28%

Source: Bay of Plenty DHB and Statistics New Zealand

It is not known how many of the total deaths in BOP occur at home or residential care facilities etc, nor do we have information of where people would prefer to die. However, we do have information on where people who are patients of the hospice services die, see Table 8 below. Table 8: Place of death of hospice patients - 2010

Eastern Bay of Plenty

Western Bay of Plenty

Home 60% 34% Hospital 21% 16% Residential care home* 19% 22% Hospice inpatient unit - 27%

*Includes those where the ARC is their ‘home’ Source: Hospice MOH monitoring returns

EBOP has a high proportion of Māori and high socioeconomic deprivation. The palliative care model of care in the region is predominantly community based and has developed to support both the socioeconomic situation of the population and the cultural preference of Māori to remain at home to die. Success of this is demonstrated in the high proportion of hospice patients who die at home (60%). Between 2008 and 2010, the proportion of deaths in residential care in EBOP declined and the proportion dying in hospital increased – see Figure 4. The exact reason for this trend is unknown but could be attributed to:

o difficulty placing residents in suitable local residential care facilities o patients becoming more sick and not being able to be cared for at home o less family support available in the home o increasing referrals resulting in more pressure on hospice and district nurses and not able to

maintain the level of care in the home for some. Figure 4: Hospice EBOP patients – place of death

Hospice EBOP - Place of death

0%

10%

20%

30%

40%

50%

60%

70%

Home 60% 54% 60%

Resthome 30% 23% 19%

Hospital 10% 23% 21%

2008 2009 2010

Source: Hospice Ministry of Health monitoring returns

In contrast to EBOP, the percentage of Waipuna Hospice patients who die at home has declined since 2008 with an increasing trend of patients dying in the hospice inpatient unit. The number of hospice patients dying in residential care is also declining – see Figure 5. This could also reflect a higher

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complexity of care required and patients being unable to be supported to die at home or in residential care facilities, and for whom the hospice inpatient unit is a suitable alternative. Figure 5: Waipuna Hospice Patients - Place of Death

Waipuna Hospice Patients : Place of death

0%

10%

20%

30%

40%

% o

f W

aip

una p

atie

nt dea

ths

HOME 38% 36% 34%

HOSPITAL 15% 15% 16%

IPU 21% 26% 27%

REST HOME 26% 24% 22%

2008 2009 2010

Source: Hospice Ministry of Health monitoring returns

Projected number of deaths According to projections by Statistics New Zealand the number of deaths in BOP is estimated to reach 1907 by the year 2016, with the most significant increases in Tauranga and WBOP territorial authorities – see Figure 6. Figure 6: Number of deaths by territorial authority – actual and projected

Source: Statistics New Zealand

In 2010, of the 1290 deaths in WBOP 415 (32%) were patients of Waipuna Hospice and of the 433 deaths in EBOP 160 (37%) were patients of Hospice EBOP. The cause of death for the remaining two thirds of deaths would include: • sudden/unexpected death e.g. heart attack, major trauma • natural death e.g. old age or other illnesses where specialist palliative care was not required • child and infant deaths. And it is likely there would be a percentage that died without specialist palliative care input who may have benefited from it. The reasons could include:

Bay of Plenty DHB region: Deaths

0

200

400

600

800

1,000

1,200

Western BOP 280 310 300 320 330 380 440

Tauranga 740 800 920 970 960 1,070 1,160

Whakatane 260 250 230 290 280 300 320

Kawerau 51 43 51 55 65 72 78

Opotiki 90 83 79 88 83 85 90

1996 2001 2006 2010 2011 2016 2021

Actual Projected

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• non referral – lack of recognition that the person was dying • lack of awareness of palliative care/hospice services • declined referral to hospice by patient/family/whānau. However, there are no sources of information on which to base an estimate of what this percentage might be.

National Palliative Care Health Needs Assessment (HNA) - estimate of need. The National Health Needs Analysis for Palliative Care published in 2011 provides estimates of the number of people who would benefit from palliative care. Mortality Collection and Hospital Admission data for 2005, 2006 and 2007 was analysed to establish how many people might have benefited from palliative care and future estimates made based on population growth. The mid-range estimate for adults in BOP DHB (those aged 20 yrs+) indicates 57.1% of all deaths would benefit from palliative care. This was projected in the HNA to an estimate of the likely numbers of people based on population growth. Table 9: Mid range estimate of the number of adults who would benefit from palliative care

BAY OF PLENTY

Midrange estimate number likely to benefit from palliative care p.a.

Increase between periods (number of people and % increase)

Baseline (2006) 913

Projected 2016 1069 156 (17%)

Projected 2026 1195 126 (12%)

Source: National Health Needs Assessment for Palliative Care Phase 1 report, Palliative Care Council of New Zealand, June 2011 p. 34

The HNA states there is limited evidence available on how the number of people who could benefit from palliative care can be allocated into the following groups: • those requiring specialist palliative care • those who could be cared for adequately by generalist palliative care providers. Because of the difficulty identifying the likely split of patients between the two service levels the estimation is of limited use in relating to current services in Bay of Plenty and planning future service volumes. The HNA states that although research is limited to date, there is some evidence showing that palliative care for people in more deprived areas requires more resources than in most affluent areas. A study undertaken by St Christopher’s Hospice in London found that people in the most deprived district of their catchment required, on average, twice as many home visits as people from more affluent districts. After the annual incidence of deaths, deprivation is therefore considered the second most important factor affecting palliative care resource needs in a population.

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6.2. Capacity to meet future demand.

Referrals The specialist services currently report an increasing trend of referrals beyond what they had expected, and that referral numbers exceed the capped volume they are funded for – see Tables 10 and 11. Table 10: Waipuna Hospice referrals

Financial year Funded volume cap

Actual referrals

Difference % above funded level

2008/09 450 470 +20 4.4% 2009/10 465 472 +7 1.5% 2010/11 473 524 +51 11%

2011/12 (current) 489 293 (6/12 actual)

Estimate full year * 586

+96

20%

Table 11: Hospice EBOP referrals

Financial year Funded volume cap

Actual referrals Difference % above/below funded level

2008/09 144 134 -10 -7% 2009/10 146 172 +26 18 % 2010/11 148 199 +51 34%

2011/12 (current) 150 116 (6/12 actual)

Estimate full year* 232

+82

55% * estimate is based on average of first 6 months multiplied by 12. There is no data available to demonstrate workload volume or trends for generalist providers such as GPs, district nurses, allied health. However, in stakeholder discussions generalist services talked about the need to prioritise palliative patients amongst other competing demands and expressed the feeling that they were compromising the level/standard of care they should be providing for those patients and family/whānau. Their time is prioritised to clinical care and felt they simply “do not have enough time” to spend with the palliative patient, family and whānau. Hospice services report that with the increasing referrals and patient numbers they too are having to reprioritise activities. Clinical care is a priority and time for social support and other activities of holistic care is declining. Specialist palliative care inpatient beds The New Zealand Palliative Care Strategy listed the number of palliative care beds in New Zealand in 1998/99 per 100,000 population. This ranged from 0.64 to 7.8 beds per 100,000 with an average of 4.3 beds per 100,000 population. At the time BOP was reported as 0.77 beds per 100,000 however since then the Waipuna inpatient unit has been developed. Palliative Care Australia recommends 6.7 beds per 100,000 population, based on an 85% occupancy rate

26. In Ireland, the recommended level in 2007 was 10 inpatient hospice beds per 100,000

population27

however it is recognised that palliative care services in Ireland are more developed than other countries. Table 12 provides a review of specialist inpatient (hospice) beds against Australia and UK benchmarks. These figures have been widely referred to in literature on palliative care however they are contingent on support from a well-managed community focus on delivery of palliative care. Also included is the NZ 1998/99 average beds per 100,000 population.

26

Palliative Care Australia 2003. Palliative Care Service Provision in Australia: A Planning Guide. 2nd

edition: Palliative Care Australia 27

Staffing Levels and Bed Numbers in Specialist Palliative Care in Ireland, 2007. Update of baseline study (2005) data. http://www.hospice-foundation.ie/index.php?option=com_content&task=view&id=240&Itemid=157

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Table 12: Required specialist inpatient beds per 100,000 population utilising international benchmarks (rounded to whole number)

Australia UK NZ

Basis

Population

6.7 per 100,000

5.1 per 100,000

4.3 per 100,000

Western BOP

2006 150,000 10 8 7

2016 projected 175,800 12 9 8

Eastern BOP

2006 50,850 4 3 2

2016 projected 50,160 4 3 2

Total BOP

2006 200,750 14 10 9

2016 projected 226,000 15 12 10

Waipuna Hospice inpatient unit currently operates 9 beds. This equates to 4.3 beds per 100,000 population for the whole of Bay of Plenty (or 5.7 beds per 100,000 if measured against the WBOP population only). The building has provision to expand to 12 beds if necessary. During 2010/2011, there has regularly been pressure to commission a minimum of 10 beds however this has not been possible due to a lack of funds available for the required increase in staff and related expenses. Based on past utilisation rates and changing patterns of demand for inpatient services, Waipuna Hospice believes the Australian benchmark would most realistically reflect the likely future need in BOP i.e. 15 beds estimated for all of the Bay of Plenty region in 2016. The key issues around increasing to 15 beds would be: • suitability of the location of beds - if all the specialist inpatient beds were developed at Waipuna

Hospice these may not be suited to the needs of the EBOP community (given the distance and the cost of travelling which would be prohibitive for many families). The economies of scale prohibit a dedicated hospice inpatient unit for EBOP based on the projected requirement of 3 to 4 beds. Alternatives might be to purchase additional beds in local hospital level residential care in EBOP with the most complex care going to Whakatane Hospital or Waipuna Hospice.

• building projects are expensive. Securing adequate funding to expand the inpatient unit and to resource the additional beds would be very difficult.

In response to growing demand for services and in an effort to delay/minimise the need to commission additional inpatient beds, Waipuna Hospice is implementing an increased day services programme. Over a 6 to 12 month period in 2011/12 the following services are being progressively introduced or expanded: • nurse and doctor led outpatient clinics (including some procedures) • access to specialist physiotherapy • day respite • art therapy • young person groups • caregiver education. It is not known what impact establishing a specialist palliative care team in Tauranga Hospital would have on the hospice inpatient unit. It is possible that current demand will increase due to identification of patients in hospital that might better be managed in the hospice inpatient unit rather than remaining in the acute hospital. If a hospital palliative care service is implemented, the effect on the hospice inpatient unit would need to be carefully monitored.

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6.3. Specialist palliative care workforce development

This section explores workforce requirements for Bay of Plenty based on international recommendations. These relate to specialist palliative care services inclusive of allied health. There is no information available on which to base workforce requirements for generalist palliative care services (e.g. district nurses, GPs, registered nurses in residential care). The increasing demand in palliative care services is an international phenomenon with recognised workforce issues. Improving the quality of health services depends on adequate levels and availability of appropriate trained workforce including the important group of volunteer workers.

Key issues for development of a sustainable workforce include: • To ensure adequate staff levels to address the growing demand • Staff recruitment and retention strategies • To ensure a multidisciplinary team approach • To have a focused approach to training and development of undergraduate, graduate and post

graduate health professionals, health care assistants, volunteers, carers and families/whānau • Promotion of palliative care approach and services to general health professionals and providers • Promotion of cultural learning • To address the needs of the palliative care workforce in rural areas • To increase Māori palliative care workforce • To provide support and supervision of the workforce In 2011, Health Workforce New Zealand published the results of a workforce service review

28 to develop

a vision and model of palliative care service and workforce for 2020 in a context of increasing demand and limited funding. Included in the report was a calculation of workforce and patient ratios (medical and nursing FTEs per 1000 patients in 2008). In the review, BOP is grouped with Waikato and Lakes DHBs as one of eight network groupings. The Waikato/Bay of Plenty/Lakes ratio of 21.6 FTEs per 1,000 patients was the second lowest (next to the upper South Island) of all eight regions. The range was 42.2 FTEs per 1,000 patients to 20.7 FTE per 1,000 patients.

Workforce calculations Internationally there is no consensus about population size or appropriate specialist-generalist service volumes for resourcing palliative care services. Most research and policy development in this area originates in the UK, Ireland and Australia where inpatient palliative care is more common than in NZ and there are differences in the models of care. Therefore using overseas estimations should be treated with caution in the NZ setting. However, in the absence of agreed national benchmark standards in NZ, we have used the guidelines published by Palliative Care Australia in 2003.

29

The planning guide provides population-based specialist palliative care clinical staffing guidelines to support an integrated palliative care system. There is some variation in the Australian model when applying it to the BOP situation. The Australian guidelines do not provide for hands on nursing care in the community and relies on this being provided by generalist community nurses (not accounted for in the resource calculations). The Waipuna Hospice community nursing team provides hands on care and Hospice EBOP has a mix of hands on care for some patients and shared care with district nurses for others. Therefore a direct comparison of all nursing components will not be possible. It is acknowledged that the current BOP DHB resourcing and funding will not meet the predicted staff level requirements stated. However the BOP DHB and hospices can prioritise where scarce resources are allocated for development of palliative care services as funds become available. The staff levels recommended by Palliative Care Australia have been applied to the BOP region as a whole - see table 13. Assumptions of the model are: • Palliative care designated beds FTE per 6.7 beds BOP DHB palliative care beds = 9

• Acute hospital beds FTE per 125 beds BOP DHB beds = 425 (324 Tauranga and 101 Whakatane)

28 Health Workforce New Zealand, Palliative Care Workforce Service Review, 2011 http://www.healthworkforce.govt.nz/our-work/workforce-service-reviews/palliative-care 29

Palliative Care Australia, Palliative Care Service Provision in Australia: A Planning Guide 2nd

Edition, 2003

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• Community FTE per 100,000 pop. BOP DHB population = 210,10030

Table 13: BOP palliative care staff requirements

Position Community based service levels

Acute hospital

consultative service levels

Palliative care

designated bed levels

Estimated Current FTE

(excluding admin & management FTEs)

Palliative care specialist1 3.15 0.9 Waipuna

Increasing to 1.1 from April 2012

Registrar 2.10 0.9 Waipuna2

Resident medical officer - - 0.34 1.2 Waipuna3

Liaison psychiatry 0.53 Referral to mental health

Nurse consultant/specialists4

Clinical nurses

Registered and enrolled nurses

6

2.1

4.25

2.55

6.5 hrs per pt day

Community teams: 11.45 RN/1.68 HCA Waipuna 3.6 EBOP Waipuna IPU RN 9.6 EN 2.2 HCA 2.2

Discharge liaison7 0.53 Included in community

RN

Psychology 0.53 0.34 0.13 Hosp. referral

Social work 1.05 0.85 0.34 1.48 Waipuna

EBOP links with DHB community service

Bereavement support 0.53 0.34 0.13 1.46 Waipuna

0.5 EBOP

Pastoral care 0.53 0.85 0.34 0.5 Waipuna

and community churches

Speech therapy 0.42 0.68 0.27 Hosp. referral

Dietitian 0.42 Hosp. referral

Physiotherapy 0.84 0.68 0.27 0.1 Waipuna

Hosp. referral

Occupational therapy 0.84 0.68 0.27 Hosp. referral

Pharmacist - 0.85 0.13 Hosp. or community pharmacists

Music, art therapist 1.05 - 0.56

TOTAL 12.09

Dedicated plus shared roles

7.82


2.78


Volunteers8

1 per 65 1 per 65 1 per 65 1 per 450 Waipuna

1 per 50 EBOP (0.5FTE)

Notes: 1. Specialist and registrar positions have both community and inpatient responsibilities

30 The population used for these calculations is 210,100 based on the information from Statistics NZ for District Health Board populations at 30 June 2010 (Subnational population estimates). Approx split WBOP 160,000 & EBOP 50,000).

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2. Shared arrangement with Health Waikato Palliative Care Service (late 2011) 3. These are Waipuna Hospice IPU non specialist doctors (0.2 FTE employee and 1.0 FTE contracted GPs) 4. Community and acute care consultation teams require consultant/specialist level nurses to act independently,

provide consultation to primary carers and to coordinate, monitor and review patient care. Clinical nurses are senior nurses who work under the direction of the consultant/specialist.

5. The Australian model excludes the direct hands on care of community nurses. Waipuna Hospice and Hospice EBOP community nurses provide hands on care in the patient’s home. Waipuna community team HCAs carry out home help and personal care for patients.

6. Designated palliative care beds require a mix of direct care including specialist & clinical nurses, RN and EN level staff, with a predominance of RNs over ENs. Patient carers may also be a part of the mix.

7. The Australian model indicates the discharge liaison could be included in a nursing or social work position 8. Based on recommendation for “process” volunteers (e.g. routine practical tasks)

In the current services there are a number of significant gaps, in particular these relate to medical staff, allied health staff and resources for an acute hospital consultative service. Priorities for the BOP DHB palliative care workforce planning include: • Palliative medicine specialist - It is has been long recognised there is an international and national

shortage of specialist palliative care physicians and the lead in time for recruitment can be significant. To recognise this issue, additional Ministry of Health funding has been provided since 2009 to establish up to nine palliative medicine advanced training positions throughout New Zealand. The scheme provides an additional $30,000 for each year of training during the three year training programme, additional to the usual funding for trainees. As trainees from this scheme qualify it is expected this will reduce some of the previous recruitment difficulties. It is recommended, as funding comes available, that recruitment of additional palliative medicine specialists would enable: o timely patient access to palliative medicine assessment, consultation and input to care planning

due to increasing number of referrals for patients with complex clinical needs

o development of the palliative care approach with other specialist services especially in the acute hospitals (the model of a hospital based specialist service to support Tauranga and Whakatane Hospitals is to be developed)

o increased delivery of palliative care education programmes

o increased support for GP’s in palliative care

o additional support for the 24 hour/7 day week palliative medicine acute on-call service for general practitioners, other specialists and for assistance and advice to the specialist palliative care nurse on-call service

o increase support to Bay of Plenty hospitals and communities in terms of outreach clinics

o reduce the risks if there is a resignation and to enhance coverage for leave. It is recommended that the development of specialist medical resources be done in a collaborative way within Midland to maximise the opportunity for sharing knowledge and expertise within the region. It is envisaged that while palliative medicine specialists will be employed by particular DHBs or hospices, they will collaborate and provide support across organisational boundaries to enhance palliative medicine in the region. This would require palliative care medical staff to be credentialed by each of the DHBs across the region. Further work needs to be carried out to fully develop this concept.

Hospice EBOP requires formalised regular specialist medical input into service provision and development.

• Registrars – Waipuna Hospice has recently gained accreditation as a core training site for

advanced palliative medicine trainees. As funding becomes available it is intended to have an advanced trainee and/or have increased involvement in the rotation of advanced trainees from Waikato DHB. The benefits of this initiative would be an opportunity to support increasing the number of specialists in New Zealand and an interim solution to assist the existing palliative medicine specialist with workload.

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• General practitioners – The GP workforce in general is ageing and there is a mixed level of engagement of GPs (particularly younger GPs) in providing palliative care and after hour’s services. The GP’s knowledge of palliative care and clinical literacy will be encouraged and strengthened by provision of educational programmes in palliative care, supported by prompt access to specialist palliative care services and community support services. Sustainable solutions to address the issues of GP availability and out of hours cover, especially for rural areas, needs to be developed as a part of PHO initiatives to deliver on the Government’s Primary Health Strategy. The opportunity to develop GPs with a special interest in palliative care should be explored.

• Nursing – If the future sustainability of specialist palliative care is dependent on increasing the capacity and capability of generalists to care for palliative patients and their family/whānau thus enabling specialist services to deal with more complex cases, then the provision of education is a critical role for specialist palliative care. The Hospice New Zealand Fundamentals of Palliative Care education package has recently been released and provides a nationally consistent tool for delivery of education across the group of generalist nurses (developed with an aged care focus in the first instance but is intended to be modified for other groups).

The specialist services need to develop an education plan for these groups in their region with timeframes and resources assigned. A commitment of support from the generalists employing organisation for release time and financial support, where required, should be considered as part of the planning process.

The New Zealand Palliative Care Strategy described specialist palliative care services as employing “a majority (over 60 percent) of their registered nursing staff with a recognised palliative care qualification and the rest working towards completed palliative care qualifications”. Currently Waipuna Hospice has 30 percent of RNs

31 with post graduate qualifications (with a further 5

undertaking study – when completed will increase the ratio to 42.5%) and Hospice Eastern Bay of Plenty has 66 percent.

The Ministry of Health and the Nursing Council have identified palliative care as one of the scopes of practice for nurse practitioner role development in New Zealand. For a registered nurse to meet the Nursing Council criteria they must have a clinical masters degree, at least four years experience in palliative care and pass a Nursing Council assessment of competencies. Registration as a nurse practitioner with prescribing rights can also be obtained. Nurse practitioners are expert nurses, have advanced levels of assessment and treatment skills to manage complex situations, promote evidence based practice to influence standards in health practice and have the ability to order, conduct and interpret diagnostic and laboratory tests and administer therapies for the management of potential or actual health needs. The nurse practitioner role has the flexibility of practice to work across a large range of settings and has the potential to contribute significantly to service provision in rural areas where access to specialist medical support is limited.

The Bay of Plenty palliative care workforce plan should promote a pathway for development of a nurse practitioner in palliative care. There may also be value in developing a higher level of knowledge and skills in palliative care within the group of practice nurses (particularly those within larger general practices).

• Allied health – Allied health professionals are an essential component of a comprehensive and

quality palliative care service. More work needs to be carried out in BOP to determine how well allied health is meeting to the needs of palliative patients when accessed through the centralised DHB model and if there is a need to have a greater range of allied health professionals specifically trained and designated as part of the specialist palliative care team. Insufficient information is available at this time to make a recommendation on this.

• Carers – The important role of carers, especially in the home, is widely acknowledged. These are the family/whānau or other carers that are most often with the patient and providing day to day care and support. There is a need to ensure they have an appropriate level of understanding and knowledge to support the patient and to be able to identify when help is needed and how to access help. Both specialist and generalist palliative care service providers have a role to play in education of carers and programmes and resources need to be developed to support this learning.

31

The percentage of RN’s is measured as a headcount of nurses (not FTE).

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6.4. Hospital based specialist palliative care

The New Zealand Palliative Care Strategy describes hospital palliative care teams as necessary to educate and advise all hospital services on the palliative care approach and the need to provide palliative care as an option for people who are dying. They would also assist in ensuring people access the appropriate palliative care services in their communities on a timely basis. Irish guidelines recommend a consultant-led multidisciplinary palliative care team in each acute hospital of 150 beds or more. Resourcing is recommended to include a specialist palliative care nurse, a social worker and a secretary, led by the palliative medicine specialist working across the range of settings and who was available in the hospital for a defined minimum number of sessions per week. The guidelines suggest that for smaller general hospitals, where it may not be feasible to employ a full-time specialist palliative care team, the specialist palliative care team serving the community should provide a service to patients in the hospital. Currently there is no hospital palliative care team or palliative care specialist medical or nursing resource in Tauranga or Whakatane Hospitals other than a hospice discharge/liaison nurse role in WBOP who works with Tauranga hospital staff. Access to specialist palliative care for a hospital inpatient is by referral to Waipuna Hospice or Hospice EBOP on discharge from hospital. Currently, there is only one palliative medicine specialist in the Bay of Plenty. This role sits with Waipuna Hospice and has a community and hospice inpatient focus. Although Waipuna Hospice works closely with the oncology service at Tauranga Hospital the palliative medicine specialist has no formal role in either hospitals (other than being available to hospital doctors as a part of the 24/7 medical telephone support service for BOP). BOP DHB has for some time identified the need to improve palliative care in the hospital setting and has indicated a desire to establish a specialist palliative care service/team at least in Tauranga Hospital in the first instance, with consideration of an appropriate service level and model of care for Whakatane Hospital. Waipuna Hospice has previously considered, and promoted, the establishment of a specialist palliative care team that serves both hospitals in the region. The hospice believes this could be a partnership between Waipuna Hospice and the DHB, but development would require a long term commitment by the DHB. The 2008 plan to develop Resident Medical Oncology and Haematology services based in Tauranga

32

identified that a resident service requires access to specialist palliative care services including access to consultation service with palliative care physicians. Radiation oncology service plan work is under way for BOP. The DHB has indicated the possible establishment of a private provider for a radiation oncology service at the Tauranga Cancer Centre. International role delineation models require radiation oncology services to be part of a comprehensive cancer service including on site specialist palliative care. One of the principles that apply to a radiation oncology service is that all patients receiving radiotherapy should have access to the same level of care and support. This will not be achieved for patients in BOP if there is no on site specialist palliative care. In addition to staffing a hospital-based service there will need to be the development of referral guidelines, clinical protocols, patient information, as well as access to support systems and resources including diagnostic services. There is an opportunity to use technology to improve access to specialist medical consultations throughout the region using videoconferencing. This was trialled recently between Waikato and Thames hospitals with a palliative care patient follow-up consultation and worked well. This would be dependent on access to appropriate videoconferencing equipment and facilities at suitable locations in the BOP. Some key points relating to palliative care in acute general hospitals in Ireland and Australia and evaluating hospital palliative care is provided in Appendix 7.

32

Hewitt J. Plan to Develop Resident Medical Oncology and Haematology Services based in Tauranga, Bay of

Plenty DHB. Midland Cancer Network, Hamilton NZ, 2008.

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7. Summary of key strengths and issues

Detailed stakeholder feedback is included in Appendix 8 and 9.

7.1. Strengths

There were many comments of support for the palliative care services provided during the stakeholder meetings. A wide range of people who provide generalist and specialist level palliative care services in the BOP are very dedicated and skilled and displayed significant commitment to improving the quality of life for their patients and their family/whānau/carers. There is wide acknowledgement of the progress made to date in Bay of Plenty, particularly in the development of the specialist services and the work of the hospices. However there are gaps and issues that require ongoing attention. Key strengths of current services include: • Single point of access and assessment by hospices as the specialist palliative care services in their

districts. • Co-ordination of care works well for patients within the specialist services. • Strong philosophy of home based care and support. • Specialist services available 24/7. • Dedicated and knowledgeable palliative care staff. • Low staff turnover in the specialist palliative care services. • Links and integration with generalist services e.g. GPs, residential care, Support Net, Kaitiaki

nurses, Māori Health providers, Mental Health services. • Strong community support for hospices (fundraising and volunteer resources). • Well developed hospice facilities for staff, patients, family and whānau.

7.2. Issues and gaps

The following summarises issues and gaps identified during the planning process. These are not presented in any priority order. • Service level gaps mean access to essential services is variable.

o Lack of a hospital specialist palliative care service for Tauranga and Whakatane hospitals. o Lack of formalised access to specialist medical consultations and education in EBOP. o There are gaps accessing suitable out of hours primary care support for palliative patients

throughout the region33

. o Lack of suitable long term inpatient/residential care facilities for palliative patients under 65

years of age. o Difficulty accessing medications especially after hours in EBOP.

• There are issues of access to palliative care services for people in remote rural areas. These are predominantly related to economies of scale for service provision and the socioeconomic status of patients, family and whānau.

33

Note: The lack of primary coverage 24/7 is outside the scope of this plan.

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• There is no regular forum in BOP for generalist and specialist services to collectively discuss the development of palliative care services or discuss issues of concern to improve the integration of services.

• There is fragmentation of services between providers resulting in variations in standards of practice.

There is a lack of clarity and understanding of roles and responsibilities between some services. • There is a lack of integrated patient information. • The lack of a palliative approach and/or providers unsure of services available often results in late

referral. • There is inequitable access to home help, personal care and funded residential care beds based on

diagnosis, care provider and/or age. There are multiple pathways to services. Inequitable access is a risk for the DHB.

• Funding of services is based on historical activities rather than assessed need and can perpetuate

inequities. Funding is fragmented and difficult to identify. The method of funding general practice is not conducive to providing quality palliative care.

• There is a lack of documented palliative care clinical guidelines and pathways for generalist

services. • There is a lack of quality standards and performance indicators for palliative care across the

generalist providers (primary practice, residential care, district nurses and other providers). There is poor availability of information to understand or monitor the amount of palliative care provided by generalists.

• There is forecasted growth in referrals due to population growth and change in population

characteristics, increasing incidence of cancer and nonmalignant diseases and increased awareness of palliative care services. Private and public funding to expand palliative care services is limited and changes to current service delivery models will need to be considered.

• There is a need to work more closely with Māori, especially in the WBOP, to identify and reduce the

cultural barriers for Māori accessing palliative care and to build mainstream service responsiveness to the needs of Māori. There is a lack of formal education and development with Māori health providers.

• Workforce development and education across the whole continuum of care is viewed as a critical

area for future sustainability of services. o There is under representation of Māori within the palliative care workforce. o It is difficult for generalists to maintain palliative care skills and up to date knowledge when the

numbers of patients are small and/or the need occurs infrequently. o The high use of locum staff reduces local palliative care knowledge of services and pathways. o The access that specialist palliative care services have to the hospitals to provide education is

limited. • The role of allied health in the specialist service multidisciplinary teams is underdeveloped and

limited by competing patient demands. Allied health professions lack access to funding to support professional development in palliative care.

• Patients who are referred to the specialist palliative care services and their family/whānau have

access to grief and bereavement support. Western Bay of Plenty PHO funds some grief support arising from depression which may include some palliative patients/family/whānau. It is not known the scope of services available for those people who do not access specialist palliative care services, and if there is an unmet need.

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8. Vision and recommendations

8.1 Vision

This section provides specific actions for BOP to 2016 using the framework provided in the draft report by the Palliative Care Council Measuring What Matters: Palliative Care (see Appendix 2 for the framework overview). The updated national palliative care strategic vision is: All people who have a life limiting illness and their family whānau who could benefit from palliative care have timely access to quality palliative care that is culturally appropriate and provided in a coordinated way.

Three long term outcomes are considered necessary to achieve the vision. These are indicated below along with the system outcomes that form the area of focus for the actions recommended in BOP palliative care service plan.

Long term outcome Palliative Care System Outcome

Access to palliative care regardless of setting

• Sufficient capacity within primary and specialist palliative care

• Appropriate referrals to specialist palliative care services

All palliative care providers are configured to ensure a seamless care pathway

• There is continuity and coordination of care

Palliative care provision is high quality

• Best practice is followed in delivering palliative care

• Palliative care meets the needs of patients, their families and whānau

8.2 Recommendations

Access to palliative care regardless of setting 8.2.1 Ensure sufficient capacity within primary and specialist palliative care Achieving this outcome requires sufficient workforce and appropriate services and infrastructure Actions

(a) Scope and implement (using a phased approach) a district wide hospital specialist palliative care team/service to provide improved access to palliative care in Tauranga and Whakatane hospitals and in the EBOP community, which integrates well with other specialist and generalist services.

(b) Investigate opportunities to implement virtual medical services e.g. use of video

conference for consultations and education to improve access for remote/rural areas, including a scope of infrastructure support requirements.

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(c) Strengthen the palliative medicine workforce o Work with other specialist services in Midland to scope a hub and spoke regional

medical team concept including a whole of region approach to medical education.

o Scope the feasibility of operating a single 24/7 regional medical telephone support service i.e combine BOP with Waikato/Lakes.

o Continue to develop the palliative medicine advanced training programme by providing trainee placements in Bay of Plenty. Make application to the Palliative Medicine Trainee Coordinating Committee (PAMTRACC) for a funded training position.

o Support GPs in palliative care by providing ongoing education and 24/7 specialist support.

o Encourage local GPs to undertake formal study in palliative care – investigate the establishment of a Clinical Diploma in Palliative Medicine programme (linking with regional training hubs).

(d) Develop a workforce plan to address identified areas of skill shortage in palliative care (specialist medical, allied, Māori in palliative care). This would include exploring the opportunities for further new roles in palliative care e.g. nurse practitioner, palliative care pharmacist.

(e) Implement the Hospice NZ programme ‘Fundamentals of Palliative Care’ for identified groups starting with the residential care sector.

(f) Implement cultural competency education for health professionals in specialist palliative

care services. (g) Develop and implement topic specific education sessions for palliative care health

professionals in caring for patients with nonmalignant conditions and dementia. (h) Ensure access to clinical supervision to monitor and support nurses and allied staff who

are providing palliative care. (i) PHOs to integrate palliative care into education and training plans of primary practices.

(j) Improve equity and consistency of approach to access NASC funding and other

supportive care services and facilities for all palliative patients: o have clearly defined referral pathways for each category. o P&F to identify opportunities to standardise and improve access based on need as

opposed to age, diagnosis, or location. o Monitor and evaluate utilisation to inform DHB P&F.

(k) Explore opportunities to enable hospice medical specialists to access diagnostic and

treatment services in Tauranga Hospital to reduce the need for patients to be referred to emergency department to enable access.

(l) PHOs to develop and implement sustainable solutions which ensure all palliative

patients have access to a general practitioner 24/7 and ensure processes allow for the GP to be familiar with the patient’s condition and care plan.

(m) Identify strategies to improve patient access to primary services and refer to DHB P&F. (n) Initiate a project to scope access to grief and bereavement services in BOP particularly

for those people who are not referred to specialist palliative care services but who may benefit from grief and loss support. Identify any gaps and refer to DHB P&F.

(o) Review access to emergency/out of hour’s medication in BOP and contribute to the

development of a Midland regional standard. Ensure all stakeholders understand how to access medication.

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(p) Contribute to the development of nationally consistent palliative care access criteria, guidelines and other resources, where possible, and implement in BOP where necessary.

(q) Support specialist palliative care services to develop community strategies to manage

patients in their home and minimise inpatient demand.

(r) EBOP district nursing and Hospice EBOP review current nursing arrangement and look at opportunities to improve.

8.2.2 Ensure appropriate referrals to specialist palliative care services

Achieving this outcome requires awareness of palliative care referral processes and understanding of palliative care principles.

Actions

(a) Ensure that access criteria and referral processes for all BOP palliative care and support services are clearly documented.

(b) Develop a BOP palliative care service directory including service description, access

criteria and referral processes and communicate to stakeholders. (c) Review and strengthen website content of the DHB, hospices, Māori health providers

and PHOs and other relevant NGOs to link with the service directory and clinical guidelines.

(d) Develop and implement a communication plan for palliative care health promotion to

increase public understanding of palliative care. Monitor and evaluate impact of actions.

(e) Develop a Bay Navigator project for palliative care to clarify and strengthen primary and

secondary relationships, referral pathways and clinical guidelines. (f) Review and standardise palliative care patient/family/whānau information and ensure it

is presented in an appropriate manner for target groups. (g) Ensure that hospitals and other PHO and NGO services have policies and protocols

reflecting the palliative care approach. (h) Educate providers in the palliative care approach through the development of

orientation and/or education sessions for: o general practice teams o residential care sector o Māori health providers o other NGOs and/or support groups o specialist clinical services of the acute hospitals o community and allied health services o volunteers.

8.2.3 Support and align with national work programme priorities

(a) Apply Resource and Capability Framework to the Midland region when published (estimated April 2012)

(b) Implement other national work programme initiatives as they become available i.e.

service specifications and any new funding models. (c) Consider the Ministry of Health EOI for the development and evaluation of a managed

clinical network and submit proposal, if appropriate, for the Midland region. (d) Implement the HISO National Specialist Palliative Care Data and Business Process

Standard when finalised.

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All palliative care providers are configured to ensure a seamless care pathway Outcome 8.2.4 Ensure there is continuity and coordination of care Achieving this outcome requires integration throughout the health sector and services/providers to be coordinated with each other. This includes the need for

o appropriate links between services o appropriate role delineation between providers o shared strategic vision across the region o appropriate information sharing.

Actions

(a) Refresh the BOP Palliative Care Work Group to oversee implementation of this plan and provide leadership tor progress the development of palliative care services within the DHB: o elect a chair o confirm terms of reference o agree and prioritise the palliative care service plan recommendations o develop an annual implementation plan and monitor progress o identify project resources as required.

(b) Develop and document service level agreements between specialist palliative care

services and generalists who provide services for care of the palliative patient. Monitor to ensure continuity of care is maintained. (also links with 8.2.3 (a))

(c) Develop a process to ensure every palliative patient has a nominated care coordinator

and there is a plan for continuity of care after hours. A care co-ordinator is required for all palliative patients not just those that access specialist palliative care services.

(d) Complete the implementation of PalCare into hospices and scope PalCare system

integration with (or access by) primary, hospital and other specialist services. Implement as agreed. Also consider interface with a regional data repository and shared care record.

(e) BOP DHB to consider hospice staff access to relevant patient information. (f) Scope requirements to capture regional minimum palliative care dataset for planning

and monitoring (also linked to 8.2.3 (d)). (g) Scope and understand how NGOs can contribute to the national initiative of a shared

care record and data repository.

Palliative care provision is high quality Outcome 8.2.5 Best practice is followed in delivering palliative care Achieving this outcome requires that standards for palliative care services are met; there is an interdisciplinary team approach to palliative care, and patient pathways are followed. Actions

(a) Implement the Hospice New Zealand Standards in hospices and hospital services (where relevant). Consider relevance of HNZ Standards to other generalist services.

(b) Complete implementation of LCP in BOP and monitor utilisation to ensure sustainability.

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(c) Implement the LCP reflective data cycle as the quality improvement cycle of LCP. (d) Encourage and promote research opportunities relevant to the BOP palliative care

population and services. Apply the learnings to BOP services. (e) Scope and support the implementation of Advanced Care Planning with primary and

specialist services.

Outcome 8.2.6 Palliative care meets the needs of patients, their families and whānau Achieving this outcome requires culturally appropriate care, meeting the needs of specific population groups and effective treatments and support. Actions

(a) Carry out a stocktake/hui to understand education and support needs for Māori health providers in BOP to inform the palliative care education planning and palliative care service development.

(b) Support specialist palliative care services to carry out cultural audits of services. Develop and implement service improvement plans in conjunction with local Māori health services.

(c) Participate in the development of national or regional clinical guidelines and standards that support a range of treatments and implement across Midland.

(d) Develop relationships with other services for support with care of people with nonmalignant conditions, multiple co-morbidities and/or dementia, and to provide input into service planning of other services where palliative care is identified as a part of the care pathway.

(e) Scope and explore strategies to improve patient transport between providers. (f) Scope and implement a Kaupapa Māori palliative care approach including initiatives to

support carers to care for their whanau in the community.

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APPENDIX 1

NATIONAL DOCUMENTS / REVIEWS – ADDITIONAL DETAIL Title Summary

Report of the Palliative Care Expert Working Group to the Cancer Control Steering Group Ministry of Health: 2003

Recognised the implementation of the New Zealand Palliative Care Strategy had gone some way to increasing access to palliative care services. However, a number of remaining areas that required further action were identified. These were:

• To continue to improve access to a defined set of essential palliative care services for people dying of cancer in each DHB

• To ensure that a seamless service is provided for patients with cancer who require palliative care, no matter where they live

• To ensure that the palliative care workforce continues to be developed so that it can meet the needs of current and future populations especially in relation to cultural diversity.

Gap Analysis of Specialist Palliative Care in New Zealand Ministry of Health: December 2009

Provides an overview of the current provision of specialist palliative care services in New Zealand and highlights gaps against the draft service specifications. The gap analysis confirmed anecdotal evidence that there are wide variations in the provision of hospice and other specialist palliative care both at local and regional levels.

Positioning Palliative Care in New Zealand Cancer Control New Zealand: Feb 2010

Provided a review of Government Health Policy in relation to the provision of palliative care services in New Zealand. The report concluded that New Zealand was still some way behind other countries in recognising palliative care as an integral part of the health care continuum; and that while there was progress across the country in setting up palliative care services and in workforce development, there were still significant gaps. It also identified a lack of monitoring and evaluation of the strategy implementation. Remaining challenges:

• Inequality of access; particularly based on diagnosis, but also in relation to ethnicity, age and geographic location

• Lack/absence of data on population need, service provision and service utilisation

• Lack of awareness/utilisation of palliative care services among the general public and health care professionals

• Lack of inclusion in national health policy and strategic planning

• Lack of a national strategic approach to research in palliative care. Seven recommendations were made to address what was considered to be a “relatively poor understanding of the need for palliative care and a lack of information on services currently being provided and how they are accessed by people with life limiting illnesses” (p. 18). The recommendations form a basis for the current work programme of the Palliative Care Council and will, over the next few years, provide further information to inform the development of palliative care services in NZ.

159


APPENDIX 2

Outcomes Framework – next page

160


All people who have a life limiting illness and their family/whānau who could benefit from palliative care have

timely access to quality palliative care that is culturally appropriate and provided in a co-ordinated way.

Access to palliative care regardless of setting

All palliative care providers are configured to ensure a seamless care pathway

Palliative care provision is high quality

Sufficient capacity within primary and specialist palliative care

Appropriate referrals to specialist palliative care services

There is continuity and coordination of care

Best practice is followed in delivering palliative care

Palliative care meets the needs of patients, their families and whānau

Sufficient workforce

Appropriate services and infrastructure

Awareness of palliative care

referral processes

Palliative care principles are understood

Palliative care is integrated

throughout the health sector

Palliative care services/providers

are coordinated with each other

Standards for palliative care services are

met

Inter-Disciplinary

team approach to palliative care

Needs of specific

population groups are met

Culturally appropriate

care

Effective treatments

and support

Long term outcomes

Palliative Care Strategic Vision

Patient

pathways are

followed

“Good

governance”

Non-IT info

sharing

IT systems info sharing

Sufficient workforce capacity

Appropriately skilled

workforce

Sufficient

scope/range of services

Provision of

palliative care is based on need

Appropriately

located

Health professionals are aware of

palliative care

Appropriate links

between specialist

PC services and wider

health services

Appropriate role

delineation between

providers of palliative

care

Public is aware of palliative

care

Shared strategic vision across

districts/ region

Appropriate information

sharing

Evidence based

guidelines are available

Appropriate range of treatments available

Appropriate range of support services available

Systems are compatible

Systems are connected

Privacy and security is maintained

Access agreements are in place

Palliative care

system outcomes

Intermediate outcomes

161


APPENDIX 3

Bay Of Plenty: Population Trends

Actual Projected % change

1996 2001 2006 2011 2016 2021

2011-2016

Western BOP 115,400 132,500 149,900 163,200 175,800 188,000 7.7%

Eastern BOP 52,000 50,880 50,850 50,740 50,160 49,260 -1.1%

Total BOP DHB 167,400 183,380 200,750 213,940 225,960 237,260 5.6%

By Territorial Authority


1996 2001 2006 2011 2016 2021 2011 to

2016 2011 to

2021

Western BOP 35,800 39,000 43,000 46,100 48,900 51,500 6.1% 11.7%

Tauranga 79,600 93,500 106,900 117,100 126,900 136,500 8.4% 16.6%

Whakatane 34,200 34,100 34,500 34,700 34,600 34,300 -0.3% -1.2%

Kawerau 8,120 7,290 7,150 6,950 6,640 6,260 -4.5% -9.9%

Opotiki 9,680 9,490 9,200 9,090 8,920 8,700 -1.9% -4.3%

167,400 183,380 200,750 213,940 225,960 237,260 5.6% 10.9%

Bay of Plenty DHB Population Change

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

1996 2001 2006 2011 2016 2021

Actual Projected

Western BOP Tauranga Whakatane Kaw erau Opotiki

Bay of Plenty DHB - Population change as a

proportion of DHB area

0%

10%

20%

30%

40%

50%

60%

70%


1996 2001 2006 2011 2016 2021

162


Bay of Plenty: AGE

Bay of Plenty DHB: Population aged 65 + (2006 baseline)

-

5,000

10,000

15,000

20,000

25,000

30,000

1996 2001 2006 2011 2016 2021

po

pu

lati

on

nu

mb

er

Western BOP Tauranga city Whakatane Kaw erau Opotoki

Bay of Plenty DHB: Proportion of total population

under/over 65 yrs

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

65 and over 23,380 27,150 31,830 36,700 43,190 49,880

Under 65 144,040 156,200 168,970 177,280 182,770 187,340

1996 2001 2006 2011 2016 2021

Eastern BOP

2006 2011 2016 2021

Under 65 44,290 43,370 41,450 39,240

65 yrs + 6,520 7,350 8,720 9,990

Total 50,810 50,720 50,170 49,230

% under 65 yrs 87% 86% 83% 80%

% 65 yrs + 13% 14% 17% 20%

Western BOP

2006 2011 2016 2021

Under 65 124,680 133,910 141,320 148,100

65 yrs + 25,310 29,350 34,470 39,890

Total 149,990 163,260 175,790 187,990

% under 65 yrs 83% 82% 80% 79%

% 65 yrs + 17% 18% 20% 21% All BOP DHB

1996 2001 2006 2011 2016 2021

Under 65 144,040 156,200 168,970 177,280 182,770 187,340

65 yrs + 23,380 27,150 31,830 36,700 43,190 49,880

Total 167,420 183,350 200,800 213,980 225,960 237,220

% under 65 86% 85% 84% 83% 81% 79%

% 65 yrs + 14% 15% 16% 17% 19% 21%

163


Bay of Plenty – Deaths By Territorial Authority


1996 2001 2006 2010 2011 2016 2021 2011/16 2011/21

Western BOP 280 310 300 320 330 380 440 15% 33%

Tauranga 740 800 920 970 960 1,070 1,160 11% 21%

Whakatane 260 250 230 290 280 300 320 7% 14%

Kawerau 51 43 51 55 65 72 78 11% 20%

Opotiki 90 83 79 88 83 85 90 2% 8%

TOTAL 1,421 1,486 1,580 1,723 1,718 1,907 2,088

Bay of Plenty DHB region: Deaths

0

200

400

600

800

1,000

1,200

1,400

1996 2001 2006 2010 2011 2016 2021

Actual Projected


164


Hospital Deaths

Site Discharge HSC 2007 2008 2009 2010

Tauranga ATR <6WEEKS-ACTIVE 10 13 14 17

GEN MEDICINE GP LED 2 5

GEN MEDICINE SPEC 238 212 274 216

EMERG/INTENSIVE MED 5 8 12

CARDIOLOGY GEN 1

CARDIOLOGY SPEC 14 12 25 39

DERMATOLOGY SPEC 1

GASTROENT. GEN 2

GASTROENT. SPEC 6 7 28 17

INFECT. DISEASE GEN 1

ONCOLOGY SPEC 2

PAED MED SPEC 1 1 1 2

RESPIRATORY SPEC 1 3 3 4

RHEUMATOLOGY SPEC 4

PALLIATIVE CARE GEN 20 13 8

ENDOCRINOLOGY 3 4

MA POSTNATAL-MOTHERS 1

MA SPEC CARE NURSERY 1 1 1

MA BABY WITH COM LMC 2

GEN SURGERY GEN 2 1 1

GEN SURG SPEC 25 37 27 36

GASTRO SURGERY GEN 1

OTOLARYNGOLOGY SPEC 1

GYNAECOLOGY SPEC 1 1

ORTHOPAEDIC SPEC 16 11 18 12

UROLOGY SPEC 2 3 2

VASC. SURG SPEC 5 4 4 5

MH MHSOP INPT ST 1 9 8 17

TGA Total 345 341 428 391

Site Discharge HSC 2007 2008 2009 2010

Whakatane Hosp ATR <6WEEKS-ACTIVE 1 1

GEN MEDICINE GP LED 5 3

GEN MEDICINE SPEC 89 72 78 80

EMERGENCY SERVICES 1 1

EMERG/INTENSIVE MED 1 2

PALLIATIVE CARE GEN 10 6 6 2

MA SPEC CARE NURSERY 1 2 3

GEN SURGERY GEN 2 2

GEN SURG SPEC 6 10 13 8

GYNAECOLOGY SPEC 1

ORTHOPAEDIC SPEC 3 1 3

WHK Total 107 101 105 100

Grand Total 452 442 533 491

165


Bay of Plenty: Ethnicity

Ethnicity as a proportion of Bay of Plenty DHB area

0%

20%

40%

60%

80%

Māori 25% 25% 26% 26%

Pacif ic 1% 1% 1% 2%

Other 74% 73% 73% 72%

2006 2011 2016 2021

Source: Bay of Plenty DHB Health Needs Assessment, Sept 2008

166


APPENDIX 4

PALLIATIVE CARE SERVICE PLANNING – Service description for Waipuna Hospice

DHB Bay of Plenty

Hospice Waipuna Hospice Incorporated Description

Waipuna Hospice provides a specialist hospice palliative care service and the co-ordination of palliative care services for the WBOP area. This incorporates direct service provision and advice and support to other health service providers. Waipuna Hospice is the sole provider of community and inpatient palliative care in the WBOP district.

Population Served Population characteristics

Population base at 2006 census: 149,000 Geographical area covers the territorial authorities of Tauranga City and Western Bay of Plenty. WBOP is 75% of the total BOPDHB population 17% Māori Population predicted to increase by 7.7% (12,560) between 2011 and 2016 Greatest growth in population will be in Tauranga city Increasing proportion of 65 years and over

• 2006 = 17% of total

• 2016 = 20% of total

Key Services

Nursing

• Specialist nursing team provides 24/7 support and care in the community.

• Care coordination and liaison with GPs and other services

• Care coordination and nursing visits are provided by the same person who is employed by hospice.

• Hospital liaison nurse to assist with referrals and discharges from Tauranga Hospital (employed by Waipuna Hospice)

• Co-ordinates placement in residential care beds for respite or end of life care Medical

• 24/7 medical service with doctors on call out of hours.

• 24/7 medical telephone service for the full BOP region.

• On site clinics for community patients including pain clinic.

• Objective is to maintain GP lead for patients with hospice specialist support as required. Specialist inpatient services

• 9 beds utilised in the 12 bed inpatient unit.

• Symptom management, respite care, end of life care where care at home is not possible.

• The additional rooms are currently being set up for expansion of day services programme. Day services programme Social networking, art therapy, physiotherapy, massage, respite, education and outpatient clinics including some procedures. Equipment loan

• Short term loan of equipment to support care at home

• Example syringe drivers, wheelchairs, electric beds, nebulizers, shower stools, commodes, pressure mattresses, Lazy boys, oxygen concentrators.

167


Family support

• Bereavement counselling and bereavement groups

• Social work

• Chaplaincy

• Biography service Education

• Syringe driver

• LCP

• RN and EN study days

• Health care assistant study days

• Practice nurse study sessions

• Caregiver study days

• Ad hoc topic specific sessions for generalists

• GP education/CME

• Undergraduate medical training and education

• Undergraduate nurse placements

• Access to Genesis Oncology Trust breakfast lectures

• Public education via invited speaking engagements

• Hospice NZ palliative care for generalists education Volunteer support services

• Formal volunteer training programme.

• Trained volunteers support day programmes, practical support such as driving, shopping), companionship, carer relief, biography service, equipment management/delivery.

Other support services

• Home help and personal care Also available within BOP but not a Waipuna Hospice service is Kaitiaki Nursing Services (Whānau cancer support nurses for Māori clients and their whānau affected by cancer). Supports Māori patients of Waipuna Hospice but also many who are not registered with Waipuna. Three Māori nurses carry out home visits. The Māori nurses are able to encourage whānau to go to the hospice or arrange for the hospice nurse to visit the patient along with the Māori nurse. This partnership model works well. This is a service specific to cancer patients in WBOP funded by the Western BOP PHO.

Workforce Waipuna Hospice has a total paid workforce of 50.4 FTE (approx 90 headcount ) as at June 2011.

• Management / admin 10.75 FTE

• Medical director/specialist 0.9 FTE

• GPs with special interest 1.2 FTE

• Registered nurse with post graduate qualifications 6.4 FTE

• Registered Nurses without post graduate qualifications 16.95 FTE

• Enrolled Nurses 2.2 FTE

• Health care assistant 3.23 FTE

• Social work/counsellors/chaplains 3.44 FTE

• Cooks 0.93 FTE

• Retail 4.41 FTE Volunteers – Around 450 volunteers contribute approximately 42,000 hours per annum. They are considered an integral part of the efficient functioning of Waipuna Hospice supporting all components of hospice services.

LCP Waipuna Hospice is the lead organisation for implementation of end of life LCP in the DHB. 2 years

168


into the implementation project. 75% complete.

Information/patient management systems

Waipuna Hospice has historically managed its patient data using MedTech and a paper based system. Currently implementing Palcare as a part of a regional initiative. Waipuna Hospice is the lead organisation for this project.

Quality standards Accredited under EQuIP4 standards.

Key Linkages Local and BOP

• General practice teams and PHO teams

• WBOP residential care providers

• Tauranga (and Whakatane?) hospital services

• BOP DHB district nurses, physiotherapists, occupational therapists, social workers

• Māori Health providers

• Cancer Society and other support groups

• Kaitiaki cancer support nurses

• Hospice EBOP Regional / national:

• Hospices in other DHB areas

• Midland Palliative Care Work Group

• Midland Cancer Network

• Hospice New Zealand

• Palliative Care Advisory Group

Gaps identified in the 2009 Ministry of Health Gap Analysis of services provided by specialist palliative care providers in New Zealand. Extracted from the summary findings from Gap Analysis: Waipuna Hospice

Identified gap Comments / Actions to address

1 Home visits by medical personnel (specialist /GP) outside of normal working hours are not provided – this is not necessarily a gap

Lack of GP home visits remains an issue. Hospice specialist does home visits for assessments when necessary.

2 Provision of a limited number of education courses for generalists, given the size of the population served by the hospice

Improved with new structure and additional FTE for education team since June 2010.

3 Absence of explicit and agreed processes to ensure those with specialist palliative care needs have access to the following equipment: home oxygen, continence, IV, enteral and parenteral supplies, lymphodema bandages and hosiery.

Continues to be an issue largely due to funding being held by district nursing and considered for DN patients only. With rising patient numbers there is pressure on the supply of equipment. (Issue also includes consumables).

4 An absence of effective and appropriate linkages with some services and organisations – but these may not be applicable for Waipuna Hospice

Not considered an issue

169


Waipuna Hospice – Patient demographics

Calendar Year 2008 2009 2010

Patients (deaths and discharges)

Total patient numbers 416 406 464 Deaths 371 367 417 Transfers/discharges 45 39 47 Active patients – average per month Age (deaths and discharges)

Average age (years) 73.0 72.3 73.0 < 65yrs 100 24% 106 26% 111 24% 65 yrs and over 316 76% 300 74% 353 76% Gender (deaths and discharges)

Male 237 57% 208 51% 250 54% Female 179 43% 198 49% 213 46% Ethnicity where stated (deaths and discharges)

European 314 84% 326 85% 360 85% Maori 51 14% 50 13% 53 13% Other 9 2% 7 2% 9 2% Place of death

Home 140 38% 130 36% 143 34% Hospital 57 15% 54 15% 68 16% IPU 79 21% 95 26% 113 27% Residential care home 95 26% 87 24% 91 22% Diagnosis (deaths and discharges)

Cancer 376 91% 366 90% 410 88% Non-cancer 38 9% 40 10% 54 12% Length of stay (days)

Average all patients 153 * 137* 132* Average LOS cancer diagnosis 158 145 140 Average LOS all non-cancer 107 62 69 Number of assessments

Initial assessments 494 388 399 Ongoing nursing assessments 1175 1349 1285 Ongoing medical assessments 2292 2310 2646 Domiciliary nursing visits - home 7217 6447 6192 Admissions to inpatient unit 273 245 247 Bed days 2147 2217 2480 Bereavement/grief and loss visits 524 491 673 Residential care (respite & end of life)

Number of days (financial year data) Average bed days per patient

Source: Ministry of Health monitoring returns as completed by Waipuna Hospice

* Adjusted to exclude patients with average LOS in excess of 5 years 2008: 3 patients – 5.2, 6.3 and 6.6 years 2009: 1 patient – 12.36 yrs ? data issue 2010: 1 patient – 5.9 years

170


APPENDIX 5

PALLIATIVE CARE SERVICE PLANNING – Service description for Hospice EBOP

DHB Bay of Plenty

Hospice Eastern Bay of Plenty (Hospice EBOP) Description

Hospice BBOP provides single point of entry specialist palliative care services in the EBOP community. The model of care is care coordination provided by the hospice with nursing visits provided either by hospice nurses or via links with district nursing services depending on the location of the patient (e.g. for patients in Te Kaha and Murupara).

Population Served Population Characteristics

Population base at 2006 census: 50,850 Geographical area covers territorial authorities of :

• Whakatane

• Opotiki

• Kawerau EBOP is 25% of total BOP DHB population 50% Māori Population predicted to decline by 1% (580) between 2011 and 2016 Increasing proportion of 65 yrs and over

• 2006 = 13% of total

• 2016 = 17% of total Rural/remote patients/families Low socioeconomic status in rural areas Lower life expectancy compared with WBOP

Key Services

Nursing

• Specialist nursing team provides community based nursing care mainly in the patient’s own home.

• 24/7 nursing support and advice for patients/whānau/carers and other generalists. Out of hours support is via phone and nurses on call.

• Care coordination and liaison with GPs and other services.

• Weekly patient review team meeting and family meetings as required.

• Coordinates placements in palliative beds for respite or end-stage care.

• In-reach service to Whakatane Hospital. Medical

• Access to 24/7 specialist medical advice (telephone support) from Waipuna specialist (not formalised).

• GP remains primary medical lead for patients. Equipment loan

• Short term loan of equipment to support care at home.

• Example syringe drivers, wheelchairs, electric beds, nebulizers, shower stools, commodes, pressure mattresses, lazy boy chairs.

Day programme

• Once weekly for social networking, respite and relaxation, massage. Grief and bereavement / family support :

171


• Counselling or support for patient and whānau encountering the grief of a terminal illness.

• Contact and support after death for all bereaved families.

• Bereavement support group and acknowledgment of the anniversary of the patient’s death.

• Biography service. Education

• Caregivers training.

• Syringe driver.

• Palliative care education days.

• LCP.

• In-service sessions for generalist s e.g. delirium.

• Address orientation sessions at Whakatane Hospital (nurses?).

• Provides access to Genesis Oncology Breakfast Lectures.

• Public education via invited speaking engagements. Volunteer support service

• Trained family support volunteers provide companionship, advocacy, practical support (driving, shopping), carer relief, day programme support, biography service.

Inpatient services/ beds

• Hospice has access to two rest home beds (for end of life or respite) funded via Support Net. Also has access to another bed via a floating fund for non-Whakatane residents.

• Access to Waipuna Hospice inpatient unit beds if necessary

LCP

Implementation of LCP is a Midland regional initiative. Waipuna Hospice is the lead organisation for implementation of end of life LCP in the DHB, including Eastern Bay of Plenty. Education and implementation completed for version 12 with

• Hospice EBOP community team

• residential care facilities in Whakatane

• Whakatane Hospital.

Workforce Total paid workforce 8.6 FTE as at 1 July 2010.

• Management/admin/public relations 4.0 FTE

• Registered nurses 3.6 FTE

• Family support /Volunteer co-ordinator 0.5 FTE

• Counsellor 0.5 FTE Volunteers – Around 50 volunteers contributed approx 3500 hours per annum on 2009/10 year (excludes shop hours). Increased to approx 7000 hrs in 2010/11. Volunteers are considered an integral part of the efficient functioning of Hospice EBOP.

Information/patient management systems

Hospice EBOP has historically managed its patient data using MedTech32, excel spreadsheets and a paper based system. Currently implementing PalCare as a part of a regional initiative. Waipuna Hospice lead organisation.

Quality standards Accredited under EQuIP4 standards.

Key Linkages

Local and BOP

• General practice teams / PHO teams

• EBOP residential care providers

172


• Home help & personal cares providers

• Whakatane Hospital services

• BOP DHB district nurses, physiotherapists, occupational therapists, social workers

• Māori health providers

• Cancer Society and other support groups

• Support Net

• Waipuna Hospice Regional / national:

• Hospices in other DHB areas

• Midland Palliative Care Work Group

• Midland Cancer Network

• Hospice New Zealand

Gaps identified in the 2009 Ministry of Health Gap Analysis of services provided by specialist palliative care providers in New Zealand. Extracted from the summary findings from Gap Analysis: Hospice Eastern Bay of Plenty

Identified gap Comments / Actions to address

1. No medical specialist resource in Whakatane. No established medical specialist clinics.

Improving with support provided from Waipuna Hospice palliative medicine specialist. Arrangement not formalised.

2. Home visits by GPs out of normal working hours are limited. Access to GPs out of hours and availability of GPs to do home visits remains inconsistent and is an issue.

3. Provision of a limited number of education courses (2007/08) although the hospice anticipates this area to grow with the recent appointment of an experienced nurse educator.

This has improved with appointment of additional nursing staff.

4. No definite plans regarding when an end of life care programme (LCP) will be implemented.

Implementation in progress, 45% complete as at June 2011

5. An absence of effective and appropriate linkages with some services and organisations but these may not be applicable for Hospice EBOP.

Not considered an issue.

6. No access to after hours pharmacist or GP. Continues to be an issue.

173


Hospice Eastern Bay of Plenty – Patient demographics

2008 2009 2010

Patients (deaths and discharges)

Total patient numbers 126 169 187 Deaths 115 91% 143 85% 160 86% Transfers/discharges 11 9% 26 15% 27 14% Active patients – average per month 54 51 50 Age (deaths and discharges)

Average age (years) 71.2 70.3 71.7 < 65yrs 37 29% 53 31% 62 33% 65 yrs and over 89 71% 116 69% 125 67% Gender (deaths and discharges)

Male 69 55% 87 51% 101 54% Female 57 45% 82 49% 86 46% Ethnicity (deaths and discharges)

European 84 67% 96 57% 116 62% Maori 41 33% 72 43% 65 35% Other 1 1% 1 1% 6 3% Place of death

6/12 months data

Home 24 60% 77 54% 96 60% Hospital 4 10% 33 23% 33 21% Residential care home 12 30% 33 23% 31 19% Diagnosis (deaths and discharges)

Cancer 99 79% 135 80% 135 72% Non-cancer 27 21% 34 20% 52 28% Length of stay (days)

Average all patients 92 125 108 Average LOS cancer diagnosis (369pts) 107 142 130 Average LOS all non-cancer (113pts) 38 57 50 Number of assessments

Nursing assessments – phone calls 1202 1884 2476 Domiciliary nursing visits - home 1918 1313 1968 Bereavement/grief and loss visits 124 30 91 Residential care (respite & end of life)

Number of days*** Average bed days per patient

Source: Ministry of Health monitoring returns as completed by Hospice Eastern Bay of Plenty *** Note this is supplied as financial year

174


APPENDIX 6

Illness trajectories and palliative care Figure 1

Source: Figure 1. Lynn J, Adamson DM. Living well at the end of life. Adapting health care to serious chronic illness in old age. Washington: Rand Health, 2003. Source article: Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ April 2005; vol 330, pp 1007-1011. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC557152/

Trajectory 1: short period of evident decline, typically cancer This entails a reasonably predictable decline in physical health over a period of weeks, months, or, in some cases, years. This course may be punctuated by the positive or negative effects of palliative oncological treatment. Most weight loss, reduction in performance status, and impaired ability for self care occurs in patients' last few months. With the trend towards earlier diagnosis and greater openness about discussing prognosis, there is generally time to anticipate palliative needs and plan for end of life care. This trajectory enmeshes well with traditional specialist palliative care services, such as hospices and their associated community palliative care programmes, which concentrate on providing comprehensive services in the last weeks or months of life for people with cancer. Resource constraints on hospices and their community teams, plus their association with dying, can limit their availability and acceptability. Trajectory 2: long term limitations with intermittent serious episodes With conditions such as heart failure and chronic obstructive pulmonary disease, patients are usually ill for many months or years with occasional acute, often severe, exacerbations. Deteriorations are generally associated with admission to hospital and intensive treatment. This clinically intuitive trajectory has sharper dips than are revealed by pooling quantitative data concerning activities of daily living. Each exacerbation may result in death, and although the patient usually survives many such episodes, a gradual deterioration in health and functional status is typical. The timing of death, however, remains uncertain. In one large study, most patients with advanced heart failure died when expected to live for at least a further six months. Many people with end stage heart failure and chronic obstructive pulmonary disease follow this trajectory, but this may not be the case for some other organ system failures. Trajectory 3: prolonged dwindling People who escape cancer and organ system failure are likely to die at an older age of either brain failure (such as Alzheimer's or other dementia) or generalised frailty of multiple body systems. This third trajectory is of progressive disability from an already low baseline of cognitive or physical functioning. Such patients may lose weight and functional capacity and then succumb to minor physical events or daily social “hassles” that may in themselves seem trivial but, occurring in combination with declining reserves, can prove fatal. This trajectory may be cut short by death after an acute event such as a fractured neck of femur or pneumonia.

175


APPENDIX 7

Palliative care in acute general hospitals: international examples The following provides a description of palliative care in acute general hospitals in Ireland and Australia. Ireland

34

In Ireland, the focus has been on establishing specialist palliative care (SPC) inpatient units as the core essential element of the SPC service in each health board area. It should be the “hub” of the service, around which all components of the specialist service revolve. SPC services in all other settings, including the community and hospital settings, should be based in or have formal links with the SPC unit.

The report has seven key recommendations for specialist palliative care in acute general hospitals in Ireland. 1. All acute general hospitals should have a consultant-led SPC service, offering advice and support to

health care professionals in the hospital.

2. The SPC team should work alongside other hospital teams, complementing their work, rather than taking over care of the patient.

3. The SPC team in an acute general hospital should consist of at least a consultant in palliative medicine, a specialist palliative care nurse, a social worker and a secretary.

4. Joint outpatient clinics should be established in acute general hospitals, allowing the SPC team to become involved in inpatient care at an early stage in the disease process.

5. Arrangements should be made to “fast-track” outpatient appointments for patients receiving palliative care.

34 Department of Health and Children: The Report of the National Advisory Committee on Palliative Care, Ireland. 2001

Specialist Palliative Care Unit

Day care centre/

Outpatients

Specialist Inpatient

Unit

Specialist Satellite

Unit

Specialist

teams in the community

Support

and Advice

Education

and Research

Specialist

teams in Acute General

Hospitals

176


6. There should be one point of entry to hospital services for palliative care patients, and subsequent referrals should be speedily organised.

7. In A&E, the patient’s condition should be rapidly assessed, and the patient should be referred to the appropriate team without delay.

Irish guidelines recommend a consultant-led multidisciplinary palliative care team in each acute hospital of 150 beds or more. Resourcing is recommended to include a SPC nurse, a social worker and a secretary, led by the palliative medicine specialist working across the range of settings and who was available in the hospital for a defined minimum number of sessions per week. Consultant specialists may have joint appointments between inpatient SPC units and acute general hospitals. Also consultant appointments that are regionally based covering hospital and community services are emerging. The Irish guidelines suggest that for smaller general hospitals, where it may not be feasible to employ a full-time specialist palliative care team, the SPC team serving the community should provide a service to patients in the hospital. Australia

35

A significant proportion of anticipated deaths still occur in acute hospitals and many patients are identified as needing palliative care while in acute hospital. The availability of specialist palliative care practitioners within hospital and clinic settings is likely to increase the timeliness and rate of referral to palliative care services and to improve the symptomatic management of these patients. Australian guidelines are based on staffing a consultative service for an acute hospital of 125 beds Specific roles for palliative care in the acute setting include: • assessment, symptom management and consultation; • discharge planning for all palliative patients; and • education of health care providers throughout the hospital. In Australia, to be considered as providing comprehensive cancer care, every cancer centre must have active, interdisciplinary specialist palliative care service participation. In-hospital palliative care delivery methods There are three methods most frequently referred to in literature and various guides. The Centre to Advance Palliative Care (Australia) gives a concise description which is amended below

36 :

• Consultative approach

Primarily operates as a consultative service. Consultant or clinical nurse specialist (CNS) undertakes an initial assessment and refers to other services as needed. Work is undertaken with family on plans for the future. Referrals received from doctors, patient or family. All units within the hospital deliver palliative care. The palliative care consultant or CNS develops protocols with treatment team and educates staff.

• Inter or multidisciplinary team approach

This is a consultative service with a team of professionals from different disciplines (e.g. doctors, nurses, social workers) assessing and following through with patients. May be primarily advisory to referring physician or may assume part of the care of the patient. This approach may include a case management component by a palliative care social worker. All hospital units should deliver palliative care as a part of their function.

• Inpatient approach

This involves an inpatient unit (ward) within the hospital with designated beds and specially trained staff. The palliative care team assumes responsibility for patient management and discharge planning.

35

Palliative Care Australia Palliative Care Service Planning in Australia: A Planning Guide, 2003 36

From Waitemata DHB In-hospital Adult Palliative Care Strategy and Service Development Plan, 2006-2010 Waitemata DHB

177


Cost effectiveness of hospital palliative care There is little research in New Zealand on the cost effectiveness of hospital palliative care. A literature review undertaken by the University of Dublin Centre for Health Policy and Management (2007) Cost-Effectiveness of Palliative Care in Hospital: A Review of Literature found that hospital-based palliative care can cost less than conventional care by: • decreasing the intensity of treatment

o a reduction in unnecessary resource utilisation (tests and drugs) and spare expensive technological resources

o improvement in communication among patients, their families, and the primary treating physician about goals of care.

• implementing structured planning. The palliative care services can be paid for from cost savings which

include: o shortened length of stay in general o decreased “bounce back” and emergency admissions on recently discharged patients who return

because of symptom management problems o decreased stays in intensive care units by, but not limited to, dying people o direct admission to palliative care unit o prevented transfers between units o death outside the hospital.

One study suggested that depending on how well referral sources are educated and informed in advance of the initiative, these substantial cost savings can be documented often within one to two years.

A number of studies included in the literature review concluded that hospitals have begun to invest in palliative care services to enhance quality of care and because of their measurable impact on reducing ICU and total bed days but also for their efficacy in supporting transitions from high intensity, high cost hospital settings to more appropriate and desired care settings, such as home.

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APPENDIX 8

WESTERN BAY OF PLENTY - Stakeholder summary

STRENGTHS

COMMENTS

1. Model of care • single point of entry for

specialist palliative care services in WBOP

• care coordination • continuity of care

• Continuity of care – no mixed model of nursing care (district nurses not involved in care of patients at home)

• Specialist medical home visits when necessary

2. Waipuna Hospice facilities

• Inpatient unit 9 beds with ability to increase to 12 • On site clinics for community patients • Scope for further development on site But lack of space in current building limits ability to expand day programme.

3. Workforce and services –

Waipuna Hospice

• Strong leadership / organisational structure • Good internal staff mix • Good medical staff support (mix of specialist and GP/MO) but

light on specialist resource for region-wide service • 24/7 medical and nursing support – mix of on duty/on call • 24/7 medical advice (telephone support) for full BOP region • hospital liaison nurse to assist with referrals and discharges

(employed by Waipuna Hospice) • Good aged care liaison with dedicated liaison nurse position • Social work, counselling, chaplain and bereavement support

resources directly employed by Waipuna Hospice • Dedicated LCP and education resource gives focus for these

activities • Good volunteer structure and training programmes in place. • Strong volunteer support

4. Good grief and loss support in district

• Hospice family support team including counselling, social work, bereavement support programmes and groups

• Hospice strength working with families and providing young family support

• Community - some PHO access to counselling/psychologist. Western PHO grief support funding

• Private grief counselling – 6 free sessions (DHB funded). Anyone can access via GP or hospice

5. Kaitiaki Nursing Services

(Whānau cancer support nurses for Māori clients and their whānau affected by cancer)

The partnership model with hospice nurses works well. However this is a service specific to cancer patients. There is no single non-oncology parallel.

6. Palliative care education/training

• Dedicated education resources at hospice • Increasing range of programmes • Relationship with Polytech - nursing student visits/placements • Waipuna Hospice accredited for medical advanced trainees and

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trainee placements provided

7. LCP implementation

Good progress on implementation of LCP

As at 30 June 2011

WBOP Total Possible

LCP education/ implemented %

GP practices Tga 28 22 79%

ARCs Tga 16 13 81%

Tga Hospital 10 6 60%

Waipuna inpatient 1 1 100%

WBOP comm team 1 0 0%

56 42 75%

8. Community support for Waipuna

Hospice

• Well supported and respected by community See also issue – level of community funding difficult to sustain

9. Strong regional relationships

• Between service providers within BOP • With Waikato specialist palliative care services

10. Residential care

• 7 fully funded dedicated palliative care beds See also issue – access to beds prioritised to those with cancer or end stage renal failure.

11. Links with district nursing

Linkages between district nurses and hospice for cross over of care for complex patients.

12. Good level of support from

mental health services for people with dementia, including support for caregivers

Severe dementia – specialised work for specific age group

13. Tauranga Hospital model of care for Māori.

Appropriate supportive care environment e.g. Kaupapa Māori ward, patient navigators.

14. PalCare information system Implementation enabling single electronic patient record. 2nd

phase opportunity will be GP access to see patient record. Need to look at how PalCare can link with Bay Navigator information technology (website) which gives GPs access to information.

15. BOP have resident medical oncology service

16. Support Net – strong

relationships across sector

However, see issues below

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ISSUES

COMMENTS

1. No hospital-based specialist palliative care team in BOP

2. Hospital discharges with poor medication planning and prescribing

Waipuna Hospice usually has to sort out the problems. Out of hours pharmacies are available up to about 9pm 7 days.

3. Out of hours availability and

home visits by GPs for palliative patients

• A lot of GP practices don’t provide after hours services. The out of hours service in Tauranga is run from a single company – not sure if patients go there.

• Home visit by GP = $400. This is prohibitively expensive for patients.

• Some aged care facilities report issues with access to GP after hours. Difficulty getting GP to prescribe after hours or in weekends. Some residents die in pain unnecessarily.

Waipuna medical and nursing support is available 24/7 - challenge for Waipuna Hospice doctors/specialist is to decide whether extra scans/xrays are needed and to advise if hospital ED is the best first point of call (e.g. there is a significant proportion of calls out of hours to do with falls)

4. Education

Medical students and RMOs don’t go through Waipuna Hospice as part of their education/training.

5. Māori cultural issues

Recognised gap for Waipuna. Requires the input of Māori to help develop cultural aspects of palliative care and end of life care. Issue is not about diagnosis or clinical aspects but Māori cultural aspects that should fit alongside other inputs. This is not exclusive to Māori but applies to other cultures as well, especially for end of life care. Need to establish links with iwi to get input/partnership: • establish what hospice needs to do to be patient focussed for

Māori • raise awareness of the needs of Māori as opposed to the needs of

the disciplines delivering service/s • develop specific packages of education for disciplines – medical,

nursing, allied health. • the coming generation all speak Māori - how will services

prepare/respond? Acknowledged that this is improving but still a work in progress.

6. Documented clinical guidelines

and pathways

• Those applying within Waipuna are available. • Not much for generalists, more for specialists. • Opportunity to improve/develop. Need consistency across Midland DHBs

7. Community palliative care access to hospital based procedures

Access to some interventions (x-ray, MRI) is more difficult if the medical specialist is outside the DHB. Currently can have some problems getting access to these interventions as hospice medical specialist has no privilege access to any imaging. Example: Hospice cannot book an MRI appointment for a patient with possible spinal cord compression. End up sending patient via ED or GP just to get an MRI.

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This is a huge limitation –opportunity to build linkages with DHB/hospital based palliative care.

8. Transportation costs • Cost of nurse-escorted ambulance journey for transfer of patient from Waikato to Waipuna (Waipuna is charged).

• Cost of ambulance transport between Waipuna Hospice and patient’s home – patient pays.

9. Access to respite beds • High occupancy rate for the current fully funded beds (7 beds).

• Ring fenced dedicated beds are prioritised to patients with cancer and ESRF and are all located in Tauranga – no equity of access. Some flexible funding exists to help address bed location issue.

• Young adults are not dealt with very well. Placed in residential care with old people.

• No equity in current system – within areas of BOP and between DHBs.

10. Support Net (NASC) funding

• Support Net works with prognosis >6 months. This impacts on ability for patient to remain at home, need to go to institution to get support (model of care/ inputs to keep people in their homes). Assessment should be based on need as opposed to prognosis.

• Current criteria excludes those in WBOP with cancer or end stage renal failure if prognosis is < 6 months – services are provided by Waipuna Hospice (see 11. below).

• Those with other chronic conditions and if considered to be at end stage (no prognosis required) come under Support Net for assessment and funding. Can get up to 7 days/week support.

• Younger people not eligible?

11. Package of care for home support/personal care reduces when a patient moves from DN (Support Net funded) to hospice care.

• Patient who moves from elderly (frail) to elderly (palliative) level of support reduces from 7 days per week fully funded to 3 days per week (part funded Waipuna Hospice 50%/DHB 50%).

• Younger people not eligible ?

12. DHB allied health services in the

community are fragmented and not funded particularly well

e.g. dietitians, speech language therapy, social work, occupational therapy, physiotherapy. • Need closer links with hospice as the specialist service –

especially for hospice outpatient clinics. Allied professions have a lot of skill to bring to services.

• Allied health in community is built around historical funding – difficult mechanism to grow AH input/role in the community.

13. Need to grow the palliative care

philosophy in the BOP

• Community awareness/perception of hospice (current focus is end

of life vs palliative) • Other health professionals understanding of palliative care

(increase awareness around timeliness of referral) • Grow understanding of palliative care for nonmalignant/chronic

illnesses • Need training around having the difficult conversations.

14. Meeting needs of younger patients in palliative care

• Younger patients don’t receive as much access to support as those who are 65+ e.g. Younger patients who require long-term hospital level care can’t go into aged residential care, and do not have the same access to NASC funding.

15. Funding • Inconsistent funding approach nationally (there is to be work on a

new national funding model)

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• Funding is fragmented - multiple organisations involved • Demand estimated to grow – pool of public funding is not • Income from bequests, donations and community funding to

support the gap in public funding for hospices is increasingly difficult to secure.

• Current model of funding not very supportive of how palliative care is delivered i.e. does not support GP visits for patient & family whānau or intermittent nature of input by specialist PC services.

• Silo funding doesn’t work - not patient centred. Doesn’t fit disease process. Needs to change.

• National issue – medication costs incl ketamine. Makes a difference between patient being at home and having to go to hospital.

• Palliative patients miss out on Enable funding for equipment and housing modifications because criteria requires assessment that they are expected to live in their own home for more than 2 years.

• No consistency across the country for people to access palliative care funding.

16. Equipment / consumables • Waipuna Hospice supplies equipment for their patients.

• If not a Waipuna patient, access to equipment is via the DHB community services or hospital inpatient services.

• Rising patient numbers puts pressure on equipment supplies.

17. Carer support • Need to have good carer support especially to make home environment more viable in the model of care.

OPPORTUNITIES

COMMENTS

Current projects under way and others identified as useful for the future 1. National palliative care projects in

progress

• Development of: o role delineation model/resource and capability framework

(2011) o models of care (2011) o national funding model (begin 2011/2012) o specialist palliative care service specifications (2012)

• MOH consideration of Gold Standards Framework • Palliative Care HNA work • Health Workforce NZ palliative care workforce service review • Hospice NZ Standards project • Hospice NZ education package development

2. Advance Care Planning (ACP)

• New Zealand national guidance document and tools for ACP now

available • Regional project opportunity for rollout (similar to LCP rollout).

Will require project resource & funding.

3. Implementation of PalCare Phase one implementation into hospices in Midland in progress under the leadership of Waipuna Hospice. Significant opportunity to: • improve patient information management • improve reporting accuracy & consistency and create efficiencies • improve access by others to patient information for provision of

care

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Phase 2 will consider access by others (non hospice) and integration with other systems.

4. PHO / primary practice - “Better,

sooner, more convenient” initiatives

• Opportunity for improved integration of services • Development of palliative care pathways in Bay Navigator

5. Improvements in technology /

availability of technology

Example • Videoconferencing palliative care consultations to improve access

to medical specialists and improve efficiency in use of medical specialist time. Comment- BOP DHB does not currently have very good MDT/videoconference facilities set up with appropriate technology. It is improving and hospital to hospital access should be available by end of 2011).

• Expand use of videoconferencing education sessions to improve access.

• PalCare – what elements can be linked to Tauranga Hospital ‘Bay Navigator’ site.

6. Education /training • Site accreditation for advanced trainees has been achieved at Waipuna Hospice. Opportunity to apply for an Advanced Training position – part funded by HWNZ & PaMTraCC.

• Include Waipuna Hospice rotations/placements as part of education/training of medical students/RMOs.

• Training to have the difficult conversations. • Carer education programme - Care for the carer, developing the

skills needed in the home. (Note Waipuna carer programme starts November)

7. Assessment tool InterRAI How does it relate to palliative patients? Duplication of information

from families. Consider relationship with PalCare – some information may be able to be linked between the systems. Hospices may be able to get read only access to InterRAI.

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APPENDIX 9

EASTERN BAY OF PLENTY – Stakeholder summary

STRENGTHS

COMMENTS

17. Model of care • single point of entry for

specialist palliative care services in EBOP

• care co-ordination

Palliative care nursing in the home working in conjunction with district nurses in some rural areas and Māori provider services as required. Good relationships between services. Good communication between district nurses and hospice.

18. Recently extended hospice

facilities

Additional property purchased to accommodate hospice’s growing need. Hospice EBOP strategic plan includes developing inpatient beds 10 plus years out. Not on current building programme. Is dependent on population need for inpatient beds and ability to secure capital and operational funding in the future, reviewed on an ongoing basis.

19. Workforce & services –Hospice

EBOP

• Strong leadership & experience in hospice • Very low staff turnover rate • 24/7 nursing support – well known and used by generalist, patient

and whānau. • 24/7 medical advice (telephone support) available from Waipuna

Hospice (but needs to be formalised) • Counselling resources directly employed by Hospice EBOP • Good volunteer support from community

20. Strong relationships with local

Māori

• Hospice EBOP has worked hard to establish good relationships and services for Māori. High proportion of patients are Māori (43% in 2009 and 35% in 2010, YTD 2011 44%) relative to:

• BOPDHB population (25%) • NZ (14.7%)

• Māori Liaison position in 2008/2009 funded through DHB Innovation Funding. Number of Māori patients went up during this time. Has now ended. MOH funded service development project followed in 2010 – interviewing Māori

Continue to strengthen relationships with Māori providers and Whānau Ora group.

21. Good grief and loss support

• Hospice counsellor and bereavement support group available to non-hospice as well

• Access to hospital chaplain and social worker • Kaumātua & Māori advocates • Biography service valued

22. Palliative care education for generalists

• Range of programmes available is increasing

23. Strong relationships

• Very good linkages between hospice and inpatient service at

Whakatane Hospital • Hospice has good access to and relationships with home based

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support agencies to support people to stay at home. • Hospice EBOP and Waipuna Hospice have developed strong

alliance and regional networks. • Hospice relationship with Golden Pond works well (2 funded beds)

24. Liverpool Care Pathway

implementation

• Good progress on implementation of LCP

As at 30 June 2011

EBOP Total Possible

LCP education/ implemented %

GP practices Whaka 15 6 40%

ARCs Whak 4 1 25%

Whakatane Hosp 2 2 100%

EBOP comm team 1 1 100%

22 10 45%

25. Community support for Hospice

EBOP

Well supported and respected by community. See also issue – level of community funding difficult to sustain.

Note: Keep access to services simple (simplify the pathways)

ISSUES

COMMENTS

1. Workforce – • Lack of palliative care

specialist medical resource • Sustainable funding for

education and building competency

• Need for palliative care social work position in the community

• Lack of palliative care specialist medical resource for regular clinics and education of GPs & hospital doctors. Could be achieved with an MOU with Waipuna but issue is shortage of palliative care specialist FTE.

• Hospice EBOP casemix is now about 30% nonmalignant. Issue is the skill base of the staff to deliver care for nonmalignant case mix as growth occurs.

2. Differences between district

nursing palliative/oncology nurse and Hospice nurse positions

• There is a DHB district nurse position with a 0.6 palliative component, located at hospice but not part of the on-call palliative nursing roster. There are issues including participation in on call roster, palliative care training, cover for leave. Filled by 2 nurses oncology/palliative care 1.2 FTE total.

• DN capacity impacts on Hospice EBOP capacity. If priority is given to oncology patients, hospice nurse picks up extra visits.

3. Out of hours availability and

home visits by GPs for palliative patients

Access to GPs can be a problem. • Some rural areas do not have on call GP services. No after hours

access in Kawerau. • Locality of GP after hours (many GPs don’t live in Eastern Bay

area). • Out of town rest homes struggle to get GPs to visit during work

hours – travel time is an issue. Some won’t visit.

4. Access to pharmacy out of hours

• Need GPs to pre-empt everything. • Whakatane - GPs can’t get Whakatane Hospital Pharmacy to issue

any drugs • Opotiki - Opotiki Health Centre 24/7 has a small pharmacy

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• Murupara - no pharmacy in town. Drugs delivered twice daily by courier from Te Ngae Pharmacy Rotorua – scripts need to be received at pharmacy by 9am to ensure delivered next day. Rotorua Hospital often discharges Murupara patients home without medication(s) – a significant issue.

• Te Kaha - GP does a lot of pre-emptive scripting from Opotiki pharmacies– has not been an issue.

5. Access to Whakatane Hospital

staff for palliative care education

• Need to improve opportunities for hospice to educate Whakatane Hospital staff on hospice services etc e.g. participate in orientation sessions and hold palliative care education sessions. Includes need to provided orientation for new doctors. Challenge is the high reliance on locums bringing high turnover – need MOU with BOPDHB.

6. Lack of documented clinical

guidelines and pathways

• LCP only • Need to improve/develop

7. Access to suitable

residential/respite care

• Two fully funded beds at Golden Pond in Whakatane for palliative end stage or respite is good but often not in location of need. Non preferred provider fund managed by Support Net is available for beds in Kawerau and Murupara if required. Opotiki hospital beds only used if GP can oversee patient.

• Shortage of hospital level beds in EBOP • Difficulty accessing suitable long term residential care for those

under 65 yrs.

8. Ambulance transport costs

Cost of St Johns ambulance transport payable by patient in some cases – expensive. Low socioeconomic group – can’t afford the cost. Applies within Whakatane and to Hamilton. Positive aspects: • hospital pays if palliative patient is discharged home to die. If not

end of life, hospital has ½ price arrangements. • If St Johns member home to hospital is free.

9. Package of care for home support/personal cares

• Social work used to pick up the cost of home support for 6 weeks post discharge from hospital but not any more. Hospice now has to pick this up for palliative patients. Change in policy interpretation – needs to be looked at.

10. Need to grow the palliative care

philosophy in the BOP

• Community awareness/perception of hospice (current focus is end

of life vs palliative) • Other health professionals understanding of palliative care esp

hospital services (earlier referral) • Grow understanding of palliative care for nonmalignant/chronic

illnesses

11. Funding • Inconsistent funding approach nationally (there is to be work on a new national funding model)

• Funding is fragmented - multiple organisations involved • Demand estimated to grow – pool of public funding is not • Income from bequests, donations and community funding to

support the gap in public funding for hospices is increasingly difficult to secure.

• Current model of funding not very supportive of how palliative care is delivered i.e. does not support GP visits for patient & family whānau or intermittent nature of input by specialist PC services.

• Ability of EBOP community to fund shortfall of DHB contract

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funding for operational costs is currently difficult. • Inequity in funding - SIA funding for palliative patients only

available in Kawerau. However, there is to be a change in how SIA funding is to be managed. Flexible funding pool will result in how GPs provide support for palliative patients in Kawerau.

12. Equipment Good sharing of equipment between hospital and hospice but

• challenge is ensuring equipment is appropriate to the person’s level of need

• sometimes time delays for assessments to be done in the community (palliative is given priority). Usually done within 2 weeks.

13. Some confusion for patients and generalists aligning across boundary to Lakes DHB

• GPs and some patients/families align to Rotorua for services. Murapara is in BOPDHB area so hospice provides services.

• Lack of clear understanding of where the boundary is between the DHBs. Need detailed map agreed.

14. EBOP requires more formal palliative care input at Whakatane Hospital.

• Formalise 24/7 medical telephone support with Western BOP • Specialist medical support from Waipuna to EBOP –

clinics/consultation and education • Hospice EBOP nursing role & activities in Whakatane Hospital

need to be formalised - MOU.

OPPORTUNITIES

COMMENTS

Current projects under way and others identified as useful for the future 1. National palliative care projects

in progress

• Development of: o role delineation model/resource and capability framework

(2011) o models of care (2011) o national funding model (begin 2011/2012) o specialist palliative care service specifications (2012)

• MOH consideration of Gold Standards Framework • Palliative Care HNA work • Health Workforce NZ palliative care workforce service review • Hospice NZ Standards project • Hospice NZ education package development

2. Advance Care Planning (ACP)

• New Zealand national guidance document and tools for Advance

care Planning now available • Regional project opportunity for rollout (similar to LCP rollout). Will

require project resource & funding.

3. Implementation of PalCare Phase one implementation into hospices in Midland in progress under the leadership of Waipuna Hospice. Significant opportunity to: • improve patient information management • improve reporting accuracy & consistency and create efficiencies • improve access by others to patient information for provision of

care Phase two will consider access by others (non-hospice) and integration with other systems.

4. PHO/primary practice - “Better,

sooner, more convenient”

• Opportunity for improved integration of services • Development of palliative care pathways in Bay Navigator

188


initiatives

5. Improvements in technology /

availability of technology

Example • Videoconferencing palliative care consultations to improve access

to medical specialists and improve efficiency in use of medical specialist time. Comment- BOP DHB does not currently have very good MDT/videoconference facilities set up with appropriate technology. It is improving and hospital to hospital access should be available by end of 2011).

• Expand use of videoconferencing education sessions to improve access

6. Māori Health services and Te

Pou Kokiri, based at Whakatane Hospital.

Potential to formalise and strengthen linkages between the hospital based team and Hospice EBOP.

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Updated: 10 April 2012

Bay of Plenty District Health Board Work Plan – 2012

Month Activity Documentation Source January No meeting February CEO Monthly Report

Approve committee Resolutions Monitor Member’s Interest

Declarations Dashboard Report (Jan & Feb) Quarterly Health Excellence

Report Draft Annual Plan SOI 12/13 External Audit Report

CEO GMGQ GMGQ

GMPF GMGQ

GMPF GMPF GMCS

March CEO Monthly Report Approve Committee Resolutions Monitor Member’s Interest

Declarations Dashboard Report Quarterly Risk Report Quarterly OSH Report Q2 AP Report Annual Plan – 12/13 Approve

draft to Minister

CEO GMGQ GMGQ

GMPF GMGQ GMGQ GMPF GMPF

April CEO Monthly Report Approve Committee Resolutions Monitor Member’s Interest

Declarations Dash Board Report

CEO GMGQ GMGQ GMPF

May CEO Monthly Report Approve Committee Resolutions Monitor Member’s Interest

Declarations Dashboard Report Quarterly Health Excellence

Report Final Annual Plan 12/13 –

Approve

CEO GMGQ GMGQ

GMPF GMGQ

GMPF

June CEO Monthly Report Approve Committee Resolutions Monitor Member’s Interest

Declarations Dashboard Report Quarterly Risk Report Quarterly OSH report Q3 AP Report Annual Plan 12/13 - Signature

CEO GMGQ GMGQ

GMPF GMGQ GMGQ GMPF GMPF

July CEO Monthly Report

Approve Committee Resolutions Monitor Member’s Interest

Declarations Dashboard Report

CEO GMGQ GMGQ

GMPF

190

Updated: 10 April 2012

Month Activity Documentation Source 6 Monthly Board Attendance

Report GMGQ

August CEO Monthly Report Approve Committee Resolutions Monitor Member’s Interest


Report

CEO GMGQ GMGQ

GMPF GMGQ

September

CEO Monthly Report Approve Committee Resolutions Monitor Member’s Interest

Declarations Dashboard Report Quarterly Risk Report Quarterly OSH Report Q4 AP Report Annual Report

CEO GMGQ GMGQ GMPF GMGQ GMGQ GMPF GMCS

October

CEO Monthly Report Approve Committee Resolutions Monitor Member’s Interest

Declarations Dashboard Report Exec/Board/Runanga Workshop

– separate day to Board Meeting

CEO GMGQ GMGQ GMPF GMPF

November CEO Monthly Report

Approve Committee Resolutions Monitor Member’s Interest


Report Code of Conduct

CEO GMGQ GMGQ

GMPF GMGQ

GMGQ

December CEO Monthly Report Approve Committee Resolutions Monitor Member’s Interest

Declarations Dashboard Report Quarterly Risk Report Quarterly OSH report Q1 AP Report

CEO GMGQ GMGQ

GMPF GMGQ GMGQ GMPF

191

Board Attendance from 01 January 2012 – 30 June 2012 SUBMITTED TO: Board Meeting 18 July 2012 Prepared by: Gail Bingham, GM Governance and Quality Submitted by: Phil Cammish, Chief Executive RECOMMENDED RESOLUTION: That the Board note the report. BACKGROUND: Attendance report as request by the Board for the period January 2012 – June 2012.

Please note that Mogens changed Committees from BOPHAC to CPHAC/DSAC

Board AFRM CPHAC/DSAC BOPHAC Board Members A NA A NA A NA A NA Mark Arundel 5 0 4 1 2 0 Yvonne Boyes 5 0 2 0 Marion Guy 4 1 1 1 Tamarapa Lloyd 4 1 2 0 Gail McIntosh 5 0 5 0 Matua Parkinson 5 0 1 1 Mogens Poppe 3 2 1 0 1 1 Ron Scott 5 0 5 0 2 0 David Stewart 4 1 5 0 2 0 Sally Webb 5 0 2 3 1 1 1 1 Jeff Williams 5 0 5 0 Punohu McCausland

5 0

Number of Scheduled Meetings

5 5 2 2

192

Report from Organisation of Economic Co-operation and Development

on Health Spending SUBMITTED TO: Board Meeting 18 July 2012 Submitted by: Helen Mason, Acting Chief Executive RECOMMENDED RESOLUTION: That the Board note the information. BACKGROUND: Attached is a report from OECD on health spending, forwarded by the Minister’s office with a request that the Chair consider including it in their next set of board papers. The information can also be found on the OECD website: http://www.oecd.org/document/15/0,3746,en_21571361_44315115_50655591_1_1_1_1,00.html

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