Forum Powerpoint_28072021

Provider Forum 28 July 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  Health System Pressures  Health Reforms update: o Transition Unit Activity o Localities Development

Strategic Priorities Whai Ora-Quality Whai Rangatiratanga-Sustainability Whai Mana-Equity

Treating people fairly often means treating people differently

Creating an organisational Culture of Equity

Supporting our General Practice Teams

• Equity vs equality –knowing the difference • Consumer engagement and co design • Equity Tool-Snakes and Ladders (with a twist ) • Foundation Standards and Cornerstone Accreditation • Cultural Training –Learning together • Equity Champions support

How have these activities impacted on patients/changed practice?

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The video (The Race) is powerful- you just get it, after watching it

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Plan to invite multi-generational whānau to walk with us through our buildings and review our communication systems (including website/Health 365 etc) to ensure a Māori perspective in all that we do.

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We are working in partnership with consumers to ensure our services are meeting the needs of the Māori population

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The Snakes and Ladders game helped highlight the actions we were already doing well and enabled the team to come up with some ideas to make patients feel even more welcome.

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We had a very strong relationship with the local hāpu many years ago and over time it is drifted off and we want to strengthen the relationship so we can work together

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I come from an era where we were not expected to say Māori words correctly… I can see why it is important to say names correctly and I am now being challenged by my children to do so

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Gave me a lot to consider re my interactions with patients and other cultures. More awareness and knowledge of bias – positive and negative.

Tā mātou mahi hei whakaohoho

Karakia/Waiata Huddles He Pounamu Cultural training Haerenga

Policies and processes – walking the talk Te Rerenga – celebrating success

How has our cultural journey influenced your mahi/changed your practice?

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Listen with curiosity, speak with honesty, act with integrity” by Roy Bennett this quote speaks to empathy and about understanding another’s story. We need to be careful about speaking with honesty in the environment we are in as we are at risk of creating an echo chamber – we need to find ways to encourage conversations with people that still need to understand the ‘why’. When we come across people in our organisation or the community that are resistant to equity concepts.

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In increasing our knowledge of Te Ao Māori we can do better to support creating environments which allow Māori to be Māori and to flourish. This is core to creating equitable health services and therefore it has to be the primary focus of our mahi

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Recognising there is no future without the past. Trying to look at inequity within healthcare (and Aotearoa society) is impossible without full recognition of the recent past events and trauma that families have faced and still feel and carry with them in very real way to this day.

Ehara te tangi tū I te mea whakamā. Mā te hunga e rapu ana, tō hua nā, e whakatau kaupapa e whakatau ana hoki.

Success is not for the timid. It is for those who seek guidance, make decisions, and take decisive action

Thank you Questions?

Fiona’s Clinical Updates

Topics 1 St John Service 2 Mammogram 3 ACC MRI access 4 Immunisation 5 Nurse Prescribing 6 Onboarding

St John Acute Demand ‘redirects’ pathway Scope of St John pathway

• 81% of St John call-outs nationally are low-acuity • Local audit showed that 26-41% of low-acuity cases transferred to hospital = appropriate for general practice Progress • 278 redirects over past financial year (just over 1 case per working day), just 1% result in admission • Redirects are trending down, without a way of measuring why • St John have recently agreed to add a ‘declined’ code to help understand and measure local need

Actions How can you help?

• Have a suitable process set-up for St John to easily discuss potential cases with someone clinical on phone (+/- on site) • If you ‘decline’ seeing a patient, please indicate the reason for this Funding tip • St John type the code referral@acutedemand (then ‘fully’ or ‘patient funded’) into their disposition notes • If St John forget to type in the referral code, send the ambulance summary along with your invoice - the PHO will try to honour whenever possible

Breast Cancer Mammography Follow up Protocol • Annual mammogram until age 70, or 10 years post diagnosis, whichever is longer • The first 5 years through outpatients' clinic then alternating Breastscreen Aotearoa and DHB funded • 2 yearly from 70-80 if in good health and life-expectancy likely to be >15 years funded by DHB • > 80 could continue screening if physically well and likely to have treatment for breast cancer • However, after 10 years this age groups residual life-time risk is close to population average • There is currently no evidence screening in this age group is beneficial. Diagnostic workup would of course be undertaken if symptomatic.

• Some women will have early discharge to GP (DCIS, low grade small cancers) in which case the GP can continue ordering annual mammogram through DHB )

ACC led MRI • GP interest • Discussion with Procare to help role this out locally • Knee, neck and lumbar MRI • Local in person training 3-4 hours

• Expressions of interest from GPs to fionaw@wboppho.org.nz

Immunisation Rates • One of the 12 priority areas for DHB and MOH

• Overall decrease at 8 months, 2 years and 5 years • Drop off for Māori more significant • DHB wanting feedback as to the current problems being encountered • Email: tim.slow@bopdhb.govt.nz

Nurse Prescribing in Community Health • Suit practices with younger population as the prescribing scope is for the normally well population (who tend to be younger before the onset of LTC) • A number of general practices across the BoP and wider Midland region have nurses completing this level of prescribing. It is a good addition to the practice skill mix.

• This is likely to become the largest group of nurse prescribers as no post graduate qualification is required for entry.

• Nurses need to have worked in the area for a minimum of one year and they need an authorised prescriber to be a supervisor.

Scope • Enables nurses to prescribe a variety of antibiotics and other medications using local guidelines: E.g. antibiotics for • cellulitis, • sore throat, • ear infection, • eye infection, • skin infection.

• If nurses have completed the family planning course and completed RNPCH they can prescribe contraception including LARC and prescribe for STIs.

The Course • The course is online and via ZOOM • Requires submission of a portfolio within one year of commencement • Next course commences 25th August. Free of charge.

On Boarding Document Purpose

Two parts

• Support orientation of new staff. May be new to area or new to primary care, or both.

•Document (hard and/or soft copy on PHO Portal)

• Supplement existing induction processes such as workplace induction and Health and Safety.

• Quarterly face to face 2 hours - Opportunity to meet staff and ask questions

What’s included in the Onboarding document?

•Primary care context

• Overview of primary care roles

•Health informatics

•Link to CME/CNE

•Link to funding stream

•Useful websites

•Māori health and key documents

•Nurse prescribing

End of Life Choice Assisted Dying Implementation Dr Andrew Corin – Clinical Director

So what do I need to do now?

• Become familiar with the MOH online information and training platforms www.health.govt.nz/our-work/regulationhealth-and-disability-system/end-life-choice-actimplementation • Consider your position for the implementation of The Act. • Discuss preparation and process with colleagues and practice staff.

• Engage with support resources such as those from Health Safety and Quality Commission, MOH, DHB, PHO.

And what will the options be from Nov 7th?

• Patient raises assisted dying.

• Medical Practitioner assesses eligibility and level of involvement

• Initiates process of assisted dying according to The Act. • Or refers to SCENZ if unable or unwilling to participate.

• Funding is modular and fee for service (details yet to be provided).

End of Life Choice Assisted Dying Implementation

Leigh Haldane NZRPT Integration Technology and LifeCurve™ researcher Bay of Plenty DHB Kathy Everitt NZRPT Project Lead – LifeCurve™ Bay of Plenty DHB

Simple, evidence-based measurement framework to understand how people are ageing A tool based on research from Newcastle University

What is the LifeCurve™? compression of functional decline

www.adlsmartcare.com

Converted research into a digital LifeCurve™ service, to map age related functional decline Gives advice that can help people slow the rate of age-related decline

What is the LifeCurve™?

Measures how people are ageing by looking at their ability to do functional activities Can be used independently by people in the community Does not require GP / Nurse / Physio / OT input

https://doi.org/10.1093/ageing/afy145

How do we know it works?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5562326/ https://www.researchgate.net/publication/232766537_The_T heory_and_Practice_of_Active_Aging

https://www.icpsr.umich.edu/web/NACDA/studies/34315/ver sions/V2

the LifeCurve™ is evidence based

WHO states that negative views of ageing can result in living 7.5 years less on average

There are things people can do right now to age better

Can you stand on one leg with your eyes closed for 10 seconds?

Can you stand up and sit down in a chair: 35 times (women) / 37 times (men) in 60 seconds?

Lower levels of physical capability at age 53 and inability to perform capability tests are associated with higher rates of mortality https://doi.org/10.1136/bmj.g2219

some background…

• Bay of Plenty DHB purchased the digital service from ADL Smartcare in the UK • Made changes to the app to make it more relevant for NZ – this is the beginning of the LifeCurve™ journey • LifeCurve™ is aligned with research taking place in NZ

100 year old vs 40 year old

Ideal LifeCurve™

Compression of functional decline

www.adlsmartcare.com

Eclipse Homecare case study

https://www.youtube.com/watch?v=r8AUaeXt Vnw

Potential benefits for primary care Prevention Independence Empowerment

The LifeCurve™ is available on the app

or on the website https://bayofplenty.lifecurve.co.nz

The LifeCurve™ can empower people to manage their own health

Take away messages

Getting older does not have to mean losing abilities and losing independence It’s about everyone having conversations about how to age well It’s about changing people’s attitudes to ageing

The LifeCurve™ can add life to years

Care Plus review Dr Fiona Whitworth – Clinical Director

Care Plus - Background 

This was a centrally developed model of care originally rolled out in 2005.

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Its aim is to developed patient led care plans to improve patient health.

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Its focus is Chronic Disease management in Primary Care – targeted to our most comorbid population. It is noted that Māori are overrepresented in this latter population.

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At its core is the identification of health goals that the patient can work towards to improve chronic health outcomes.

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It can be initiated by both doctors and nurses.

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It is often provided through the nursing team.

Care Plus objectives include: 

Early identification of chronic illness (co-morbidities)

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Provide improved support for people to self-manage their chronic

conditions 

Prevent complications where possible

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Slow the progression of the disease

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Prevent other conditions from developing

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Close monitoring of those who have a significant disability or have

significant burden of morbidity

Eligibility Criteria  Patient is expected to need ‘intensive clinical management (2hr+) in the next 6 months AND at least one of the following:  6 First level Service Primary Care visits in the past 6 months

 2 acute non surgical admission in past 12 months  a terminal illness

 2 or more chronic conditions  Is on active review for elective services

Current Program Details • Practices are allocated a number of patients slots – each slot comprised up to 4 patients reviews. Each review was invoiced by the practice at the time of review.

• 1/7/20 - 1/7/21 – there were 11.2 K patient allocation slots across the Bay. • Slots were allocated centrally from MOH through a formula based on practice demographics - this has been developed and refined since 2005. Allocations are adjusted each month.

• The Reviews may be completed by various members of the primary health care team e.g.

GP, nurse, nurse practitioner, clinical pharmacist.

• At practice discretion a co-payment may be charged, but the patient MUST receive lower cost services as a result of being on Care Plus.

Analysis of current program

Unused Percentage 94.0% 91.7% 81.1% 79.1% 78.7% 75.5% 74.9% 63.0% 58.8% 49.4% 47.4% 46.1% 42.7% 42.2% 40.0%

37.4% 35.6% 34.8% 32.7% 30.2% 25.8% 22.7% 22.1% 19.6% 17.3% 16.2% 9.0% 3.4% -21.8% -40.0%

-20.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Review of Data • The percentage of unused appointment varies between practices from 16% to 80% by practice

• Only 1000 patients used all 4 reviews • Some GPs use the system more than others • Some practices use the system more effectively than others • No practice is effectively using the program fully for their patients

Practice Feedback 

Discussions with experienced clinicians and practice managers has highlighted many challenges with the current scheme



4 sessions is inflexible and not tailored to patient need

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Mainly targeted at diabetic patients

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Often misused as a way for free / low-cost appointments for patients

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Care plans are frustrating and cumbersome and are often not filled in

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Degree of confusion as to which patients are eligible

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Not always targeting patients who could benefit

Relaunch of program 

The concept of patient allocation slots has been modified to be a flexible number of patient reviews 2-8

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A Simplified Halcyon form is going to be available.

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Practices are being encouraged to look at their risk stratification data to enable targeting of their resources with an equitable and needs led approach.

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The risk stratification tool is relatively new and is only just been utilised – it focuses on patients with high functional morbidity – ie. numerous Primary care attendance, hospital visits – alongside underlying chronic disease.

Halcyon form Instructions

Additional Support • Risk Stratification Information • Development of a helpful resource guide • Reviewed by : • Director of Maori Health – Kiri Peita • Experienced clinicians and allied health

Risk Stratification Data

Care Plus Resource Guide Care can be provided through a multidisciplinary environment utilising    

Practice nurse Pharmacist GP Nurse prescriber or practitioner

To fully achieve a patient centered approach there may be some reoccurring themes that run through the care that can be provided.

Case Scenarios

Patient presents with concerns over Dementia Mable 84 attends with her daughter – they have concerns over general short term memory loss Appointments might be used for: 1.

2.

3.

4.

5.

6.

Completion of MiniACE by Practice nurse Review of collateral information from family and patient Discussion re diagnosis and onward referral for investigations / Ct scan where applicable Review of medication and resource options Reviewing advanced care planning documentation Reviewing medication benefits if used.

Outcome – Alzheimer’s Disease diagnosed, driving assessment completed, medication’s altered ( amitriptyline stopped) Advanced care plan written, Referral to Alzheimer’s Society.

Patients with suspected heart failure Rawiri 68 presents with a 3 month history of increasing shortness of breath when walking over 100m and also at night. PMH IHD. Lives with his wife.

Appointments might be used for : 1.

2.

3.

4.

5.

6.

7.

8.

Clinical review and referral for investigations Discussion re diagnosis – possible referral to cardiology or in house care Formulation of a patient/whānau centered care plan Pharmacist review of medication – risks of polypharmacy Health Coach input to look at exercise and healthy eating.

Practice nurse review of care plan objectives Monitoring of heart failure levels – New York scale Advanced care planning if appropriate

Outcome: CCF confirmed, blood tests undertaken and referral for echo made, medication commenced.

Care plan written in conjunction with patient and allied health involved to support his independence at home a CCC referral made ; mobility factors identified as barrier to accessing effective health care and therefore Parking permit applied for.

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