Forum Powerpoint_02062021

Western Bay of Plenty Primary Health Organisation

Provider Forum 2 June 2021

Whakataka te Hau Karakia Timatanga (opening) Whakataka te hau ki te uru Whakataka te hau ki te tonga Kia mākinakina ki uta Kia mātaratara ki tai E hī ake ana te atakura He tio, he huka, he hau hū Tīhei mauri ora!

Cease the winds from the west Cease the winds from the south Let the breeze blow over the land Let the breeze blow over the ocean Let the red-tipped dawn come with a sharpened air A touch of frost, a promise of a glorious day

PHO Update Lindsey Webber

CEO, Western Bay of Plenty Primary Health Organisation

BOP NBSP Primary Care Education WBOP PHO Provider Forum 2nd June 2021

Dr Alex Lampen-Smith Clinical Lead BOP NBSP

4

Bowel Cancer in NZ NZ has one of the highest bowel cancer mortality rates in the OECD

10%

EARLY detection

th 6

rd 3

Highest

Highest

Bowel Cancer is the second highest cause of cancer death in NZ

SAVES LIVES

RISK rises

nd 2

EACH YEAR

Highest 5

chance of survival with late diagnosis

90% chance of survival after early diagnosis

75 years old

5.6% 50 years old

0.6%

NBSP a quick summary • Free programme to detect bowel cancer at an early stage • Eligible people are invited to participate every two years around time of birthday • Age range 60-74 years • Automatic invitation from a population register – no registration required • GP’s refer positive FIT patients to DHB for a colonoscopy

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Role of Primary Care - Important • Encourage participation • Advise patients of positive results and send e-referral • Select appropriate pathway – National Bowel Screening Programme – asymptomatic, age 60-74 – encourage FIT test NBSP participation – Symptomatic referral – any age – Increased risk – asymptomatic surveillance colonoscopy (FHx colon cancer)

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Pathway from Primary Care Perspective

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Encouraging participation National Coordination Centre (NCC) has a role: • Contacting non-responders in the target groups (Māori, Pacific, Quintile 5) within eight weeks • Then referring to outreach services Primary Care • Extra benefit in promotion from the primary care team people know and trust • Opportunistic • Patient prompt BPAC • Especially for those at higher risk of non-participation

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Support appropriate participation Information on “who should do the test” is provided in this participant brochure

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Community Health Promotion and Out Reach BoP NBSP Outreach Plan BoP NBSP Programme Manager, Administrator, Kaihautū Hauora Navigator, CNS. The BoP NBSP team will provide outreach services to those hard to reach to engage them and assist in getting them in participating with the programme. Supports priority population which includes Māori, Pacific and deprivation 9 and 10.

Collaboration with PHO/PHA/NMO, Te Pare o Toi, Community Providers to deliver support, education and information to those at risk of not participating with the FIT kit or attending for colonoscopy.

Educational Tools and Patient Resources • •

Additional resource s available from NBSP team Can order online for free at HeatlhEd

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Prelaunch outreach NBSP CME Eastern BOP 13th April • •

Alex Lampen Smith Lead Clinician BOPDHB NBSP Session available on line

NBSP CME Western BOP 18th May Primary Care Practice Visits - NBSP Enablement • • • • •

1 August – 1 November For practices wanting a visit or zoom meeting Led by CNS NBSP Brighid Coordinated with WBPHO, EBPHA and NMO Attendance records

Educational Tools and Patient Resources •

Info packs will be distributed to practices 12

The Test

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NBSP Test KIT NBSP Invitation Letter sent 2 Weeks Later NBSP Test Kit sent NBSP FIT KIT contains instructions, NBSP consent form. and faecal immunochemical test (FIT) Simple test completed at home Drop pack into post, goes direct to central lab Must be received by lab within 7 days of sample being taken

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Understanding the test The faecal immunochemical test (FIT) detects tiny traces of blood in bowel motions Advantages of FIT over guaiac FOBT: • More sensitive • Single sample approach – no fridge storage required • No dietary restriction • Higher return rate • Improved stability • Automated analysis 15

Understanding the test Cost-effectiveness assumptions Parameter

Mean (95% CI)

FIT sensitivity adenoma < 10 mm

7.7% (7.1 – 8.4%)

FIT sensitivity adenoma > 10 mm

25.2% (22.2 – 28.2%)

FIT sensitivity Stage I and II cancer

59.7% (27 – 92.5%)

FIT sensitivity Stage III and IV cancer

85.9% (67.4 – 100%)

FIT specificity

94.7% (94.4 – 95%)

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The Referral

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Positive FIT test Positive FIT TEST

Localising midland develop BPAC eReferral form Used successfully throughout Midlands

GP Notified of +ve FIT Test GP informs patient in person / phone

GP eReferral to ‘Positive FIT’ – regardless of plan <10 days $60+GST automatic payment, no need to invoice

No charge to patient

Resources and GP and Pt Info embedded within eReferral form

CNS NBSP completes family history and pre assessment <15 days 1st Appt coloscopy or alternative investigation <45 days

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Colonoscopy v CTC • Preference for colonoscopy due to the high chance of advanced polyps / cancer • GP can suggest if CTC felt to be more appropriate • If pre-assessment identifies any concern re appropriateness of colonoscopy Clinical Lead discretion, can liaise with GP.

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Primary Care Resources Resource

Purpose

Video overview of the NBSP

Excellent overview by Dr John McMenamin, National GP/Primary Care Lead of the NBSP.

NBSP Bay of Plenty Guide for Primary Care

Provides and overview of programme information, roles and responsibilities, payment information, symptomatic, surveillance, referral process and online resources 3 page ref guide for primary care

NBSP Quick Reference Guide for Primary Care NBSP Pathway

NBSP Treatment Pathway

BoP Briefing for Practices within DHB

One page Briefing document for primary care

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Pilot evaluation: Key findings for General Practice • Face to face consultation important for those who: – Are highly anxious – Have comorbid conditions – Are reluctant to have a colonoscopy

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Safety net Role of BOP DHB NBSP team • BOP NBSP also informed of positive results • If no GP referral received our CNS attempts to contact participant • If failure to contact – Liaises with Primary Care team – Participant sent discharge letter – Close episode and recall two years

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How many participants in the NBSP will be found at colonoscopy to have polyps or cancer?

• Approximately 7 in 10 people will have polyps – if removed may prevent cancer developing • Approximately 7 in 100 people will be found to have cancer and will require treatment • Over 900 cancers have been found in asymptomatic people via the screening programme so far!!

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The impact of FIT testing It Saves Lives ü 16% reduction in mortality rate in the age group offered screening ü 25% risk reduction with at least one round of screening

Even more lives could be saved with: ü Higher participation rates ü Widened age range

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BOP NBSP Numbers 21/22

22/23

23/24

24/25

Eligible Population age range

60-74

60-74

60-74

60-74

Eligible Population

44,190

44,890

45,530

46,150

Number of invites per annum

24,525

24,525

26,257

25,130

Number of positive FITs

734

734

613

572

Numbers of colonoscopies

657

657

550

512

Numbers of surveillance colonoscopies

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59

96

228

Number of cancers

50

50

31

28

Number of months

11

12

12

12

25

Colonoscopy Waiting Time Indicators

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Our Contact Details BOP NBSP Programme Contact Details BOP NBSP Mobile: 027 2094672 BOP NBSP Email: bowelscreening@bopdhb.govt.nz

BOP NBSP Clinical Lead: Dr Alex Lampen-Smith BOP NBSP Clinical Nurse Specialist: Brighid McPherson Mobile: 027 225 3914 BOP NBSP Kaihautū Hauora Navigator - TBC

: BOP NBSP Business Leader: Sandra Fielding BOP NBSP Programme Manager – TBC BOP NBSP Programme Administrator – TBC

www.timetoscreen.nz/bowel-screening/

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Whakawhitinga korero – Lets talk

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"Ngā mihi nui ki a koe” Thank you

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Western Bay of Plenty Primary Health Organisation Clinical Update

Introduction – Clinical Directors Dr Fiona Whitworth Dr Andrew Corin

Fact 1 - COPD New Guidelines • COPD new guidelines – breathlessness plans and action plans are mainstay of the update COPD program – can be found: COPD Resources - NZ Respiratory Guidelines

• There is an update for Nurses to be held on Wed 14th July from 8.30 – 1 to provide support in the set up of practice led COPD clinics • Aims: • improve patient care • avoid hospital admission • Subsequent development of Halcyon form for claiming for the provision of this program

Fact 2 - Care Plus • Care Plus relaunch of the service is up and coming • There will be a staged role out with: • An updated Halcyon form for claiming • Opportunity for flexible use of appointments 2-8 tailored to patient need Opportunities to improve practice utilisation: • increased resources and examples of when Care Plus could be utilised • Medication review recourses • Suggested uses of the risk stratification data

Fact 3 - Diabetes • Diabetes update was launched by MOH earlier this year: Type 2 Diabetes Management Guidance - New Zealand Society for the Study of Diabetes (nzssd.org.nz) • Weight based Insulin start • Decreased inertia in diagnosis • Newer agents • Algorithm

Basal Insulin • Start with weight-based dosing of isophane (Protaphane or Humulin NPH) or glargine (Lantus) insulin • 0.1 units/kg daily if HbA1c < 64 mmol/mol or BMI < 18 kg/m2 or elderly or renal/liver failure • 0.2 units/kg daily if HbA1c > 64 mmol/mol and BMI > 18 kg/m2

• Basal insulin is best administered at night as major role is to counteract hepatic gluconeogenesis • Continue lifestyle management and other glucose lowering therapies (including sulfonylureas) • Monitor fasting blood glucose (FBG) levels • If 3 consecutive FBG levels > 7 mmol/L then increase dose of basal insulin by 10% or 2 units • Stop uptitration of basal insulin once any hypoglycaemia OR FBG < 7 mmol/L OR doses reach 0.5 units/kg/day – • Then : - consider adding rapid acting insulin with meals if above target HbA1c and capillary blood glucose data to show post meal rise

Asymptomatic Screening Diabetes • Reminder; as part of CVD risk assessment, • all adults should have an HbA1c performed • men from age 45 years • women from 55 years • Start from 30 years in men 40 years in women if Māori, Pacific or Indo-Asian ethnicity

• Two abnormal tests (HbA1c or fasting) are required to confirm the diagnosis either on same day or subsequent test without delay • Patients with prediabetes (HbA1c 41 – 49 mmol/mol) – annual measurement • Women with a history of gestational diabetes – annual measurement

Fact 4 - Health in Aging • Dr Esra Venecourt- Jackson is our Community Geriatrician • She is keen to connect with practices to support improved clinical care • We are looking to recruit 3 practices to offer regular (? Bimonthly) clinical catch-up meetings with Local Practices for the clinical team to review Clinical problem – please contact via – fionaw@wboppho.org.nz • Work is also being done on Deprescribing guides for the older patient – watch this space!

Fact 5 - St John Ambulance Acute Demand Service • Recent review identified that approximately 30-40% of possible patients are not utilising this service.

• Some of the barriers include communication with the practice.

• Opportunity to look at your own systems that could facilitate more effect use of this service

Fact 6 – Read Codes • The PHO have been looking at offering some standardisation for clinical coding and have produced a one page READ code formulary for common medical conditions.

• It was created by amalgamating a number of other READ code formularies used in other PHOs. • This may be something that you wish to incorporate into your medical summarisation protocols and / or offer to clinicians to support their coding of medical conditions.

• The latter would commonly be done when reviewing letters or on diagnosis of new conditions.

• If used it will allow easier clinical audit for clinical care.

• All feedback to help improve this is welcomed. http://portal.wboppho.org.nz/members/read-code-formulary/

Fact 7 – Cellulitis • Dr Kate Grimwade introduced improved clinical care guidelines for cellulitis earlier in the year.

• This brings us into line with our local colleagues in the Eastern Bay and the Lakes.

• The link to this training is: (669) Cellulitis Pathway Update – YouTube • The bottom line is a move away from IV antibiotics to only the use of oral therapy • Full guidance is on Bay Navigator https://baynav.bopdhb.govt.nz/dermatology/cellulitis/?pathways

Fact 7 – 3 Hs • Heath Pathways – for clinical programmes and guidelines https://midland.communityhealthpathways.org/LoginFiles/Logon.aspx?ReturnUrl=%2f username – midlanduser Password -midlandpassword • Health Navigator – for resources for patients + also some really good resources for providers as well https://www.healthnavigator.org.nz • HealthPoint – as a place to go to find out about all health related services (both national and local) Includes local iwi services, NGO’s, counselling providers etc https://www.healthpoint.co.nz

and finally A message regarding CME attendance • The WBOPPHO Education team will only issue certificates and register attendee details on the RNZCGP CME register for those who attend events in person.

• Those who attend via Zoom or watch a recorded version of the event at a later date are able to claim CME points by entering the event as an ‘individually planned learning activity’ and completing a self-reflective activity via the RNZCGP Dashboard.

Integrated Primary Mental Health and Addiction Services Rollout Integrated Practice Teams – model for mental health in primary care Sylvia Donaldson, Primary Mental Health Programme Lead, WBoP PHO

Overview In response to He Ara Oranga, the report of the Government Inquiry into Mental Health and Addiction, Budget 2019 provided an investment to increase access to, and choice, of primary mental health and addiction services as a critical first step in transforming our mental health and addiction services.

The aim of these services is to: • Increase access and equity of access • Increase choice in addressing people’s holistic needs • Reduce wait times and • Improve outcomes and equity of outcomes

Overview • This model of care, named Te Tumu Waiora (‘to head to wellness and health’) been designed as a holistic model, supporting and addressing the physical, emotional and social needs of the person rather than the traditional focus on mental health or addiction needs.

• The aim of this model is to deliver a small amount of targeted, brief intervention to a large number of people, as opposed to a large amount of therapy to a small group of people, as well as to connect social and specialist support across one continuum of care.

Purpose and vision • A primary mental health system that is more accessible, engaging and connected and that gives every New Zealander their right to live well.

• Enhanced general practice teams • Self-management support • Referral-based talking therapies • Increased access to NGO-delivered community support workers • Enhanced interface between primary and secondary services.

Key Components There are ‘key components’ of the service which will look similar across New Zealand. The key components of the service include: • Health Improvement Practitioner (HIP) - an experienced and registered mental health clinician who will provide assessment and brief intervention therapy as needed • Health Coach (HC) – a trained support, peer or cultural worker who will support the individual to manage their health through a range of personalised interventions • Support Worker (SW) who will provide access to cultural and social supports within the local community • A confident and competent general practice team • Effective links and coordination between primary and secondary services

Health Improvement Practitioner (HIP) – for the patient • •

• • • • •

Based on a primary care behavioural health approach Registered health professional who meets HPCA requirements, with knowledge and experience in evidence based talking therapies and who has completed HIP training Works as a generalist seeing anyone of any age whose thoughts, feelings or behaviours are impacting on health and wellbeing Delivers evidence-based brief interventions to individuals, whanau and groups to help people make changes to enhance their health and wellbeing 30 minute appointments - sees 5 – 8+ people per 8 hour day Enters clinical records directly into PMS Has appointment template within PMS – open to other members of the team booking people in for appointments

Health Improvement Practitioner (HIP) – for the Practice • Takes a whole of population view to enable the primary care team to meet all need • Is an integrated member of the general practice team • Is located within the practice close to other members of the team • Works with the team to build capability • Develops pathways for high impact problems within the practice • Provides advice and support to the other members of the general practice team, including running teaching sessions

Health Coach (HC) Health Coaches may be registered or unregistered. They encourage people to identify their own priorities for change and support them to find the resources, tools and supports to meet their goals.

The five key roles of the health coach are: • Self-management support • Acting as a bridge between clinician and patient • Navigation of Health and Social Services system – linking to appropriate community supports • Emotional support • Providing continuity within a busy primary care team

What are the benefits?

• Barrier-free access – no entry criteria • Immediate or fast access to services and supports • Person-centric support, including culturally responsive options From pilot evaluation: • 70% experienced an improvement in wellbeing • Improvements in broader determinants of wellbeing such as housing and money matters • Benefits also seen for Maori, Pacifica and youth • Fewer referrals to psychological services • Saves GP and nurse consulting time

Focus on equity and priority populations Requirements: • An understanding of the priority population and their needs • A focus on improving equity of outcome for Maori • Participating general practices reflect the priority population groups (Maori, Pacific Peoples and Youth (13 – 25 years) Outcomes and measures: • Better equity in service utilization for the priority population groups • Better health outcomes for the priority population groups

What does the Practice need to do?

• Contact your local implementation lead to find out more about the service in your region.

• Identify practice champions (clinical and management) • Provide a room or a space for the HIP and HC to have private patient conversations. This can be a dedicated space or a flexible space to fit in with how your practice team works.

• Provide the IPMHA staff access to your PMS.

Onboarding Practices • Partnership with PHO • Support structures • Communication • Time frames • Provide understanding of the model • Recruitment process • Documents/service brochures/ practice flyers

“I cannot recommend this service strongly enough. Initially I was sceptical, but if funding for the service disappeared, we would 100% fund it ourselves now.”

Northland GP

MOH Integrated Primary Mental Health And Addiction Video Final - YouTube

Just in Case plans Enabling better care for your patients with advanced illness and end-of-life care needs

Ruth McChesney

Acute Demand Specialist Nurse Project Lead of Just in Case plans 2 June 2021

To Cover •

Recap and review the purpose of Just in Case plans for general practice teams

•

Explain some upcoming developments for an extended roll-out into secondary care

Purpose of Just in Case plans Enabling patient & whānau centred care to be available to those with advanced and progressive conditions when they need it most.

Just in Case plans involve anticipating the likely future care needs of the patient, developing a shared healthcare plan & prescribing in advance of symptomatic need.

Background • Multiple studies show that most people want to die at home • Over a third of older New Zealanders (≥65 yrs) die in acute hospitals • Approx 26% of community palliative care patients do not have hospice support • Recent BOP data showed that 74% of acute palliative admissions to TPH were self- or family referred • Palliative deaths in BOP are projected to increase by over 45% between 2016-2038.

• Non-cancer deaths are expected to triple non-cancer deaths. Dementia, frailty & long-term conditions will become the highest causes of death.

Process of developing a Just in Case plan •

Invite appropriate patients to discuss developing a plan around their future needs and wishes. N.B. average time is 30 mins

•

Whānau/family members ideally present - or discussed with after

•

Complete Just in Case plan template, attaching other notes and management plans as applicable

•

Prescribing clinician to sign Just in Case plan & Authority to administer Prescription chart

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Patient to sign form

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Scan copy to notes. Copy to patient (for their fridge), and scan/ fax copy to Medical Records.

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Send an invoice to the PHO - for each plan developed & shared

Other considerations •

Consider prescribing other anticipatory medications, to manage future susceptible issues: infections, anxiety, oral analgesics, (constipation).

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Whether to dispense ampules to patient (waste/cost/risks vs ambulance stock in WBOP vs hospice requirements). Note: fentanyl is the only opioid available on ambulance.

•

Making a contact number available on the form, or with hospital telephony, with some boundaries – for scenarios of uncertainty (St John)

•

Recommending annual St John membership if not already, WINZ

•

Informing hospice of JIC plan and whether drug chart ‘copy’ needs to be made if other drug charts in use

Examples of Just in Case plans… demonstrating pre-emptive planning to provide care centred around the patient and their whānau/ family

Page 1 of Just in Case plan…

Personalising the background and advanced directives to the patient…

Outlining the priorities for the patient, to inform others…

Providing a plan to manage scenarios and symptoms

Anticipatory prescribing of ‘core medicines’ for end of life symptom management

Addressing other prescription needs to manage recurrent episodes & exacerbations

Need more for your patient? → call me to discuss

An example (of excellence)

Free text also provides the best quality plans for everyone involved

An example (of excellence) St John application of Just in Case plan

When to think about a JIC? •

Those with dementia, frailty, advanced chronic conditions, in residential care (or at risk of), cancer, congenital high needs patients

•

Recent ED or hospital admission(s)

•

Those potentially underserved – Māori, living rural, unpredictable needs

•

Keep asking the ‘surprise’ question – nearing EOL?

•

A deterioration has already happened – urgent ‘just in time’ plan

•

When referring to hospice…

•

Suggested by another provider

Other provider involvement • There has been agreement that GP teams cannot tackle the future care needs of patients alone • Project work is underway with secondary care for serious illness conversations and Just in Case plans to be started in hospital • These plans would be valid for 2 weeks – a period of time to allow the patient’s primary provider to review and countersign/ change, and have ongoing clinical oversight • Communication would be via phone call, Transfer of Care (discharge) letter, plus fax and CHIP/MCP record • Same funding available for WBOP PHO practices to review temporary plans and share/ upload updated copy

A Just in Case plan started by hospital colleagues

Front page to countersign if in agreement, OR write a new one.

Authority to administer Prescriptions to countersign, change, add to…

Then copy to patient, scan to Medical records and Invoice to PHO.

Where do I find the Just in Case plans and resources?

The Portal, the Portal, the Portal

portal.wboppho.org.nz/

Also Midland Pathways & Bay Navigator (but without User Guide)

More on anticipatory prescribing ´ First appeared in literature 2005, now recognised as a central component of good end-of-life care planning in the U.K., Australia and New Zealand. ´ Ministry of Health (2017) Te Ara Whakapiri: Principles and Guidance for the Last Days of Life ´ National Institute for Health and Care Excellence (2015) Care of Dying Adults in LDOL ´ British Medical Association (BMA) webpage: Anticipatory prescribing for end-of-life care.

´ In line with St John scope of practice ´ St John will send you a Care Summary of patients with JIC plans, not-transported to hospital ´ In U.K. Just in Case medication boxes go to every patient → waste and cost issues. ´ Two options here to have meds with St John only, or dispense to patient.

Summarising & reflecting ´ Important aspect of care to provide a good death – clinical expertise of GPs ´ Best practice – recognised through evidence and guidelines ´ Patient and whānau centred ´ Funded ´ Integrated, interdisciplinary approach to meeting these needs ´ Do use members of your General Practice teams to help you ´ What would you want? ´ What do your patients want?

By encountering death many thousands of times, I have come to a view that there is usually little to fear and much to prepare for.

Kathryn Mannix, Palliative Care Consultant, U.K., Author of With the End in Mind

Recommended video: Courtenay and Demar, their story.

Health Quality & Safety Commission website

Thank you

Ruth McChesney Project Lead for Just in Case plans 07 577 3190 adsadmin@wboppho.org.nz 021935600 ruthm@wboppho.org.nz

HOW do Just in Case plans fit with other plans?

Advanced Care Plans and Serious Illness Conversation Guide

JIC q LATER STAGE OF LIFE

SICG q A CHANGE

ACP q ANYTIME

Kia tau Karakia whakamutunga (closing) Kia tau kia tātou katoa Te āio, te aroha me te marutau Tīhei Mauri Ora

May peace, love and safety Be upon us all Let there be life