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Counties Manukau District Health Board – Community & Public Health Advisory Committee Agenda

Counties Manukau District Health Board Community & Public Health Advisory Committee Meeting Agenda Wednesday, 19 August 2015 at 1.30pm – 4.30pm, Manukau Boardroom, CM Health Board Office, 19 Lambie Drive, Manukau Time Item

1.30pm 1. Welcome

1.30 – 1.40pm 2. Governance 2.1 Attendance & Apologies 2.2 Disclosure of Interests/Specific Interest 2.3 Confirmation of Public Minutes - 8 July 2015 2.4 Action Items Register

1.40 – 2.15pm

3. Presentation 3.1 Integrated Care presentation Manukau Locality (Susan Fryer & Fonofili Tafea)

2.15 – 2.45pm

4. Population Health Update 4.1 Asian Health Demography (Dr Simon Thornley)

Afternoon Tea 3.00 –3.50pm

3.50 – 4.20pm

5. Director of Primary Health & Community Services Report (Benedict Hefford) 5.1 Glossary, Contents & Executive Summary 5.2 National Health Targets 5.3 Adult Rehabilitation & Health of Older People 5.4 Primary Health 5.5 Child Youth & Maternity 5.6 Mental Health & Addictions 5.7 Intersectoral Initiatives 5.8 Progress with Systems Integration 5.9 Financial Report 5.10 Locality Reports – Social Services Integration in Otara/Mangere (Sarah

Marshall)

4.20 – 4.25pm 6. Resolution to Exclude the Public

4.25 – 4.30pm

7. Confidential Items 7.1 Confirmation of Confidential Minutes - 27 May 2015 & 8 July 2015

Next Meeting: 30 September 2015

Manukau Boardroom, CM Health Board Office, 19 Lambie Drive, Manukau

Counties Manukau District Health Board – Community & Public Health Advisory Committee 19 August 2015 2

BOARD MEMBER ATTENDANCE SCHEDULE 2015 – CPHAC Name

21 Jan Feb 4 Mar 15 Apr 27 May June 8 July 19 Aug 30 Sept Oct 11 Nov 16 Dec

Lee Mathias (Board Chair)

No

Mee

ting

No

Mee

ting

No

Mee

ting

Colleen Brown

X

Sandra Alofivae (CPHAC Chair)

X X

David Collings

* * * *

George Ngatai

X X X X

Dianne Glenn

X

Reece Autagavaia

X

Mr Sefita Hao’uli

X

Ms Wendy Bremner

X

Mr Ezekiel Robson

Mr John Wong

Anae Arthur Anae**

* no longer on this Committee ** newly appointed to Committee from 19 August.


COMMITTEE MEMBERS’ DISCLOSURE OF INTERESTS

19 August 2015

Member Disclosure of Interest

Dr Lee Mathias, Chair • Chair Health Promotion Agency • Chairman, Unitec • Deputy Chair, Auckland District Health Board • Director, Health Innovation Hub • Director, healthAlliance NZ Ltd • Director, New Zealand Health Partners Ltd • External Advisor, National Health Committee • Director, Pictor Limited • Advisory Chair, Company of Women Limited • Director, John Seabrook Holdings Limited • MD, Lee Mathias Limited • Trustee, Lee Mathias Family Trust • Trustee, Awamoana Family Trust • Trustee, Mathias Martin Family Trust

Colleen Brown • Chair, Disability Connect (Auckland Metropolitan Area)

• Member of Advisory Committee for Disability Programme Manukau Institute of Technology

• Member NZ Down Syndrome Association • Husband, Determination Referee for Department of

Building and Housing • Chair IIMuch Trust • Director, Charlie Starling Production Ltd • Member, Auckland Council Disability Advisory Panel

Sandra Alofivae

• Member, Fonua Ola Board • Board Member, Pasefika Futures • Board Member, Housing New Zealand

Dianne Glenn

• Member – NZ Institute of Directors • Member – District Licensing Committee of Auckland

Council • Life Member – Business and Professional Women

Franklin • Member – UN Women Aotearoa/NZ • Vice President – Friends of Auckland Botanic

Gardens and Member of the Friends Trust • Life Member – Ambury Park Centre for Riding

Therapy Inc. • CMDHB Representative - Franklin Health


Forum/Franklin Locality Clinical Partnership • Vice President, National Council of Women of New

Zealand • Member, Disabled Women’s Group • Member, Pacific Women’s Watch (NZ) Ltd • Justice of the Peace

George Ngatai

• Arthritis NZ – Kaiwhakahaere • Chair Safer Aotearoa Family Violence Prevention

Network • Director Transitioning Out Aotearoa • Director BDO Marketing • Board Member, Manurewa Marae • Conservation Volunteers New Zealand • Maori Gout Action Group • Nga Ngaru Rautahi o Aotearoa Board

Reece Autagavaia • Member, Pacific Lawyers’ Association

• Member, Labour Party • Member, Auckland Council Pacific People’s Advisory

Panel • Member, Tangata o le Moana Steering Group • Employed by Tamaki Legal • Board Member, Governance Board, Fatugatiti Aoga

Amata Preschool

Sefita Hao’uli

• Trustee Te Papapa Pre-school Trust Board • Member Tonga Business Association & Tonga

Business Council • Member ASH Board • Board member, Pacific Education Centre Advisory roles: • Tongan Community Suicide Prevention Project (MoH) • Tala Pasifika (NZ Heart Foundation Pacific Tobacco

Control) • Member Pacific People’s Advisory Panel, Auckland

Council Consultant: • Government of Tonga: Manage RSE scheme in NZ • NZ Translation Centre: Translates government and

health provider documents. • Promotus GSL on Rheumatic Fever campaign (HPA) • Taulanga U Society Rheumatic Fever Innovation

project (MoH)


Ezekiel Robson

• Department of Internal Affairs Community Organisation Grants Scheme Papakura/Franklin Local Distribution Committee

• Be.Institute/Be.Accessible ‘Be.Leadership 2011’ Alumni

• Member, CM Health Patient & Whaanau Centred Care Consumer Council

Wendy Bremner

• CEO Age Concern Counties Manukau Inc • Member of Health Promotion Advisory Group (7 Age

Concerns funded by MOH) • Member Interagency Suicide Prevention Group

John Wong

• Director, Asian Family Services at The Problem Gambling Foundation of New Zealand (PGF), also part of the PGF national management team

• Member, National Minimising Gambling Harm Advisory Group

• Chairman and Trustee, Chinese Positive Ageing Charitable

• Chairman, Chinese Social Workers Interest Group of the Aotearoa New Zealand Association of Social Workers

• Chairman, The Asian Health network of East Health Trust

• Founding member and council member, Asian Network Incorporation (TANI)

• Board member, Auckland District Police Asian Advisory Board

• Member, Auckland and Waitemata DHBs Suicide Prevention Advisory Group

• Board member, Manukau Institute of Technology (MIT) Chinese Community Advisory Group

• Member, CADS Asian Counselling Service Reference Group

• Member, Waitemata DHB Asian Mental Health & Addiction Governance Group

• Member, Older People Advisory Group (ACC) • Member, University of Auckland Social Work Advisory

Group • Member, Community Advisory Group of Health Care

New Zealand • Member, Auckland Regional Public Health Service –

Asian Public Health External Reference Group Arthur Anae

• Councillor, Auckland Council • Member The John Walker ‘Find Your Field of

Dreams’


COMMUNITY & PUBLIC HEALTH ADVISORY COMMITTEE MEMBERS REGISTER OF DISCLOSURE OF SPECIFIC INTERESTS

Specific disclosures (to be regarded as having a specific interest in the following transactions) as at 19 August 2015 Director having interest Interest in Particulars of interest Disclosure date Board Action Mr George Ngatai

CMH Quit Bus Mr Ngatai is a Director of Transitioning Out Aotearoa who is a partner provider along with CMDHB and Waitemata PHO in the Quit Bus.

26 March 2014 That Mr Ngatai’s specific interest is noted and the Committee agree that he may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Mr Sefita Hao’uli

Rheumatic Fever national campaign

Mr Hao’uli is currently undertaking some work with the Ministry of Health on the Pacific campaign on Rheumatic Fever.

Updated 21 January 2015

That Mr Hao’uli’s specific interest is noted and the Committee agree that he may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Mr Geraint Martin

Renewal of the Regional After Hours Agreement

Mr Martin’s wife is the Executive Director of Takanini Care Medical Services Limited Partnership. The company comprises 2 A&M clinics and 2 general practices at the same location.

21 May 2014 and 20 August 2014

That Mr Martin’s specific interest is noted and the Committee agree that he may participate in the deliberations of the Committee in relation to this matter because he is able to assist the Committee with relevant information, but is not permitted to participate in any decision making.

Ms Colleen Brown Richmond NZ Trust Ltd Ms Colleen Brown has been involved with the family involved with this Trust.

22 October 2014 That Ms Brown’s specific interest is noted and the Committee agree that she may remain in the room and participate in any deliberations of the Committee in relation to this matter because she is able to assist the Committee with relevant information, but is not permitted to participate in any decision making.


Director having interest Interest in Particulars of interest Disclosure date Board Action Mr Sefita Hao’uli Alliance Health+

Mr Hao’uli is currently undertaking some work for AH+.

4 March 2015 That Mr Hao’uli’s specific interest is noted and the Committee agree that he may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Dr Lee Mathias Otahuhu Boundary Change Dr Mathias is the Deputy Chair of ADHB.

4 March 2015 That Dr Mathias’ specific interest is noted and the Committee agree that she may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Ms Dianne Glenn

Auckland Region Public Health Service update report

Ms Glenn is a member of the District Licensing Committee of Auckland Council

15 April 2015 8 July 2015

That Ms Glenn’s specific interest is noted and the Committee agree that she may remain in the room and participate in any deliberations of the Committee but is not permitted to participate in any decision making.

Ms Margie Apa Integrated Home & Community Support Services Redesign – Minister’s Briefing

Ms Apa is Chair of the Northern Presbyterian Support Services Network who are a current provider of home-based services.

8 July 2015 Ms Apa specific interest is noted and the Committee noted that she will excuse herself from the room whilst this item is discussed.


Minutes of the meeting of the Counties Manukau District Health Board

Community & Public Health Advisory Committee Wednesday 8 July 2015

held at Counties Manukau Health Boardroom, 19 Lambie Drive, Manukau

commencing 1.30pm

COMMITTEE MEMBERS PRESENT: Dr Lee Mathias (Board Chair & acting Committee Chair) Mr David Collings Ms Dianne Glenn Ms Wendy Bremner Mr Ezekiel Robson Mr John Wong

ALSO PRESENT:

Mr Geraint Martin (Chief Executive) Mr Benedict Hefford (Director, Primary Health & Community Services) Ms Margie Apa (Director, Strategic Development) Ms Karyn Sangster (Chief Nurse Advisor, Primary & Integrated Care) Charlie Saunders, Franklin Family Support attended the Public section of the meeting.

APOLOGIES: Apologies were received and accepted from Ms Colleen Brown, Mr George Ngatai, Ms Sandra Alofivae, Mr Apulu Reece Autagavaia, Mr Sefita Hao’uli, Dr Campbell Brebner and Mr David Collings (for leaving early).

WELCOME The Chair opened the meeting by welcoming everyone present. 2.2 DISCLOSURES OF INTERESTS The Committee noted that as from 30 June 2015 Dr Mathias is no longer a Director of healthAlliance (FPSC) Ltd and as from 1 July 2015 is a Director of NZ Health Partnerships Ltd. The Committee also noted Ms Dianne Glenn is a Member of the Auckland Disabled Women’s Group, a Member of the Pacific Women’s Watch (NZ) Ltd and a Justice of the Peace. 2.2 SPECIFIC INTERESTS The Committee noted Ms Dianne Glenn’s specific interest in relation to Item 5.4 on this agenda and Ms Margie Apa’s specific interest in relation to Item 5.1 on this agenda. 2.3 ACRONYMS The acronym list was noted with no amendments.


2.4 CONFIRMATION OF PREVIOUS MINUTES Confirmation of the public minutes of the Counties Manukau District Health Board Community & Public Health Advisory Committee meeting held 27 May 2015. Resolution (Moved Mr John Wong/Seconded Ms Wendy Bremner) That the public minutes of the Counties Manukau District Health Board Community & Public Health Advisory Committee meeting held on 27 May be approved. Carried 2.5 ACTION ITEMS REGISTER Resolution (Moved Dr Lee Mathias/Seconded Ms Dianne Glenn) That the Action Items Register of the Counties Manukau District Health Board Community & Public Health Advisory Committee be received. Carried 3.0 RESOLUTION TO EXCLUDE THE PUBLIC The individual reason to exclude the public was noted. Resolution (Moved Ms Dianne Glenn/Seconded Mr David Collings) That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000 the public now be excluded from the meeting as detailed in the above paper. Carried 1.42pm Public excluded session. 2.20pm Open meeting resumed. 5. HEALTH OF OLDER PEOPLE Ms Dana Ralph-Smith, GM Adult Rehabilitation & Health of Older People took the Committee through her presentation. A copy of the presentation is available on the CMH website. Ms Ralph-Smith gave an overview of the Adult Rehabilitation & Health of Older People Service. 6. POPULATION HEALTH UPDATE Dr Doone Winnard, Clinical Director, Population Health took the Committee through her presentation. A copy of the presentation is available on the CMH website.


6.1 Life Expectancy in CM Health Life expectancy at birth in 2014 refers to the average number of years that a new born child is expected to live, if they are born now and experience the 2014 age specific mortality rates over the rest of their life. The overall picture is one of continued gain with the gap for Maaori narrowed but there has been a flattening of life expectancy trends in the last two years and the gaps remain wide – approximately 9years for Maaori and 6years for Pacific if compared with CM Health non-Maaori/non-Pacific. There is ongoing need to incorporate equity considerations in all decisions and implementation processes. The specific steps to address equity should be explicitly defined as part of the core components of business planning and decision making. Dr Winnard stated that an important issue going forward will be preventing over diagnosis and over treatment and that this will be an issue we will hear more about in the next 5 years. Over diagnosis/over screening & over prescribing has negative impacts on health. Dr Winnard undertook to come back with a paper that would unpick this issue a little further and which would help inform our approach to things like screening programmes and initiatives that are effectively screening programmes, which require an understanding of the whole pathway and the potential benefits and harms. Ms Bremner commented that older people tend to spend less on oral health and hearing and that there has been a link between hearing loss and reduced cognitive ability and asked if there has been a cost benefit analysis undertaken around actually spending more on those issues to help prevent other illnesses. Dr Winnard advised that there has not (as far as she is aware) but would provide some information on this for the next CPHAC meeting. 6.2 NZ Health Survey Results for CM Health Population The biggest increase in obesity has been in young women coming into child-bearing age (15.8% in 2006/07 compared to 30.7% for women 15-24 years). (Mr David Collings departed at 3.08pm) Counties Manukau children were also less likely to meet recommendations for fruit and vegetable intake and sedentary behaviour (ie) TV watching, than the national picture. Obesity has been identified as a priority by the regional Child Health Network and fits with the First 2000 Days and a focus on the Best Start in Life. When asked about what they thought about their child’s weight, only a quarter as many parents thought their child was overweight (10 %) compared with the proportion of children who were measured as overweight or obese (40 %). This is similar to the quantum of difference for adult perceptions of their weight in the historical Let’s Beat Diabetes (LBD) surveys. Access to oral health services for adults is an ongoing issue. Dr Winnard undertook to provide some evidence to the Committee about the links between poor oral health and heart disease. 6.3 Birth & Delivery Trends for Selected CM Health Population Groups Dr Winnard advised that the Asian population living in Counties Manukau is currently our fastest growing ethnic sub-population and is projected to continue to be our fastest growing in the next decade. Within the Asian population between the census in 2006 and in 2013, the Indian population grew proportionately from 41% to 46.5%. Approximately 30% of our Indian population live in Papatoetoe, 25-28% in Howick, 19% in Manurewa and 7% in Papakura.


Dr Winnard also advised that births for Indian women have been trending upward with an overall 20.7% increase in babies born to Indian women from 2010- 2014. The largest number of Indian women giving birth lived in Papatoetoe followed by Manurewa and Howick however, Papakura has had the largest percentage growth of Indian women giving birth over the 5 year period with a 93% increase. Dr Winnard commented on the Youth 2000 Survey Series which shows there has been a decrease in risk taking behaviours in young people (ie) smoking and alcohol and undertook to share this information with the Committee at an upcoming meeting. 6.4 Update on Psychoactive Substances Currently there are no approved psychoactive products on the NZ market. Development of a local Approved Products Policy (LAPP) by Auckland Council has restricted the location of licensed retail premises, exclusion zones. For example, they are not allowed within 500m of a school teaching students year 7 and above or within 500m of a mental health or addiction treatment centre, not allowed in areas of high social-economic deprivation (declines 8-10). Council appear to have worked very closely with government stake holders and there are very few areas where people will be able to set up and sell products. The Chair thanked Dr Winnard for her update on population health issues for Counties Manukau Health. 7.0 RESOLUTION TO EXCLUDE THE PUBLIC The individual reasons to exclude the public were noted. Resolution (Moved Dr Lee Mathias/Seconded Ms Wendy Bremner) That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000 the public now be excluded from the meeting as detailed in the above paper. Carried 3.35pm Public excluded session. 4.13pm Open meeting resumed. 9.0 DIRECTOR’S REPORT The Director’s Report was taken as read. 9.1 Progress with Systems Integration Ms Claire Naumann and Dr Harry Rea took the Committee through their presentation. A copy of the presentation is available on the CM Health website. There are now over 12,000 patients enrolled in the ARI programme. If we reach 40,000 patients we will start to see a change in the acute demand curve. There are a lot of moving parts to this


and working in partnerships is critical. It is still very much work in progress but what has been achieved to date is extraordinary and we are starting to see some impacts (ie) we have only had 2 dot days this year. Self-management support is aiming for 50,000 patients. Appendix 2 – Community Pharmacy Services Agreement Mr Trevor Lloyd, Portfolio Manager, Pharmacy Service took the Committee through this paper. The driver nationally has been to move away from paying for prescriptions to be filled and handed over the counter to a service that helps people with adherence and poly-pharmacy issues. That has not been easy to implement. Pharmacy LTC service – this is where pharmacists focus on the top 5% of the population, walk alongside the patients, talking about what was causing the problems and come up with solutions. Some pharmacies are doing really well and working at the highest level, top 5-10%, there is a lot in the middle and some at the bottom that aren’t doing anything more than enrolling and handing over medicines. Pharmaceutical margins – pharmacies make a 1.07% margin, but not evenly spread. The really cheap medicines (50% of the medicines) are dispensed at a 4% loss (4% of a maximum of $5). More expensive medicines attract a 5% margin and they can make as much as $100 off that dispensing at a margin. Once averaged out pharmacies are making 1.07%. The problem is if a pharmacy dispenses a lot of cheap medicines, they are losing quite a bit whereas if you have a pharmacy close to a hospital where there are a lot of cancer treatment prescriptions coming through, they are sitting pretty. Need to readdress the way the margins are paid. There has been a lot of activity around the margins recently and the Pharmacy Guild is currently focusing on whether to discontinue the contract. Immunisation As at 30th June, 95% of 8month old babies immunised, 91% Maaori babies. June saw 93% Maaori babies immunised. Resolution (Moved Dr Lee Mathias/Seconded Ms Wendy Bremner) That the Community & Public Health Advisory Committee receive the report of the Director Primary Health & Community Services Carried The Chair closed the meeting at 5.00pm. The minutes of the Counties Manukau District Health Board Community & Public Health Advisory Committee meeting held 8th July 2015 be approved. (Moved /Seconded ) Acting Chair Dr Lee Mathias Date

Items once ticked complete and included on the Register for the next meeting, can then be removed the following month.


Community & Public Health Advisory Committee Meeting – Action Items Register – 19 August 2015

DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

8.7.2015 4.0 Update from Auckland Regional Public Health Service every 6 months on current issues.

3 February 2016 Mr Hefford

22.10.14 4.0 The Committee would like to hear from some of the staff/people out in the community at the cutting end of change who are actually doing the work (ie) where they’re at with their refreshed job descriptions, the changes in the traditional models, the authority and accountability that’s come with this change - 20min presentations spread over a few months. Some examples given were: a nurse practitioner doing work on a marae, a district nurse, a practice nurse doing care coordination and how things are different in practices now.

19 August

Ms Sangster

26.11.2014 5.0 Mr Nia Nia to provide an update on the NHC integrated service agreement work.

Pending Mr Hefford/Ms Apa

Deferred pending further work being undertaken.

15.4.2014 4.4 Mental Health & Addictions – 2016 suicide prevention plan to be presented to CPHAC when available.

11 November Mr Hefford/Ms Ahern

27.5.2015 3.2 Update on the ARI programme from the Franklin Primary Care Practices

Early 2016 Ms Sangster

27.5.2015 4.1 Asian health planning /Asian health data reporting, quantifying our various Asian sub-populations, language competency information of our Asian sub-populations.

19 August

Dr Winnard

8.7.2015 6.1 Population Health Update – cost benefit analysis on oral health & hearing. Over diagnosis, over screening & over prescribing = bad health. Paper to unpick the issues which

30 September 11 November

Dr Winnard Dr Winnard

Items once ticked complete and included on the Register for the next meeting, can then be removed the following month.


DATE ITEM ACTION DUE DATE RESPONSIBILITY COMMENTS/UPDATES COMPLETE

will help inform us how to prioritise certain screening programmes (ie) bowel cancer screening. Oral health – evidence that links poor oral health leads and heart disease. Youth 2000 Survey Series results which shows there has been a decrease in risk taking behaviours in young people (ie) alcohol, smoking

30 September 30 September

Dr Winnard Dr Winnard


Counties Manukau Health Community & Public Health Advisory Committee

Overview of the Asian Demography and Selected Health Indicators in the CM Health District

Recommendation It is recommended that the Community & Public Health Advisory Committee: Receive this report as an overview of the demography and introduction to the health status of Asian people who live in CM Health district. Prepared and submitted by Simon Thornley, Public Health Physician, Population Health Team (with input from Doone Winnard, Mildred Lee, Wing Cheuk Chan, Kar Po Chong and Marianne Scott). Purpose This paper has been prepared in response to questions from CPHAC about the demography and health status of the Asian populations who live in the CM Health district. Background About a quarter of the CM Health district population self-identify as ‘Asian’. This group is diverse and has differing health needs. This paper summarises some of the information that the Population Health team has readily available as context for policy and strategic decision making. Summary The Asian population living in the CM Health district represents a quarter of all residents in the area, and is likely to grow, owing to immigration trends. Nearly half of the estimated 110,100 people identified as Asian in the CM Health population in 2013 are Indian, while a third are Chinese. Asian people living in in the CM Health district:

• have a high proportion of people in the late teens to thirties age groups, with fewer older people than the general population

• tend to live in urban regions in the CM Health district (Indian: Papatoetoe, Ormiston and surrounding suburbs, and Mangere South; Chinese: Eastern suburbs such as Ormiston, Millhouse, Meadowland, Highland Park and Murvale

• have a higher average level of formal education, and access to the internet, compared to other ethnic groups

• have older people of Chinese, Korean and Indian ethnicities with relatively limited ability to speak English.

Selected health indicators The life expectancy of people identified as Asian in CM Health is higher than NZ European/Other ethnic groups. Health status was assessed for diabetes prevalence and oral health in children:


• Indian people have a high age-specific prevalence of diabetes (similar to Pacific, who have the highest levels), with Chinese prevalence slightly higher than ‘NZ European and Other’ ethnicities who are lowest prevalence.

• In 5 year old Auckland children during 2014 (n = 3,072), Chinese and Indian burden of dental caries (mean number of decayed, missing from caries, or filled primary teeth: 1.9 and 1.5 respectively) were about mid-way between New Zealand European and Other (mean 0.7; lowest), and Pacific (mean 3.2; highest) ethnic groups.

At a clinical level, Asian people have been noted in published research to be reluctant to engage in advance care planning. In New Zealand, local palliative care research has identified the following issues as important in providing end of life care to Asian populations.

• family roles in decision-making, • a perceived need to ‘do everything’, • and a reluctance to discuss death and dying issues. 1

Ethnicity data collection In health, there are two main methods available for reporting ethnic group information:

• for most health reports ethnicity data is prioritised so that we can count people only once for the purposes of funding and planning services; or where

• reporting ethnicity is total response where an individual who reports several different ethnic groups is counted in each group they belong to, so they may be counted more than once, resulting in total numbers that add up to more than 100% of the group

In this report, data is available from different sources, with generally prioritised ethnicity used, since it is the standard for the health sector. Important issues in 2015 related to ethnicity reporting that affect Asian health information are:

• some data sets have coding limited to level 1 only (Maori, Pacific, Asian, NZ European/Other) that does not distinguish the different health issues sub groups; and

• misclassification may also affect ethnic group recording in health care data, where people who identify as ‘Asian’ may be instead, for example, entered as ‘NZ European/Other’.

The level at which ethnicity is recorded in health systems is likely to change in the future, which would allow accurate capture of more detailed ethnicity coding, to include Asian subgroups. CM Health staff are working with WDHB and ADHB colleagues to clarify from the Ministry of Health about how these changes will be implemented. Work is also being undertaken to identify and rectify misclassification, where recorded ethnicity differs from how people self-identify.

1 Frey, RA ; Raphael, D ; Bellamy, G ; Gott, M. Advance care planning for Māori, Pacific and Asian people: the views of New Zealand healthcare professionals. Health and Social Care in the Community, 2014, 22 (3), pp. 290 - 299


Report Detail Background

Classification of ethnicity Analysis of Asian health status is dependent on the detail of reporting of ethnicity. In the NZ health sector, ethnicity data collection follows a hierarchical structure, with increasing detail at higher coding levels.2 At present, in the health sector, data is collected up to level 2, with level 3 and 4 only available from the census. For example, a Sinhalese person from Sri Lanka, will, ideally, have their ethnicity coded as:

• Level 1: ‘Asian’ (from: ‘European’, ‘Māori’, ‘Pacific Island’, ‘Asian’, and ‘Other ethnic group’) • Level 2: ‘Other Asian’ (~52 codes available, including Indian and Chinese) • Level 3: ‘Sri Lankan’ (~72 codes available), and • Level 4: ‘Sinhalese’ (~360 codes available).

Two main methods are available for reporting ethnic group information. For most health reports ethnicity data is prioritised so that we can count people only once for the purposes of funding and planning services. This means that an individual is classified as ‘Maaori’ if that person reports several ethnic groups in which Maaori is one. The next highest priority is given to Pacific people, then Asian groups, with Indian prioritised over Chinese. The classifications of people who select only one ethnic group remain unaffected by these different methods. The other main method of reporting ethnicity is total response. In this case an individual who reports several different ethnic groups is counted in each group they belong to so they may be counted more than once. This means total numbers add up to more than 100% of the group. In fact in the Census 2013 usually resident population data for people identifying as Asian, there is only a small difference between numbers for prioritised and total response groups In this report, data is available from different sources, with generally prioritised ethnicity used, since it is the standard for the health sector. When smaller Asian population data is reported (beyond Chinese and Indian), this is generally total response ethnicity. Much of the data reported here relates specifically to people who live in CM Health district, whereas some information is drawn from reports that describe the characteristics of Asian people living in Auckland, where data is not available for CM Health. The distinction is pointed out under each section. The report is divided into three parts that describe: (1) the demography, (2) selected health status indicators for the Asian populations in CM Health district, and (3) future changes to the way ethnicity data is planned to be collected in the health sector. Part 1: Demography Asian people account for close to a quarter of all people living in CM Health district (24% in 2015). Asian people come from a variety of different geographic areas and have widely varying cultures and languages. The largest Asian ethnic groups in CM Health, based on Census 2013 total response ethnicity, consist of Indian and Chinese people. Indian people comprise 47% (almost half) and Chinese 34% (a third) of all ‘Asian’ people in the district (Figure 1). The next largest group is Filipino, who make-up 6% (~1/20 people) of Asian people in the CM Health district.

2 Ministry of Health. 2004. Ethnicity Data Protocols for the Health and Disability Sector. Wellington: Ministry of Health.


Figure 1. People of Asian ethnicity living in CM Health region (total response ethnicity; 2013 ‘Usually Resident’ population).

Age-sex structure The age and sex structure of the Asian population is derived from estimated resident population data with ethnicity prioritised. Figure 2 shows that the CM Health Asian population (a) is generally younger than the NZ European and Other population (b). The age structure of males is represented on the left, and women on the right. A higher proportion of men and women of ‘Asian’ ethnicity are present in the 15 to 34 year age group, with reciprocal changes in the proportions of older men and women, compared to ‘NZ European/Other’ groups.

Other Asian

Filipino


(a)

(b)

Figure 2. Overview of the age and gender distribution of (a) Asian people in CM Health, compared to (b) NZ European and Other groups (2014). Source: Census 2013, ‘estimated resident population’ projected to 2014 with prioritised ethnicity.

Female Female

Female


The age-sex structure for Indian and Chinese is similar, although, the Chinese population has fewer children aged 5 to 14 than the Indian,3 perhaps related to the one child policy enforced in the Peoples’ Republic of China.

Births In Counties Manukau district, the largest annual number of births is in Pacific, followed by NZ European/Other groups, with Maaori total numbers ranked third (Figure 3). Annual number of births for Indian, Chinese and Other Asian people, are each about one quarter the corresponding number for NZ European/Other groups. In recent years, Pacific, Maaori and NZ European/Other annual birth totals have declined in number, whereas Asian births have increased over the same period. Of the women who live in CM Health district, during 2014, Chinese are more likely than any other ethnic group to give birth in ADHB facilities (56.3%; 355/630), compared to 11.2% of Indian and 21.4% of Other Asian women.

Figure 3. Total number of annual births recorded for the Counties Manukau Health population (2010 to 2014), prioritised ethnicity. Source: NMDS data.

Language and education This information is derived from the 2013 census for the population of the CM Health district using total response ethnicity. Figure 4 shows the proportion of people from the largest Asian ethnic groups who speak English in the CM Health district, by age. In general, Asian people who live in CM Health have high levels of English ability at younger ages, but this falls to 40% or less in older Korean and Chinese peoples. Indian and Filipino people report higher proportions of English speakers at all

3 Friesen, W. Asian Auckland: The multiple meanings of diversity. Asia New Zealand Foundation. 2015


ages, compared to Chinese and Korean people. Conversely, older Asian people are more likely than younger ones to speak a selected language from their country of origin (Figure 5).

Figure 4. Proportion of Asian people who speak English, by age category. Source: Census 2013; CM Health usually resident population; total response ethnicity.

Figure 5. Proportion of Asian subpopulation able to speak selected native languages (Chinese: any Chinese dialect) Source: 2013 census; CM Health usually resident population; total response ethnicity.


Figure 6. Access to internet at home, and highest qualification level of ethnic groups in CM Health Source: 2013 census; prioritised ethnicity. When internet and education level are examined, Asian people in CM Health generally score higher than Maaori, Pacific, and NZ European/Other groups (Figure 6).

Geography and locality This information is derived from total response ethnic group from the 2013 census, ‘usually resident’ population. The number of people, identifying as Asian, living in each census area unit was divided into deciles (by count) and mapped (Figure 5).4 The map shows the CM Health district, divided by census area units (suburbs), and shaded by the decile of the total number of Asian people living within these units. Locality outlines are also present and labelled. The localities that have the highest density of people who identify as Asian are: Eastern (Pakuranga, Howick, Ormiston, Dannemora, Botany), Mangere (Mangere South), Manukau (Papatoetoe, Redoubt South). There are relatively few Asian people living in rural areas, Mangere bridge, Otara and Manukau central (Figure 7).

4 Maps are interactive and available online at the following URLs (best viewed in either a Mozilla Firefox or Google Chrome web browser): Total Asian : https://www.google.com/maps/d/edit?mid=z2VZcf4Y96j8.kZIDYVkxSqPY South Asian: https://www.google.com/maps/d/edit?mid=z2VZcf4Y96j8.kkMO509Gw8WM Chinese: https://www.google.com/maps/d/edit?mid=z2VZcf4Y96j8.koh0QF-be7AM&usp=sharing Filipino: https://www.google.com/maps/d/edit?mid=z2VZcf4Y96j8.klkvqPbNz0c8

https://www.google.com/maps/d/edit?mid=z2VZcf4Y96j8.kZIDYVkxSqPY

https://www.google.com/maps/d/edit?mid=z2VZcf4Y96j8.kkMO509Gw8WM

https://www.google.com/maps/d/edit?mid=z2VZcf4Y96j8.koh0QF-be7AM&usp=sharing

https://www.google.com/maps/d/edit?mid=z2VZcf4Y96j8.klkvqPbNz0c8


Figure 7. Distribution of Asian people in CM Health district, by census area unit and locality (2013 census; total response ethnicity). Densely populated Asian regions are represented by darker shades of maroon. Interactive maps are available online (see footnote). Indian and Sri Lankan (South Asian) people live in greatest numbers in Papatoetoe, Ormiston and surrounding suburbs, and Mangere South. In contrast, Chinese people are more densely populated in the Eastern locality, particularly in Ormiston, Millhouse, Meadowland, Highland Park and Murvale.

Immigration trends Asia is by far the most rapidly growing source of new migrants into Auckland. In the last 30 years, immigrants from Asia have increased in number 16 fold (Figure 8). In 2013, the highest proportion of new permanent resident approvals was from people who were born in the People’s Republic of China.5 However, for the CM Health district, a higher percentage of the Asian population identified as Indian in 2013 compared with the 2006 Census (41% in 2006, 47% in 2013) and a lower percentage as Chinese (38% in 2006, 34% in 2013). Also, the Filipino population is now larger than the Korean group (a reverse compared with 2006). Of the total-response Asian population in Census 2013, 73% were overseas born. Of those born overseas, half (52%) had been in NZ for ten or more years, while another quarter 5 to 9 years, and 4% had arrived in New Zealand less than a year before the census date. 5 Friesen, W. Asian Auckland: The multiple meanings of diversity. Asia New Zealand Foundation. 2015

Eastern

Manukau

Franklin

Mangere

Otara


Figure 8. Immigrants settling in Auckland, by year and region of the world. Source: Friesen, W. Asian Auckland: The multiple meanings of diversity. Asia New Zealand Foundation. 2015 Living in areas of socioeconomic deprivation

‘NZDep’ ranks small areas according to their level of socioeconomic deprivation, which is updated after each Census.6 The measure ranks suburbs on a scale according to residents’ reports of such factors as: access to the internet, income, employment, qualifications, housing tenure, living space and transport. Overall, 22% of the total-response Asian usually resident Census 2013 population were living in NZDep 9 and 10 (the most socioeconomically deprived areas), but there was a ‘bimodal’ distribution of the Asian population, with a peak in decile 3, and another in decile 9 (Figure 9). If ethnic group were unrelated to socioeconomic status, the expected proportion of Asian people who live in each decile would be 10% within each category (NZDep is a relative, rather than absolute, measure of socioeconomic status).

6 An interactive map of NZdep13 by suburb is available at: http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11254032 (accessed 3/8/2015)

http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11254032


Figure 9 Counties Manukau Asian ‘usually resident’ Census 2013 population by NZDep2013 deciles

Part 2: Selected Health Status Indicators

Life expectancy Figure 10 shows life expectancy at birth, calculated from observed mortality rates in the 2012 to 2014 CM Health ‘constructed population’, by ethnicity. The ‘constructed population’ consists of people who have accessed health services and live in the CM Health district. Such health services include, for example: PHO enrolment, having a laboratory test, being treated in hospital, or being dispensed a drug. The demographic profile of the ‘constructed population’ is very close to census estimates of the total population. The constructed population is used here because we do not have an estimated resident population for CM Health district in which Indian and Chinese survival is able to be calculated.


65

70

75

80

85

90

95

Maa

ori

Paci

fic

Indi

an

Chin

ese

Oth

er A

sian

NZ

Euro

pean

/ O

ther

Maa

ori

Paci

fic

Indi

an

Chin

ese

Oth

er A

sian

NZ

Euro

pean

/ O

ther

Male Female

Life

exp

ecta

ncy

(yea

rs)

CM Health prioritised ethnicity, by gender

Figure 10. Life expectancy for CM Health residents (2012 to 2014). The dashed blue bar indicates the CM Health population average. Life expectancy is an estimate of the expected years of life lived at birth, calculated by applying observed age-specific death rates to a theoretical population. It is generally considered a useful summary measure of population health, often used to compare and rank the health of populations. Men tend to live less long than women, so life expectancy is divided by both ethnicity and gender. Maaori and Pacific people in the CM Health population have the lowest life expectancy, with Indian, Chinese and Other Asian groups higher than NZ European/Other groups. A limitation of using life expectancy is that it does not account for high morbidity, low mortality conditions, such as mental illness or arthritis. Chinese are known to have high longevity, however, it is a little surprising that Indian life-expectancy is so high, given that this group has a high prevalence of high morbidity conditions such as cardiovascular disease and diabetes. Part of the reason for this finding may be related to the ‘healthy migrant effect’ (people who migrate here bringing their good health with them), or Asian migrants returning to their country of birth, once they are diagnosed with a life limiting illness.

Diabetes prevalence Diabetes is an important disease, due to its high prevalence, the high likelihood of complications, high mortality, and significant costs associated with treatment. The prevalence of diabetes can be calculated by aggregating diabetes-related test results, available in the Auckland region. Figure 11 shows the prevalence of diabetes in Auckland by age and (prioritised) ethnic group. Diabetes prevalence is strongly related to age, with prevalence increasing up to the age of 70 years, from a very low prevalence in the early 20s.


Pacific people have the highest prevalence of the disease (almost 1/3 of people aged 55 to 59 years and 45% in those aged 65 to 74 years); however, Indians also have a high prevalence. In contrast, Chinese people have a lower prevalence, similar to that of NZ European/Other groups (about 1/10 people age 55 to 59 years). People in the ‘Other Asian’ group have a prevalence similar to Maaori.

Figure 11. Diabetes prevalence, by age and ethnicity (Auckland, 2013). Source: TestSafe data, personal communication Wing Cheuk Chan.

Child health: dental caries Data were available for the mean number of decayed, missing and filled primary teeth (dmf) for five year old children in 2014, in those who had attended a clinic administered by the Auckland Regional Dental Service. Mean number of dmf was 0.7 in children in NZ European/Other groups, with the highest prevalence in Pacific children (3.2). Chinese and Indian children had levels of decay mid-way between these extremes, while children from ‘Other Asian’ groups had levels of decay similar to Maaori children (2.2) (Figure 12).


dmf (primary teeth)

Per

cent

of T

otal

0

20

40

60

80

0 2 4 6 8

mean =

1 Maori

mean =

2 Pacific

mean =

3 Indian

0

20

40

60

80

mean =

4 Chinese0

20

40

60

80

mean =

5 Other Asian

0 2 4 6 8

mean =

6 NZ Euro/Other

Figure 12. Histogram of total number of decayed, missing or filled teeth in the ARDS database, 2014, among 5 years olds, by ethnic group (n = 3,072). The vertical line within each sub-plot represents the mean for each ethnic group. Source: Auckland Regional Dental Service, analysed by Simon Thornley for Auckland Regional Public Health Service. Smoking prevalence Overall, smoking prevalence at the time of census 2013 for the prioritised Asian population, was estimated at 6.6%: the lowest of all large reported ethnic categories. Within this group, male smoking prevalence (11.7%) was much higher than female (1.8%). Mental Health Along with Pacific peoples, Asian groups have a much lower prevalence of receiving care for mental health disorders (this includes medications prescribed in primary care as well as secondary mental health and addiction service use) than Maaori and NZ European/Other groups. For further details see please refer to the following report: Populations who have received care for mental health disorders. Counties Manukau Health (2014) at http://www.countiesmanukau.health.nz/about-us/performance-and-planning/health-status-documents/

http://www.countiesmanukau.health.nz/about-us/performance-and-planning/health-status-documents/

http://www.countiesmanukau.health.nz/about-us/performance-and-planning/health-status-documents/


End of Life Care Asian patients' understanding of their illness and the decisions they make about their care are likely to be influenced by cultural factors. International research has found lower completion rates of advance care directives for ethnic minorities compared to European-based populations.7 8 A New Zealand survey of palliative providers found challenges for Maaori, Pacific and Asians related to a number of cultural issues including:

• family roles in relation to decision-making, • a perceived need to ‘do everything’, • and a reluctance to discuss death and dying issues. 9

In navigating the process of providing end of life care, clinicians are recommended to consider the length of time a patient has lived in their adopted country and degree of acculturation. Identifying the role of family members in patient care, especially the family's process of decision making, is critical when information about a serious diagnosis is being conveyed to a patient and family. 10 Part 3: Ethnicity data collection Mandatory coding of at least one ethnicity to level 4 (detailed) is expected as part of an interim Health Identity Standard (HISO) released in 2014. This standard is intended to be evaluated in late 2015. This change in coding would allow more accurate analysis of Asian subgroups in health data. Currently, health information systems are not set up to store and output coding at this level (current coding is at level 2, which does not distinguish between smaller Asian subgroups). CM Health staff, with WDHB and ADHB colleagues, are seeking to clarify from the Ministry of Health how these changes will occur. Misclassification may also affect ethnic group recording in health care data, where people who identify as ‘Asian’ may be instead, for example, entered as ‘NZ European/Other’. CM Health staff are working with primary care practices to implement the ‘Ethnicity Data Audit Tool’ in the region, which aims to identify and rectify these errors.

7 Pietch JH, Braun KL. Autonomy, advance directives, and the patient self-determination act. In: Braun K, Pietsch JH, Blanchette PL, eds. Cultural issues in end-of-life decision making. Thousand Oaks, Calif: Sage, 2000:37-53. 8 Baker ME. Economic, political and ethnic influences on end-of-life decision-making: a decade in review. J Health Soc Policy. 2002;14:27-39. 9 Frey, RA ; Raphael, D ; Bellamy, G ; Gott, M. Advance care planning for Māori, Pacific and Asian people: the views of New Zealand healthcare professionals. Health and Social Care in the Community, 2014, 22 (3), pp. 290 - 299 10 Windsor JA, Rossaak JI, Chaung D, Ng A, Bissett IP, Johnson MH. Telling the truth to Asian patients in the hospital setting. NZMJ 28 November 2008, Vol 121 No 1286.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Windsor%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=19098952

http://www.ncbi.nlm.nih.gov/pubmed/?term=Rossaak%20JI%5BAuthor%5D&cauthor=true&cauthor_uid=19098952

http://www.ncbi.nlm.nih.gov/pubmed/?term=Chaung%20D%5BAuthor%5D&cauthor=true&cauthor_uid=19098952

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ng%20A%5BAuthor%5D&cauthor=true&cauthor_uid=19098952

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bissett%20IP%5BAuthor%5D&cauthor=true&cauthor_uid=19098952

http://www.ncbi.nlm.nih.gov/pubmed/?term=Johnson%20MH%5BAuthor%5D&cauthor=true&cauthor_uid=19098952

CPHAC: Asian demography and health status

Simon Thornley, Public Health Physician, on behalf of the Population Health Team

030

Summary

How many Asian people live in the district?

• What ethnic groups are meant by ‘Asian’?

• Age structure; birth rates; immigration; SES

• Language, education & internet access

• Where do Asian people live?

Health status • Life expectancy

• Diabetes prevalence

• Dental caries (children)

• Smoking prevalence

• Mental health

• End-of-life care

031

Demography (CM Health)

~ ¼ of CM Health population

032

Age structure (CM Health)

Female

033

Immigration trends (Auckland)

Source: Friesen, W. Asian Auckland: The multiple meanings of diversity. Asia New Zealand Foundation. 2015

034

English speaking, by age (CM Health)

Korean

Chinese Indian

Filipino

035

Education & internet (CM Health)

036

Geography (all Asian; CM Health)

Manukau

Eastern Otara

Mangere

Franklin

037

Life expectancy (CM Health)

65

70

75

80

85

90

95

Maa

ori

Pac

ific

Ind

ian

Ch

ines

e

Oth

er

Asi

an

NZ

Euro

pe

an /

Oth

er

Maa

ori

Pac

ific

Ind

ian

Ch

ines

e

Oth

er

Asi

an

NZ

Euro

pe

an /

Oth

er

Male Female

Life

exp

ect

ancy

(ye

ars)

CM Health prioritised ethnicity, by gender

038

Smoking prevalence (CM Health)

039

Diabetes prevalence (Auckland)

040

Dental caries 5 years (Auckland)

dmf (primary teeth)

Pe

rce

nt o

f T

ota

l

0

20

40

60

80

0 2 4 6 8

mean = 2.3

1 Maori

mean = 3.2

2 Pacific

mean = 1.5

3 Indian

0

20

40

60

80

mean = 1.9

4 Chinese0

20

40

60

80

mean = 2.2

5 Other Asian

0 2 4 6 8

mean = 0.7

6 NZ Euro/Other

041

End of life issues

Less likely to engage in advanced care directives (cf. European)

• Affected by length of stay in adopted country and acculturation.

Challenges

• Family decision making (roles)

• Desire to ‘do everything’

• Reluctance to discuss dying and death

042

Summary

Asian people ~ ¼ of CM health population

• Diverse but small number of groups dominate

• Indian >> Chinese >>> Filipino >> Korean

Young age structure; well educated & connected to internet

Long life expectancy

• diabetes high prevalence among Indians

• dental caries moderate

Smoking

• generally low %, but men >>> women

Cultural factors related to end-of-life 043


Counties Manukau District Health Board Community & Public Health Advisory Committee

Director’s Report Recommendation It is recommended that the Community & Public Health Advisory Committee receive the report of the Director Primary Health & Community Services. Prepared and submitted by: Benedict Hefford, Director Primary Health & Community Services Glossary of Terms

Acronyms Description A&D / AOD Alcohol and Drug ACP Advanced Care Plan AH+ Alliance Health Plus ARDS Auckland Regional Dental Service ARI At Risk Individuals ARPHS Auckland Regional Public Health Service ARRC Aged Related Residential Care AT&R Assessment, Treatment and Rehabilitation AWHHI Auckland Wide Healthy Housing Initiative B4SC Before School Checks CCM Chronic Care Management COPD Chronic Obstructive Pulmonary Disease CSW Community Support Worker DHS Director Hospital Services DNA Did Not Attend EOI Expression of Interest GAS+ Group A Streptococcal Positive GP General Practitioner hA healthAlliance HBSS Home Based Support Services HBT Home Based Community Team HHC Home Health Care HOP Health of Older People IDF Inter District Flows IFHC Integrated Family Health Centre IPIF Integrated Performance & Incentives Framework LTCF Long Term Conditions Facilities MOH Ministry of Health NGO Non-government organisation PHN Public Health Nurse POAC Primary Options to Acute Care PRIMHD Project for the integration of mental health data PSAAP Primary Services Agreement Amendment Protocol SUDI Sudden Unexplained Death of Infant VHIU Very High Intensive User VLCA Very Low Cost Access


Contents

1. Actions from Previous CPHAC Meetings 2. National Health and Integrated Performance & Incentives Framework Targets 3. Primary Health 4. Child, Youth and Maternity 5. Mental Health and Addictions 6. Adult Rehabilitation & Health of Older People 7. Intersectoral Initiatives 8. Progress with Systems Integration 9. Locality Reports 10. Financial Report

Executive Summary • The Integrated Performance and Incentive Framework target provisional results show that CM

Health has met the targets for More Heart and Diabetes Checks, Better Help for Smokers to Quit and Increased Immunisations at eight months and 24 months. PHO’s, Practices and CM Health have worked very hard to achieve these targets and were congratulated at the Alliance Leadership Team meeting. Although Quarter four results for cervical screening coverage are not yet available we are encouraged that the increased coverage of PHO enrolled populations may result in achievement of the CM Health cervical screening target of 75%. Efforts will continue to ensure the health target achievements continue to improve, are sustainable and become business as usual.

• The Mana Kidz Rheumatic Fever Prevention Programme was established in 2012. Data shows a reduction year on year since 2013 of the number of probable and confirmed rheumatic fever cases. In addition the Ministry of Health reported that CM Health has had a statistically significant reduction in rheumatic fever cases. Although attribution of this reduction could be argued, it is likely to be Mana Kidz which is having the biggest impact on rheumatic fever rates.

• It has been identified that tooth decay requiring fillings has been starting in high risk population groups as young as 18 months. The plan for 2015/16 is to focus on enrolments for babies at five months or earlier so an examination prior to their first birthday can occur with oral health education and preventative care being given. The target of enrolments of 85% of the population is to be achieved by 31 December 2015 and 95% by December 2016. A gap in age zero to two year olds has been identified, particularly with Maaori, Pacific and Asian populations.

• National and international evidence shows employment as a key part of mental health recovery. Workwise, in conjunction with Te Pou, Counties Manukau Health and Auckland DHB have commenced an initiative to improve employment outcomes for clients assessing adult mental health. The aim is to identify opportunities to improve service delivery, outcomes for clients and to ensure that the clinical/employment partnership approach is sustainable. This 12 month project commenced in May.

• The At Risk Individuals programme now has 99 practices across the district working within the model of care, with 12,193 patients enrolled in the programme. Phase two of the programme is currently being developed to provide a focus on quality improvement, palliative care, mental health, complex households, child health, frail elderly and diabetes.

• The Primary Health & Community Services Directorate came under budget for the past financial year by $6m mostly driven by reduced demand for aged Residential Care relative to a budget set to an over 65 population growth of 4%. While achieving this surplus there were a number of offsetting variances as the Localities and Community Integration activity increased.


5.2 National Health and Integrated Performance & Incentives Framework Targets

Target

14/15 Target

14/15 Q1

14/15 Q2

14/15 Q3

14/15 Q4

On Track

More Heart and Diabetes Checks

90% 91.1% 91.3% 91.2% 92.3% Yes

Better Help for Smokers to Quit

90% 98.0% 95.5% 95.1% 96.1% Yes

Increased Immunisations – 8 months

95% 95.0% 94.0% 93.0% 95.2% Yes

Increased Immunisations – 24 months

95% 96.0% 96.0% 95.0% 95.3% Yes

Cervical Screening Coverage 75% 70.0% 71.5% 71.4% N/a Improvement required

Table One: CM Health Performance for the National Health Target / Integrated Performance and Incentive Framework Targets to June 2015

PROGRESS Provisional results for Integrated Performance and Incentive Framework Measures target reporting show that CM Health has met the targets for More Heart and Diabetes Checks, Better Help for Smokers to Quit and Increased Immunisations at eight months and 24 months. Quarter four results for cervical screening coverage are not yet available although anecdotally PHOs are reporting increased coverage for their enrolled populations which we hope will result in achievement of the CM Health cervical screening target of 75%.

More Heart and Diabetes Checks

Historical Quarters* Current

Month

PHO 2015-Q1 2015-Q2 2015-Q3 Jun-15

Alliance Health Plus 90.5 89.9 92.0 91.8 East Health 90.8 91.1 90.4 91.4

NHC 89.4 88.6 87.7 90.0

ProCare 91.2 91.1 92.3 92.9 Total Healthcare 87.7 88.5 89.3 90.7 CMDHB 91.1 91.3 91.2 92.3 National 84.7 87.0 87.7 89.0 Target 90.0 90.0 90.0 90.0

*Quarterly data for PHO is MoH published Table Two: More Heart and Diabetes Checks Performance to June 2015


Graph One: CM Health Cardiovascular Disease Risk Assessment Performance at June 2015

Progress • The preliminary CM Health result for More Heart and Diabetes Checks for June is 92.3%. This is a

slight increase from last month at 90.5%. All PHOs have reached the 90% target by 30 June for the Total Population. CM Health met the target for Pacific (91.3%) and Asian (92.5%) populations however not for Maaori (88%), although this result is an improvement on the previous three quarters. The PHOs will continue to focus on improving performance for Maaori during the 15-16 year.

• PHOs received additional funding earlier in the year to maintain and increase the skills of practice nurses in phlebotomy to enhance collection of blood results for Cardio Vascular Disease Risk Assessment (HBA1c and Lipids). This funding has been used to upskill nurses to collect bloods within practices, enabling patients to have complete Cardio Vascular Disease Risk Assessments in the practice and reducing the risk of blood tests not being completed. Several have requested that any underspend be carried forward to the 15-16 year.

• A National Health Target GP Clinical Champion has been appointed from the 1st of July for six months to continue progressing key pieces of work and ensure performance is sustainable over the 15-16 year.

• PHOs are currently developing quality improvement plans for the Integrated Performance and Incentive Framework targets that detail what activity will be undertaken during the year in order to maintain current performance.

• CM Health Occupational Health Nurses wish to screen wellbeing in existing staff and are investigating offering Cardio Vascular Disease Risk Assessments as part of the package. We have begun discussions with the Ministry of Health about the use of the ANZACS-QI system which the District Health Boards are currently licensed for and which is used in the Coronary Care Unit. This enables electronic pre-population of the data and results to be sent back to the staff member’s GP for follow up.

• PHOs analyse the practice data weekly to determine which practices require assistance with the Cardio Vascular Disease Risk Assessment target and practice facilitators then connect with the practice to assist them to improve performance. This is currently done weekly in most PHOs. Benchmarking of performance is a driver for practices to lift their results.

• Cell group education sessions on Cardio Vascular Disease Risk Assessments are held for all PHOs. • The CM Health monthly Integrated Performance & Incentives Framework meetings include a focus

on the More Heart and Diabetes Checks target, where PHOs share issues and learning to assist each


other to achieve the targets. • PHOs actively facilitate sharing of successful initiatives with practice teams to assist poorer

performing practices. • PHOs continue to use practice advisors to assist practice staff to use the decision support tools and

to collect data for Cardio Vascular Disease Risk Assessments and Management. • Non face-to-face assessments are conducted with the assistance of Test Safe (laboratory results)

data. • Initiatives including after-hours clinics, nurse led clinics, weekend clinics and the provision of

transport for high needs patients are being offered by general practices. • Improved data collection with systems enhancements such as “Dr Info” – one click and

appointment scanner functions, queries and recall systems enable more accurate reporting of data and identification of patients who are overdue for an assessment.

• Exploration of the possibility of offering Cardio Vascular Disease Risk Assessments through pharmacies has begun. This would involve the use of Point of Care testing. Green Cross Health are leading this initiative and linking with both Roche and Enigma to develop a business case. This is based on identifying the populations who have not yet been screened and those who are currently under screened according to the National Guidelines.

• PHOs frequently link with Non-Government Organisations e.g. The National Heart Foundation for resources and advice regarding Cardio Vascular Disease Risk Assessments.

Better Help For Smokers To Quit

Historical Quarters Current

Month

PHO 2015-Q1

2015-Q2

2015-Q3

Jun-15

Alliance Health Plus 91.0 89.0 94.7 91.9 East Health 100.0 98.0 95.5 93.9 NHC 91.0 89.0 81.4 96.2 ProCare 102.0 99.0 99.7 101.3 Total Healthcare 93.0 93.0 90.1 89.4 CMDHB 98.0 95.5 95.1 96.1 National 88.0 89.0 88.6 90.1 Target 90.0 90.0 90.0 90.0

Table Three: Better Help for Smokers to Quit Performance to June 2015

Progress The preliminary CM Health result for Better Help for Smokes to Quit at the end of June is 96.1%, which is the result of a significant amount of work from the practices, PHOs and CM Health after the dip in performance during April and May. The target has been met for Maaori (95.1), Pacific (93.2) and Asian (96.9) populations. A letter has been written to the MoH raising PHO and CM Health concerns about the change to the target definition for the 2015-16 year which will have a significant impact on performance. In early June the Ministry of Health advised that two technical changes will be applied to the target, including removing the wording ‘seen by a health practitioner’ which removes the need for an adjustor and changing the numerator to 15 months rather than 12 months. PHOs estimated that this will result in a drop in performance of between 8% and 11%.


PHOs have agreed that sustainable activity and increased cessation support will be the focus for the 15-16 year. Quality improvement plans are in development and include targeted activities to improve the numbers of smokers quitting. Discussions have begun with the PHOs on setting a local Cessation Support target of 50% which would need to be achieved by June 2016. An outline of current activity to support smoking cessation and brief advice is provided below: • Call centre staff have been contacting patients to ask about smoking status and give brief advice and

offer cessation support. The additional funding has been used to increase this activity in order to reach the target.

• There is continued focus on provision of cessation support by general practice teams, PHOs and other key stakeholders, in particular to refer smokers to local cessation support services tailored to the CM Health population.

• The Primary Care smoking cessation coordinator is strengthening current work in practices to improve results and up-skill general practice staff in all areas of smoking cessation.

• Data is being obtained from Quitline to augment the cessation support numbers for CM Health. • Face-to-face consultations and group cessation sessions, with a focus on self-management are being

offered to patients through general practice and PHO support services. • Practice facilitators and PHO Smokefree Target Champions identify low performing practices and

encourage these practices to implement quality processes that will ensure sustainable activity. • The CM Health Integrated Performance & Incentives Framework clinical champion continues to

collaborate with and support PHOs and practice teams to achieve the Smokefree target. • All PHOs have representatives who attend the monthly CM Health Integrated Performance &

Incentives Framework meetings where the targets are discussed. This is a forum where issues and initiatives are shared amongst PHOs, the District Health Board and the clinical champions, to improve results for the Smokefree target.

• Monthly practice level data will be used to identify practices with high numbers of smokers so the Quit Bus can be sent to these areas to provide promotion and additional support.

Immunisations The current target is for 95% of children to be fully immunised by their milestone age of eight months, and 24 months. For the eight month target, CM Health is reported to have achieved 95% for Total Population, 97% for Pacific and 91% for Maaori showing an overall improvement on last month’s performance. The 24 month target is reported at 95% for Total Population, 98% for Pacific and 90% for Maaori showing a decline in Maaori rates. Strategies to sustain and improve the targets respectively are outlined as follows: • Strengthened engagement with the CM Health Maaori Unit • Continued targeted approach to engage and support Maaori whaanau to immunise on time. We are

exploring the use of local media editorials and examples of children suffering negative health outcomes when not immunised.

• Continuing with outreach immunisations services to follow-up hard to reach families / whaanau • The Immunisation Nurse Leader is working with PHOs to improve the timeliness of immunisation.


Cervical Screening

Total 3 year coverage at March 2015

Maori Pacific Asian European/Other

CMDHB 71.4% 61.5% 73.4% 62.0% 79.8% National 76.3% 62.6% 72.8% 62.6% 82.2%

Table Four CM Health 3 Yearly Cervical Screening Coverage to March 2015 Source: National Cervical Screening Programme Register – women aged 25-69 years Note: Monthly reporting on cervical screening coverage at PHO level is not available.

Progress PHOs and CM Health have been working closely together over the past month to improve cervical screening coverage, in particular for Maaori, Pacific Island and other high needs women who are overdue for their three yearly cervical smear test. Focus on cervical screening has increased substantially over the last three months which should begin to show increased cervical screening coverage and achievement of the CM Health 75% target. A summary of current planning and activities is provided below:

• Delivery on key actions in the CM Health Cervical Screening Action Plan and PHO-level cervical

screening action plans. These activities include: • Identification and opportunistic screening of women attending clinics for other reasons who

are overdue for a smear. More members of the practice team are now engaged in this process.

• Promotions, weekend and after hours clinics, incentives, prizes and other community-based clinics, e.g. marae, community centres, churches etc.

• Improved systems to identify women who are overdue for their smear or who have never had a smear, then targeting recall activity at those women.

• Referral pathways between general practice teams and community providers to engage women who have difficulty in attending a clinic to complete a smear.

• We have employed a nurse who is working with PHOs and low-performing practices to support quality improvement, recalls and invitations for women who are overdue for a smear, with a focus on Maaori, Asian and high needs women. Work is underway to organise community and practice-based clinics targeting women who attend temples and marae. In addition, weekend cervical screening clinics offering free smears are being planned to coincide with the Otara and Mangere market days.

• The regional cervical screening governance group is dedicating funds for a targeted media campaign aimed at Maaori and Asian women (the two groups with the lowest coverage rates in CM Health) to raise awareness of the benefits of cervical screening and how to access screening services. This will link in with CM Health promotional activities for cervical screening. Billboards, posters, decals for the hospital floors, Daily Dose communications and flyers are being developed for September cervical screening month.

• Two PHOs in our district are offering free smears to all women and some PHOs are offering after hours and free smear clinics specifically targeting Asian and Maaori women.

• We are working closely with the National Screening Unit to improve primary care access to cervical screening data, which will help PHOs to more accurately and proactively identify enrolled, eligible women who are overdue for a smear. Monthly data is now available to PHOs which assists with identification of unscreened and underscreened women for practices.

• We are offering free cervical smears clinics to all CM Health staff.


5.3 Adult Rehabilitation and Health of Older People OBJECTIVE: To support older people in their homes and communities with integrated, locality based services that maximise independence through rehabilitation and quality care. PROGRESS POAC Winter Initiative Inpatient hospital services began referring to the Primary Options for Acute Care Winter Coordination Service from Monday 15th June. Two weeks on from the implementation date, referrals for clients currently receiving short term home based support services are now starting to be sent out by Primary Options for Acute Care to the localities coordinators for review and identification of further needs; including specialist support equipment or general practitioner follow up. We continue to work with the inpatient teams, localities teams and Primary Options for Acute Care to identify opportunities to streamline the process as queries arise. Home Health Care - Community District Nurses and Allied Health Teams – The Home Health service is available to people in their own home or at a clinic facility at four sites aligned to the four localities. The Home Health teams consist of allied health, district nursing, care assistants and other locality based staff with professional, clinical and cultural skills. Home Health Care received 1,154 referrals; discharged 1,269 clients and completed 9,935 contacts across all bases for the month of June.

Community Allied Health - (delivered from Home Health Care) – The physiotherapy waiting list continues to be contained. There has been a decline in the volume of occupational therapy referrals to Orakau Locality over the past seven months since the multi-disciplinary team meetings commenced. The waitlist has continued to drop at Orakau with a steady increase in the Eastern Locality. Ongoing project work to explore options of outpatient clinics for occupational therapy intervention is currently taking place at Orakau.

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Home Health Care Contacts

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Waitlist - Acute Allied Health Outpatients Waitlist Activity – The priority two target for musculoskeletal patients continues to be an issue with a vacancy in the team contributing to it remaining high. Referrals continue to exceed the ability to manage the demand. The hyperventilation service has been doing some phone triaging and reviewing the patients on the waitlist which has reduced the waitlist by 15% from last month. 1

1 The waiting list data is reported as a point in time, reflecting the number of patients waiting at the time the reported is generated. The reports are set to run in the early hours of the first of each month. Logically last month waiting plus added during the month less the seen and removed should give the numbers waiting for following month, however due to the lag in entering referrals and to a lesser extent removing patients, there will be always be a variance in this figure.

Assessment and Coordination of Care for Older People –100% of facilities are either training or booked for training - (Reported Quarterly in arrears)

• 93% (40) of facilities have completed training. • 7% (3) of the above including one new facility are in the process of completing training.

Needs Assessment and Services for Older People – Work continues on developing and implementing the new locality multidisciplinary model aligned to the At Risk Individual Programme and developing pathways to align to the community central model. A proposal has been sent out to teams for consultation on alignment of the inpatient Needs Assessment and Services for Older People team and Needs Assessment and Services for Older People and Home Health Care Administration teams to the Community Central Structure. A decision on the final structure of these teams will be developed based on feedback received and is planned to be finalised in mid-July. Discussions continue with the ‘forms on line’ developer regarding changes to allow accurate extraction of work load/waitlist data for the needs assessors across all bases.

Month Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15Added 418 513 417 502 538 380 384 284 430 508 455 440 433Seen 273 368 220 387 332 364 290 242 299 397 322 389 385Removed Other 104 67 94 94 105 112 51 87 109 153 100 103 99

Total on Waiting List 818 819 830 865 928 846 908 881 941 907 958 925 891Waiting > 150 days 10 10 17 16 31 36 51 75 97 81 80 67 51Waiting > 120 days 18 31 22 45 41 32 63 63 58 61 38 28 37Waiting > 90 days 79 65 97 62 79 94 110 113 113 85 66 111 101Waiting > 60 days 148 120 147 159 115

Previous month Total Orakau Manukau Franklin Eastern

Waiting list Dietetics 15 19 0 4 14 1 Contacts Dietetics 94 82 12 42 11 17 Waiting list Occ Therapy 138 133 35 58 0 40 Contacts Occ Therapy 336 336 139 77 53 67 Waiting list Physiotherapy 22 28 15 8 1 4

Contacts Physiotherapy 299 277 82 73 43 79


Early Supportive Discharge – Supporting Life after Stroke – Approval has been received as part of the 20,000 days project for a permanent doubling of the pilot full time equivalent employees. With this change the scope of the Early Supportive Discharge service will increase to the whole of Counties Manukau Health area, including full time equivalent employees being allocated to Franklin to provide an extended service as part of their existing community based services. The early supportive discharge/Community Based Rehabilitation Team service delivery model will be revised, combining the early supportive discharge and Community Based Rehabilitation teams to deliver one seamless service. The level of support patients receive will be determined by need with early discharge being an option when home environment and supports are appropriate. The aim of combining these two services is to ensure the delivery of early discharge options with timely rehabilitation support without loss in service continuity or rehabilitation gain. Currently patients may experience a gap in rehabilitation support of up to three weeks from time of discharge from inpatient stay, when referred solely to Community Based Rehabilitation Team; the revised model will diminish this wait time. In addition combining the teams will remove the transitional barrier between the two community based services. It is expected that through this model change a reduction in combined service length of service will be possible. National and Regional Spinal Strategy – There have been 76 patients through the Acute Spinal Service since 1 July 2014, with a continuing high number of complete and incomplete cervical injuries. Work continues with Canterbury District Health Board and Burwood Spinal Unit on a consistent approach to service delivery. Collaboration on patient experience has been the main focus this month with sharing of information to develop a better approach to receiving and utilising patient feedback. A patient forum has been held using agreed areas for questioning and an Initial meeting of the stakeholder group has been held. Challenges remain in ensuring skilled staff are available to support patients’ needs, in particular allied health. Funding approval has been received to increase Physiotherapy and Occupational Therapy inpatient staffing by one full time equivalent and approval to recruit has been given for 0.5 full time equivalent for Psychology. Recruitment is underway, although this is a challenge with few skilled practitioners available. Nursing full time equivalent has also been increased for the nursing outpatient team to ensure nurse availability in particular for urology sessions. Equipment trial of an Urodynamics machine has been completed with all criteria met; delivery of the machine is expected this month. With this machine plus a specialised chair there will be improvement in the quality of assessment of need and patient comfort during procedures. Community Geriatric Services – An important component of the Systems Integration/Locality development is to provide additional Geriatrician support to primary care practices and aged residential care. The Community Geriatric Services team provided support to three GP practices and five residential care providers during the month of June. 28 aged residential care facility staff attended the June education forum which was focused on respiratory diseases and palliative care in Chronic Obstructive Pulmonary Disease residents. Year to date, 338 aged residential care facility staff have attended the Educations Sessions provided by the Community Geriatric Services team. Target <100 Emergency Care presentations from residential facilities per month <25 Potentially Avoidable Admissions • June 2015 saw 109 Aged Related Residential Care Clients present to Emergency Care. Of these,

nine presentations were falls related and 17 were potentially avoidable admissions.


Community Specialists Health of Older People Teams (reported quarterly) – Continue to provide proactive support to Aged Related Residential Care and primary care by Gerontology Clinical Nurse Specialists and Geriatricians. The monthly aged related residential care education session for facility staff continues to be well attended, with an additional 117 Registered nurses attending education forums during quarter four, bringing the 2014-15 year to date attendance to 338. Throughout the 2015-16 year, this data will be utilised to identify reasons for admissions. This analysis will enable the community geriatric team to develop a support plan for identified Aged Residential Care Facilities. The ATRACT education program for Registered Nurses in facilities continues to be promoted by the CMH Community Geriatric team. • Target: Provide 25 hours Gerontology Clinical Nurse Specialists and Geriatrician support per

month to five primary care practices including clinics and education sessions with GPs End of year average of 27 hours per month of Geriatrician support was provided to five primary care practices during the 2014-15 year.

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Quarter 4 5 24 hours


• Provide 26 hours Geriatrician support per month to six Age Related Residential Care Providers for medication review case conferences

An average of 41 hours per month of Clinical Nurse Specialist and Geriatrician support was provided to six Age Related Residential Care Providers during the 2014-15 year.

Percentage of Home Based Support Services client interRAI assessments complete by locality – Each of the locality teams continue to roll out interRAI assessments for all clients receiving home based support services. Between April and May 2015 87.2% of patients receiving home based support services have had an interRAI assessment at some point. Locality Clients # w/InterRAI Percentage

Eastern 1059 852 80.5%

Franklin 659 598 90.7%

Mangere/Otara 570 524 91.9%

Manukau 1487 1317 88.6%

CMDHB 3775 3291 87.2%

Memory Team (Dementia Care Pathway) January 2015 – The Memory Team are continually refining their processes. Definition of the criteria for keeping cases open or closing them has been confirmed and the Team is applying this definition to current cases. It is expected that a significant number of open cases will close in the coming months with options of discharge, handing over to the General Practitioner or Alzheimers Auckland Charitable Trust. Business planning for 2015/2016 has been completed with the following four key focus points identified; locality model of care, measurements and reporting and projects and publicity. A team member will be presenting at the Australasian Society for the Study of Brain Impairment, Conference in Australia during the first week of July.

Geriatrician Number of ARRC Providers Visited

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Quarter 1 6 Average 42 hours per month





Long Term Support Chronic Health Conditions update on service mix provided – (Reported Quarterly) Utilisation as at 31 March 2015 There are 200 clients receiving long term supports for chronic health conditions and who are receiving the following services:

Service Number of clients Community Residential Services Dementia 6 Hospital and Specialised Continuing Care

23

Rest Home 18 Respite 6 Rehab and Community - Carer support 13 Household Management 40 Personal Care 75 Individualised Funding 17 Dementia Day Care 2 Total 200


5.4 Primary Health

OBJECTIVE: To deliver comprehensive in and out of hours primary health care which is ‘Better, Sooner, and More Convenient’. PROGRESS Zero Fees for Under 13s At 1 August 2015 CM Health had 100% of the general practices in the district providing zero fees for children under 13 years of age. The four After Hours providers in the district are also providing Zero Fees for Under 13s and nine pharmacies in Counties Manukau have been contracted for free prescriptions after hours for children under 13. Self Management Support Campaign As part of the “Healthy together” strategy for CM Health the Manaaki Hauora Supporting Wellness Campaign has been running since January 2015. A request for proposals for collaborative teams was sent out to health networks and the community resulting in the formation of 18 collaborative teams. These teams are using the Model for Improvement methodology to develop and test different approaches of self-management support over the whole of system and the community. Once the Collaborative teams’ tests of change have proven quality self-management delivery these numbers will then be expanded up across the Counties Manukau district. A measurement group has been set up and is in the process of creating a dashboard of results to measure the aim to reach and support 50,000 people living with long term conditions by 1 December 2016. Ko Awatea’s campaign team of improvement advisors, project managers and co-ordinator are supporting the teams to achieve this. Three Learning Sessions involving the 18 collaborative teams and a series of smaller workshops for specific topics e.g. Health Literacy have been held and further workshops are planned for later in the year. Auckland Regional After Hours Network The procurement process for the provision of Auckland Metro After Hours services is now progressing from the Expressions of Interest to the Request for Proposals phase. CM Health has had strong legal and planning and funding input into the Request for Proposals evaluation and assessment criteria to better ensure after hours coverage and equitable access for our population. The Request for Proposals will be released shortly with an expectation that the process will be completed with new arrangements in place by March 2016. Existing After Hours services contracts have been extended with an end date of 29 February 2016 and provision has been made in the contracts for earlier termination with 3 months’ notice if the process is concluded prior. Primary Care Nursing Update Over the past month the CM Health Primary Care Nursing team has been actively involved in supporting implementation of priority health initiatives and public health planning. A summary of key activity is provided below:

• Primary Health Care Nurses continue to support the immunisation programme, cold chain accreditation and assessment of new vaccinators. Immunisation targets have been achieved. We now need to maintain targets by developing sustainable methods such as actively following up all declines and ‘fail to immunise’ by outreach services. The Franklin locality continues to be the lowest in obtaining eight month immunisations. There are historically a higher number of declines in this area.


• Both clinical nurse specialists are supporting the localities with nursing advice and establishing networks of practices. Advance Care Plan work continues with ongoing support to nurses and GPs in primary care.

• ARI care coordination stories of success continue to be shared at events. The value of having more time to spend with patients is clearly reaping rewards with patients benefitting from increased self-management and understanding of long term conditions. Two care coordinator training sessions have been held with another two planned for 2015 for those new to the ARI programme.

• The practice nurse workforce has increased by 22 people since 2006. Data has been obtained by asking PHO Nurse Leaders for the numbers of nurses working in their PHO.

• School nurse youth specialists have been supporting the implementation of the Rheumatic Fever rapid response sore throat clinics within funded secondary schools in collaboration with the National Hauora Coalition. The contracting of support staff in the school for rapid response sore throat clinics has been devolved to the schools.

• The wound care project is now underway to divert low acuity wound care referrals to primary care. Data collected from district nurses and referral audits has indicated 30-40% of low acuity wound care could be managed in primary care. The extra capacity in district nurse teams is to be utilised for early supported discharge and rapid response functions.

Regional Clinical Pathways Programme 54 regionally approved pathways have been developed and reside on Healthpoint, providing a comprehensive road map for the local management of patients with common conditions. The pathways site has over 5000 individual hits per month, up 300% on the previous year. The purchase of the HealthPathways (Canterbury model) is complete and a regional team is working to align the Healthpoint pathways and adapt the HealthPathways content. This is yet to be rolled out across primary care. The dynamic pathways pilot (Nexxt) continues with 936 patients enrolled on a pathway being utilised by 245 clinicians across 57 practices. Target is 92 practices and the pilot will run until March 2016. An Evaluation Advisory group is up and running to ensure the programme delivers on its intentions through robust analysis of the measures of success. Regional Data Sharing Initiative Following the endorsement by Metro Auckland Clinical Governance Forum and the Care Connect Governance Group for the data sharing policies and processes, a Privacy Impact Assessment was required prior to submission to the Auckland/Waitemata Alliance and Counties Manukau Alliance for sign-off. The Privacy Impact Assessment and the Policies and Process documents were presented at the Regional Privacy Advisory Group meeting in mid-July in which the privacy and security of consumers’ healthcare data was considered in respect of two of the four existing significant data sharing initiatives (two were ruled out, as one instance had ceased, and one which is still in early phase development may require its own Privacy Impact Assessment). The results of this assessment and discussion were very favourable. The Metro Auckland Data Sharing Policy and Process are to be tabled at the Auckland/Waitemata Alliance and Counties Manukau Alliance for sign-off in mid-September. These will act as standards for operational data sharing initiatives that involve primary care data across the Auckland region. The additional procurement of a HealthSafe repository, appropriate analysis and reporting tools, and the employment of a Healthsafe Manager to oversee the day to day operation of the data sharing programme are currently in the planning stage.


Primary Mental Health Two large group Continuing Medical Education sessions were held in June in order to communicate the Chronic Care Management Depression changes that were launched on the 1st of July. These changes support greater integration across primary and secondary care as well as improved access to Cognitive Behavioural Therapy. Feedback from these sessions was very positive however there is a need for ongoing education for clinicians around depression and anxiety. A generic Power Point presentation will be developed and uploaded onto the Ko Awatea website for all primary care clinicians and Non-Government Organisation staff. An audit project has begun in order to explore the barriers to ongoing participation in the Chronic Care Management Depression programme, particularly for Maaori as engagement rates for Maaori are significantly lower than for non-Maaori. A sample of 50 patients has been generated (10 per PHO) and practices visits have been organised in order to review the PMS data. The results of this analysis will be used to strengthen existing approaches and/or develop new ways to engage Maaori with moderate to severe depression. Palliative Care CM Health, hospices and other key stakeholders have recently been exploring how new funding for palliative care that was announced in the Budget 2015 can best be used to support the current and future palliative care needs of the local population. There is shared agreement amongst stakeholders that sustainability of hospice services and a more coordinated approach is required and that this should be aligned with locality developments and the model for integration of community health services. This will include establishment of a clinically-led working group which will be linked with Locality Leadership Groups and the CM Health Alliance Leadership Team, to provide overarching direction for the following approach: • Review of progress with the model for palliative care as outlined in the 2011 report “Palliative

Care in Counties Manukau”, commissioned by CM Health and Totara Hospice • Identify gaps and opportunities • Development of a three year plan to build on the model for palliative care with clear goals and

measures. The work will include a focus on strengthening the role of primary care and enhancing integrated care between hospital, hospices, general practice teams, Aged Residential Care facilities and other community providers. CM Health is working closely with Totara Hospice South Auckland and Franklin Hospice in the initial planning phase, in particular to agree how the new funding streams that support sustainable hospice services and innovations in primary, community and ARC settings will be utilised.

Business cases will need to be developed with input from key stakeholders for use of the ‘Innovations’ funding stream. Workshops are currently underway to begin the planning for the business cases. Early consideration is being given to the potential for both local and regional initiatives.


5.5 Child, Youth and Maternity Services

OBJECTIVE(S) To integrate maternal and child health services; reduce perinatal mortality; improve care in the First 2,000 Days of life; intervene early to support vulnerable children; reduce Rheumatic Fever by two-thirds to 1.4 cases per 100,000; and improve youth services. 1st 2000 days-Maternity Early Engagement The Early engagement media campaign commenced on 4th May 2015 and is progressing well. All communications that have been developed contain the message about the importance of early pregnancy care. During July active connections have been made with Non-Government Organisations and face to face meetings to discuss the message and how the community based organisations can support the campaign’s aims. An interview was undertaken with the Manukau Courier about the Best for Baby, Best for You campaign and a mother who had used the maternity services and a Lead Maternity Carer midwife also shared her story. Pregnancy and parenting education The Metro Auckland Region have contracted Connectus to produce a curriculum for the delivery of pregnancy and parenting education. Connectus were selected via a contestable process and are contracted to deliver a curriculum and an application for use on mobile devices. The expected completion date is 30 November 2016. CM Health will then undertake a closed process (via Localities) for the delivery of the service. 1st 2000 days - Improving Infant Nutrition Project The overarching aims of the Improving Infant Nutrition Project are to: • Improve nutrition and promote healthy feeding of infants and toddlers (aged 0-2 year olds) with a

focus on breastfeeding and age appropriate introduction of healthy first foods through peer and community based support, and engagement with wider whaanau/family environments; and

• Enhance the way maternity, child health, primary and secondary care health professionals engage and communicate with parents and whaanau/families around infant and toddler nutrition through a workforce development initiative.

A community initiative with four major components is being piloted in 2015/16 in the Manukau locality with a focus on Papakura and Manurewa. • A Peer Support Programme based on an adapted La Leche League Peer Counsellor Model; • Community action initiatives and workshops that improve nutrition and promote healthy feeding

of infants and toddlers; • Community-based baby feeding clinics to provide breastfeeding and baby feeding support and

advice to mothers and whaanau; • Supporting implementation of the Baby Friendly Community Initiative in the two contracted

organisations, and supporting organisations in Counties Manukau who are already Baby Friendly Community Initiative accredited to maintain their accreditation.

A Programme Coordinator/Lactation Consultant has been employed to coordinate and support the establishment of this programme of work; and Papakura Marae and Greenstone Family Clinic have been contracted to establish and deliver the Peer Support Programme, with the contracts having


commenced 1 July 2015. Activity in the past month has focused on planning and development, stakeholder engagement and consultation, staff training, completing a stocktake of community breastfeeding and support services, and initial conversations with the organisations regarding Baby Friendly Community Initiative. Health Workforce Development Workbase Education Trust have been contracted to develop and deliver the Health Workforce Development training and mentoring initiative. Since June eight workshops have been delivered to 70 Well Child Tamariki Ora providers, Lead Maternity Carers, General Practice and other health and social service providers, and a further two workshops are scheduled for delivery during August. Mentoring services have also been established. Each individual who has completed the training receives between one and three face to face mentoring sessions with Workbase staff. The main purpose of the mentoring is to observe and coach participants in relation to the Three-Step Health Literacy model. However mentors have also observed less than optimal clinical practice and failure to refer clients to specialist support. The main issues identified by mentors have been around listening skills, use of technical vocabulary and providing too much information too quickly. Participants have generally responded well to on the spot coaching between mentoring sessions. 1st 2000 days -Sudden Unexpected Death in Infancy Safe Sleep Programme The safe sleep device programme continues to provide pepi-pods to whaanau with newborn babies in unsafe sleeping environments. From January to July we have supplied 174 Pepi-pods to families/whaanau with unsafe sleeping environments for babies. A number have declined due preference of a cot or bassinet. We are investigating a range of options for on-going management and supply of safe baby beds as we are required to ensure a safe sleeping environment for high risk babies until 12 months of age. Safe Sleep policy and pepi messaging is being implemented in all maternity wards and primary units and was evaluated in a pilot audit in late January 2015. The Northern Regional Alliance Safe Sleep audit criteria has been added into the weekly audit schedule for CMH maternity facilities using the CMH “Point of Care measurement Tool”. Audit data will be collected onto a handheld electronic device weekly and reported monthly to District Health Board, and six monthly at Northern regional and Ministry of Health level. Workforce training & Development Roll-out of workforce development Safe Sleep / Sudden Unexpected Death in Infancy online learning programme choice of two online versions • Ministry of Health Learn Online Website: (Currently in the Well Child Health Section) http://learnonline.health.nz/course/categorylist.php?viewtype=course. • Whakawhetu Sudden Unexpected Death in Infancy Online Workshop http://lms.conectus.org.nz or http://www.whakawhetu.co.nz/sudi-training Safe Sleep education will be a requirement for all staff and contracted organisations in maternity and child health. Whaanau Hapu Waananga (Ministry of Health funded pilot) A Community based Sudden Unexpected Death in Infancy initiative is being planned which will aim to engage pregnant Maaori Women and their whaanau in a series of “Whaanau Hapu Waananga”. This will include a comprehensive antenatal, childbirth and post-natal education programme which aims to reduce sudden unexpected death in Infancy risk factors within a kaupapa Maaori service delivery model.

http://learnonline.health.nz/course/categorylist.php?viewtype=course

http://www.whakawhetu.co.nz/sudi-training


Invitations for Registrations of Interest are to be published in August with a closed tender in late September. Well-child / Tamariki Ora Checks The four Northern District Health Boards are working together on a Well Child Tamariki Ora quality improvement project. The quality improvement framework has been developed and Ko Awatea is assisting with training of all providers. The initial focus is to ensure all Well Child / Tamariki Ora providers have a plan to improve access & engagement of families/whaanau to ensure tamariki/children receive their entitlement of checks in their first year of life. Before School Checks Significant changes to the programme have resulted in early achievement of the Before School Checks target to June 2015. At the end of June (end of financial year) CM Health was at 100% overall. A total of 8067 of children were checked and 3531 of these were Quintile five (high deprivation). This has set us in good stead for the start of the new financial year. The new Ministry of Health targets for the 2015-2016 year is 8,025 Before School checks overall, and 3,565 of these need to be Quintile five. At the 31st of July we are at 16% overall and 11% for Quintile five. All strategies implemented in 2014/15 will continue to ensure maintenance of coverage in to 2015/16. Rheumatic Fever Prevention The Ministry of Health Rheumatic Fever Prevention Programme was established in 2011 to prevent and treat streptococcal throat infections, which can lead to rheumatic fever. The Programme was expanded significantly from 2012 following the introduction of the rheumatic fever Better Public Services target. Data from Auckland Regional Public Health Service shows that the number of probable and confirmed rheumatic fever cases has reduced year on year since 2013 (Figure 1). In addition the Ministry of Health reported to the Social Sector Priority Ministers in June 2015 that CM Health has had a statistically significant reduction in rheumatic fever cases (77 in 2013 vs 51 in 2014). While attribution of this change could be argued the Alliance Leadership Group1 believe, on the basis of the proportion of swabbing done in the school based service compared to primary care and secondary schools and the low throughput of the Auckland Wide Health Initiative, that it is likely to be Mana Kidz which is having the biggest impact on rheumatic fever rates. 1 Alliance Leadership Group has been delegated governance of RF plan in Counties Manukau. The group consists of David Jansen (chair), Nettie Knetsch, Carmel Ellis, Pip Anderson, Anna Bailey and Lorraine Hetaraka-Stevens.


Note: 1. These data are presented by admission date and not notification date. This may result in changes from previous

updates provided due to late notification of some cases. 2. Confirmed and probable initial attack cases only 3. Recurrences are excluded 4. Age is at admission date (or onset date if admission date is missing). 5. 2015 data is to 30.06.2015 2013-2015 notification data are likely to be more complete than data from 2012 and earlier due to active case finding processes implemented in 2013 between Auckland Regional Public Health Service and the regional DHBs Oral Health Increase Enrolment of Preschool Children aged zero to four years Preschool children are required to be enrolled at nine months through the Well Child/ Tamariki Ora providers however most preschool children have been enrolled from two years. As tooth decay requiring fillings has been starting in high risk population groups at as young as 18 months the plan for 2015/16 is for focus on enrolling the baby at five months at the latest so the child can be examined by their first birthday with oral health education and preventative care given. Snapshot of enrolments is taken at June and December each year to allow for incoming births and children turning five transferred to school. The chart below shows the snapshot of preschool enrolments by ethnicity at year end June 2015. The target is 85% to be achieved by 31 December 2015 and 95% by December 2016. Current achievement is short of the target with 95% of three to four year olds enrolled but only 53% of zero to two year olds enrolled. The gap is currently babies zero to two years, and particularly Maaori, Pacific and Asian. We are working alongside the Auckland Regional Dental Service to update the Preschool Oral Health Strategy to reach the required number of children. Preschool education programmes with supervised toothbrushing continue in 150 targeted preschool centres with high proportions of Maaori and Pacific children, and this captures further enrolments and referrals of children for urgent attention in the dental service.

Cumulative initial attack Acute Rheumatic Fever Notifications in five to 12 year olds by Admission Year and Month, CMH 2010-2015


Adolescent Oral Health Services Adolescent utilisation of dental services is 85%. Counties Manukau preliminary result for 2014 achieved 74.4%. Final confirmed result for 2014 will be released in October 2015 due to late claims due to NHI collection and school decile changes. Adolescent utilisation achievement is consistent with national results:

Growth in Adolescent utilisation of dental services in Counties Manukau has come from providing mobile dental services on-site at secondary schools where prior utilisation has been as low as 50%. In Counties Manukau we have two providers of mobile dental services: Mighty Mouth (mobile and dental clinics) and Raukura Hauora O Tainui (mobile only), plus approximately 80 other contracting dentists.

Asian European /Other NZ Maori Pacific Grand Total

00-04 years enrolled 5,597 8,112 6,468 8,386 28,563

00-04 population 8780 8270 11500 13360 41,910

% enrolled 64% 98% 56% 63% 68%

- 5,000

10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000

CMH Preschool children aged zero to four years enrolment in Dental Services snapshot by ethnicity at June 2015


The mix of mobile dental services at schools to fixed dental clinics is approximately 57% mobile at school versus 43% at corner dentists. Regional growth of Adolescent utilisation over time is consistent regionally.

Oral Health Pilot for Women with Diabetes in Pregnancy The Ministry of Health funded low cost oral health pilot for Women with Diabetes in Pregnancy to receive free dental care over three years commenced in February 2013. The pilot will be completed in March 2016 and is under on-going evaluation by a Ministry of Health evaluator. The outcome of the pilot will be an assessment of unmet need filled by clinical treatment and oral health education, quality of life survey compared to the 2009 NZ Oral Health survey, and costs to provide dental care to high needs vulnerable patient groups. The mix of clinical services provided is higher than expected due to the interaction between oral health and diabetes and includes 52% having extractions 92% having fillings, and 7% requiring clearance of teeth and partial or full dentures. The planned cohort is 400 women and to end of July 2015 the participant breakdown is below:

# of patients

Category Detail

3 Waiting list Awaiting First Specialist Appointment

121 Active FSA completed, currently under treatment 165 Incomplete /

exited FSA completed, incomplete treatment, not exited as unable to contact, moved out of area, or do not wish to continue dental care

99 Completed FSA, completed treatment, exit interview (Litmus)

388 Total patient cohort

304 Declined Referred never seen - Did not attend, Uncontactable, Declined - did not want to take part

692 Referrals Total referrals into the pilot

Youth Health The revised Youth Health Leadership Group met for the first time on the 2nd of July. The group agreed to focus on developing comprehensive school-based health services, ensuring that nurses are working at the top of their scope with access to Medical Practitioner Supply Order, standing orders

0%5%

10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Prelim

2015target

Adolescent Utilisation of Dental Services - Northern Region DHBs

Northland Auckland Waitemata Counties Manukau


and support from a named general practice as required. The group will focus on the integration and delivery of primary and secondary mental health services within school-based settings. The use of the At Risk Individual programme for young people and their whaanau is being investigated. In the first instance, school-based health staff may use the shared care plan tool. The Youth Health Leadership Group is also focussing on at-risk youth. The workstream is being scoped at present but is likely to focus on students enrolled in Alternative Education and those in Private Training Establishments. This group of young people often have complex health and social needs, are not enrolled with a general practice, and would benefit from a comprehensive wrap-around service and strong whaanau engagement. Regionally and nationally, Alternative Education services are under review by Auckland Agencies for Youth (an Auckland multi-sector youth-focussed information sharing forum) and the Ministry of Education. The group will scope this workstream in Quarter one and Quarter two. Work in the ‘Continuous quality improvement’ space is progressing. There is already a quality improvement framework for schools that is being implemented across all CMH funded schools. A youth health framework for primary care is in the pipeline and the Northern Region Alliance Youth Health Team are developing a similar framework for secondary care.


5.6 Mental Health and Addictions

VISION: That the communities of Counties Manukau will support mental health and wellbeing and be able to get support when they need it, quickly and easily, in their local community.

PROGRESS PP6 Access Rates Please note there is a three month report lag due to national data assurance requirements.

The following graph shows access rates for Maaori by population percentage

This Ministry of Health performance measure provides a view on the whole of population access to specialist Mental Health & Addiction services. This includes all CM who access CM provider arm specialist Mental Health services, regional specialist Mental Health and/or Addiction services (e.g. specialist Alcohol and Drug Forensics) and/or Non-Government Organisation services (both Mental Health and Addictions). What is evident is the increase in access to these services for the CM population. Of concern is that nearly one in 10 adult Maori now resident in CM are accessing a specialist Mental Health and Addictions service.


The graph below shows access rates for total of ethnicities by population percentage

The current challenge is how to ensure adequate access to specialist services while enabling and supporting specialist services to enhance the capability and capacity of the primary care level services to provide MH&A services. This is being undertaken through integration initiatives, IT developments and the work on enabling specialist clinicians and services to report on non NHI defined clinical consultation to other providers. Whole of System Integration and Co-design The programme of work to develop ‘whole of system’ integration for mental health and addictions is being informed by a comprehensive process of co-design engagement. The co-design process involves a wide range of stakeholders including service users, family/whaanau, primary care, NGO providers, secondary/specialist mental health and addictions, and broader community partners. Engagement is taking place with a focus on the four CM Health localities, ensuring the opportunity to hear and understand what is important for each of those communities. People are being encouraged to share ideas and experiences around what is working well, areas for improvement and the issues and challenges that need to be addressed. By July 2015, 22 co-design engagement sessions had been held. Additional sessions will be held in August, including sessions dedicated to Maaori and Pacific service users and family/whaanau, with an opportunity to also contribute via an on-line survey. To date almost 350 people, across a range of stakeholders, have contributed to the co-design discussions. The feedback from the co-design process will be crucial in informing the development of the integration implementation plan for the period 2015 – 2020, with the Integrated Mental Health and Addictions Leadership Group leading and overseeing the development of the plan. The plan will reflect the importance of continuing to focus on meeting the needs of our population with the most severe and enduring mental health needs whilst also enabling early intervention in the life course

00.5

11.5

22.5

33.5

44.5

May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15

% S

een

12 months period ending

Maori and Non-Maori clients seen by DHB of Domicile, Ethnicity - Total

0-19 Yrs 20-64 Yrs 65+ Yrs

Target 0-19 Yrs Target 20-64 Yrs Target 65+ Yrs


and in the course of an illness or addiction. The plan will also recognise the importance supporting both the physical and mental well-being of our population.

Themes emerging from the co-design process focus strongly around the importance of good communication (with consumers/family/whaanau and between providers), joined-up care, access to information, and care that respects and empowers individuals and their family/whaanau. Supported Employment In line with Rising to the Challenge and Blueprint II, employment has been identified as a key part of recovery. There is national and international evidence on the relationship between employment and health, particularly mental health. For people in contact with mental health services, Individual Placement and Support is an evidence-based practice which can successfully support people to gain and maintain competitive jobs. Workwise, in conjunction with Te Pou, Counties Manukau Health and Auckland DHB have commenced an initiative looking to improve employment outcomes for clients assessing adult mental health (at Counties, this will be the four Community Mental Health Centre’s). The aim is to identify opportunities to improve service delivery, outcomes for clients and to ensure that the clinical/employment partnership approach is sustainable. There will be a fidelity review by an independent assessor with a plan implemented to ensure improvements are achievable. There is also an opportunity to look at how the model could be rolled out to primary care. This 12 month project commenced in May. Over the next 12 months, we will be working with all community teams to ensure recording within the Health Care Community (colloquially known as HCC) clinical notes regarding employment status is accurate. Preliminary data analysis indicates that current statistics are outdated and a number of clients have nothing recorded in this section. We expect to have up to date information by December 2015 and this will complement the work that is occurring with the Workwise employment consultants

Hinemoa Lodge In February 2015 notice was given by Hinemoa Lodge Ltd of the impending closure of the residential facility in Papakura. This service was home to a total of ten clients with varying mental health and intellectual disability needs. In the following months a range of agencies worked in collaboration with the facility, the clients and where appropriate their families to try and achieve the best possible outcomes for the clients. In all cases, every effort was been made to ensure that client’s wellbeing was at the forefront throughout the process. This included client reviews, the views and wishes of the clients and their families, assessments from appropriate clinicians including Needs Assessment and Service Coordination assessments, Occupational Therapy assessment and psychological assessments, input from the Mental Health Clinical Teams, Primary Care, Taikura, Health of Older People and a great deal of teamwork. The facility closed its doors on the 30th June 2015, with all clients being appropriately re-homed and settled.

Mental Health Services “Big Dot” - 25% reduction in Counties Manukau suicide rate in five years Official suicide data is released from the Ministry of Health after determination and aggregation by the Coroner’s office in annual reports, typically three years retrospectively. The latest annual data available is from 2012. The implementation of a systematic multisectorial postvention response led by the DHB to suspected suicide deaths in collaboration with the Coroner’s office has enabled the determination of the number of suspected suicide deaths of people who were open to Mental Health services or had been open to our services within the year prior to their death. This indicates many suicide deaths are amongst people accessing specialist MH services and gives the opportunity


to focus on care delivery issues identified through the systematic review of these serious incidents. In addition it appears that young people and Maaori are the least likely to have had contact with our services and provides useful direction regarding which groups should be the focus of efforts to enhance access to Mental Health services. The baseline suicide data for the 12/13 year based on suspected suicides known to service is not available as the data was not reported in that way. In 13/14 the Coroner confirmed that there were a total of 48 suspected suicide deaths in CM. Our postvention response team received information on 42 deaths. In 14/15 we have received postvention information on 44 suspected CM suspected suicide deaths. We await confirmation from the Coroner on their total numbers for this past year. We are able to report that in 13/14 there were 18 suspected suicide deaths of people known to specialist mental health services. In the 14/15 year this has dropped to 13 suspected suicide deaths representing a decrease of five (28%). Once again the concern is the high numbers of Maaori and youth (aged less than 25 years) deaths accounting for a total of 45% and 34% of all suspected suicide deaths in Counties respectively. There appears to be an increase in suspected deaths in people who are not known to specialist Mental Health services. Every suicide is a tradegy and significant efforts are made by mental health services to review processes including triage, protocols and serious incident reports. Senior leadership groups ratify review recommendations and remedial actions, and use Mortality and Morbidity meetings to more widely engage the clinicians in the findings and quality improvement activities that follow the reviews. The need to focus on youth, Maaori and the broader access to specialist Mental Health services has been highlighted and is part of the focus of the new Integrated Mental Health and Addictions leadership group. Emerge Aotearoa On 1 July the former Recovery Solutions and Richmond NZ merged to become Emerge Aotearoa. Mind & Body Ltd, while remaining a separate standalone company that provides peer support and training services, also joined the Emerge Aotearoa Group. A launch was held at the Ngā Kete Wānanga Marae, MIT Marae, in Auckland and at the Emerge Aotearoa South Island offices in Christchurch.

The new organisation operates in 17 of the 20 DHB geographic areas, and employs approximately 1000 people. Within Counties Manukau, Emerge Aotearoa provides a suite of mental health and addiction services including community supports, residential services, culturally specific services and peer support services. Group Chief Executive, Dr Barbara Disley said that the primary objective of the merger was to be better placed to provide for people who access services, their families/whaanau and communities. “We want to ensure that we build upon the positive legacy of the two founding organisations and to reflect our special and unique context in Aotearoa. Our


particular drivers are to understand and meet the needs of Maaori, respond to the needs of Pasifika peoples, and foster the participation of people with lived experience in decisions that affect them, including strengthening peer services. And, partially responding to one of today’s current issues, but also based on our own long term understanding of the importance of having somewhere stable and warm to live, we will be introducing an additional focus on the provision of social housing,”

Indigenous Work Force Exchange Te Ara Whiriwhiri is a collective of Kaupapa Maaori Non-Government Organisation providers. A key objective of this group is to ensure that mental health and addictions services are responsive to the needs of Maaori residents within the CMH district. The group has recently cultivated a partnership with the Victoria Aboriginal Health Service, to develop a workforce exchange that creates enhanced indigenous learning and integration of service delivery across each participating organisation. The aim of the exchange is to support exploration of potential development areas and strategic enhancements to further develop indigenous practice for integrated health and wellbeing. Integrated Care Adult 2014/15 Development of the Non-urgent pathway Since the implementation in August 2014 of the Intake and Acute Assessment team, there has been a small group of clinicians working alongside the Intake and Acute Assessment team to further assess and determine the appropriate clinical pathway for all non-urgent referrals coming to the adult services. Further development of this team will occur once the outcomes from the Keyworker/ Primary Care Liaison roles have been confirmed. Feedback received to date has been mostly positive with teams reporting a decrease in non-urgent referrals coming into the service (meaning an increase in suitable referrals) and primary care indicating that there has been an increase in responsiveness to their queries. The clinical head who works in the non-urgent pathway has endeavoured to increase the interface between mental health services and the various locality groups. This has occurred sporadically during 14/15 and will be a key focus for the coming 12 months.


5.7 Intersectoral Initiatives OBJECTIVE Target populations/communities with high health, housing, social, employment and education needs to improve the health status and reduce health inequalities. PROGRESS Warm Up – Counties Manukau (Retrofitting Home Insulation Project) Warm Up Counties Manukau is a free home insulation programme that retrofits insulation into the homes of low income families with high health needs. This programme is funded and delivered through a working partnership between the Energy Efficiency Conservation Authority, Autex Industries Limited, The Insulation Company, Counties Manukau Health and the Middlemore Foundation. We insulate the homes of low-income families with health issues that may be related to housing, creating ‘healthier homes’ which are more energy efficient, thus ensuring that the home contributes to the health of the family. In addition, we offer a comprehensive health and social assessment for participating families to ensure that they are accessing appropriate health and social services. This approach ensures that we can address both housing and health issues. Referral Generation Counties Manukau Health is responsible for referral generation. Families/households can self-refer or may have the programme suggested to them by their health professional. We target the programme through information accompanying outpatient clinic appointments and by working in partnership with health professionals, government agencies, the non-government sector and the local community. Project Outcomes for the Warm up – Counties Manukau Project (1 July 2014 to 30 June 2015)

Month

Total

Number of Referrals

Total Number of Homes Insulated

Total Number of Home Visits completed post

install July 2014 313 98 48 August 2014 251 107 47 September 2014 169 83 48 October 2014 148 139 27 November 2014 81 143 43 December 2014 64 116 15 January 2015 42 103 21 February 2015 55 70 56 March 2015 56 56 51 April 2015 62 42 46 May 2015 127 42 57 June 2015 165 3 38 Total number of referrals generated

1,533 1002 497

Please note: There is a time delay between referrals being received and the completion of the insulation install.


Self-identified ethnicity by household (total referrals received 1st July 2014 to 30th June 2015):

Ethnic Group Number of referrals Percentage of total referrals

Asian 151 8% European 547 28%

Indian 48 3% Maori 440 23% Other 63 3% Pacific 681 35% Total 1,930 100%

Providing Access to Health Solutions Programme Providing Access to Health Solutions is an intersectoral programme resulting from a partnership between Counties Manukau Health, and the Ministry of Social Development that was established in 2004 in an effort to help tackle the growing problem of long-term benefit dependency. The aim of the Providing Access to Health Solutions programme is to assist people in receipt of certain benefits to return to work (the programme is voluntary), using an intensive individualised case management model aimed at reducing health barriers to employment. The key objective of the Providing Access to Health Solutions programme is to reduce health barriers to employment by providing an appropriate health intervention, which enables participants to return to employment. Total Number of Voluntary Participant Enrolled onto the PATHS Programme

Month Total Number of Participants

enrolled July 2014 15

August 2014 20 September 2014 13

October 2014 19 November 2014 13 December 2014 13

January 2015 16 February 2015 14

March 2015 11 April 2015 13 May 2015 11 June 2015 12

Total Number 170


Housing Reforms Changes to Residential Tenancies Act - New standards proposed for rental homes The Government is proposing to amend the Residential Tenancies Act to improve rental standards and tenancy services. The proposed changes are:

• a new requirement for smoke alarms in all residential rental properties from 1 July 2016. • new requirements for ceiling and underfloor insulation in residential rental properties (with

specific exemptions), by 1 July 2016 for Housing New Zealand and Community Housing Provider tenancies where tenants pay an income-related rent, and by 1 July 2019 for all remaining tenancies.

• strengthened “retaliatory notice” provisions, to increase tenants’ confidence in exercising their rights, together with strengthened enforcement provisions for the Ministry of Business, Innovation and Employment to act in the most serious cases.

• changes to enable faster resolution of tenancy abandonment cases, to allow rental properties to be re-let more quickly.

A Bill to introduce changes to the Residential Tenancies Act will be introduced to Parliament later in 2015.


5.8 Progress with Systems Integration Objective: That by December 2019 every Counties Manukau resident will have a more local, integrated experience At Risk Individuals The transition to the At Risk model of care has been implemented across Counties Manukau, with the Chronic Care Management programme now phased out. 99 practices across the district are now working within the model of care. Enrolment volumes are on track with 12,193 patients enrolled in the programme, representing 2.6% of the CM Health population (as at 01.07.15). PHO and locality performance is indicated below:


Phase two of the programme is currently being developed to provide a focus on the following areas:

• Quality improvement: A district-wide approach to quality improvement within primary care has been developed and is currently being rolled out to practices via Primary Health Organisation facilitators. This provides potential funding for practices to invest in quality improvement and training within their teams, based on a care bundle approach looking at development of the care plan.

• Palliative care: Expansion of the Eastern and Franklin locality pilots to identify aspects that can be systematised across the district.

• Mental health: Increasing primary care capability to optimise mental well-being for all and increasing shared care of patients with complex mental health needs between primary and secondary care.

• Complex households: An initial working group has met to discuss the development of an intersectoral approach to supporting families to build resilience and wellness. Current work focusses on identifying the barriers to access and engagement with primary care and draws on the experience of primary, community, whaanau ora and fanau ola teams. An approach to engaging more broadly with MSD and housing is current being discussed.

• Child health: Development of the programme to support children with complex health needs. A pilot is currently being worked up with CMH paediatricians to begin work with a small number of practices with children with bronchiectasis.

• Frail elderly: Development of a frail elderly pathway in partnership with ACC to expand the At Risk Individuals patient cohort.

• Diabetes: A clinical working group has been established to develop a revised model of care for diabetes within Counties Manukau. Once agreed, this will result in modification of the existing Diabetes Care Improvement Package to improve outcomes for diabetics and more closely align with the At Risk Individuals model of care.

Community Health Service Integration Objective: To increase the capability and capacity of community services, facilitating integration with primary, Non-Government Organisation and speciality services. A business case is currently being developed to consolidate existing case management, assessment, rehabilitation and community care services into four locality based integrated care teams based around general practice clusters. These teams will support the ‘healthcare home’ with proactive care planning and co-ordination through delivery of admission avoidance, early supported discharge and rehabilitation. The programme of work will increase the capacity and be delivered through three project work streams, which have progressed as follows: 1. Reablement Workstream The reablement workstream focus is on the development of locality community teams to assist people to be as well as they can be at home (“reablement”), particularly during and after an acute deterioration. This includes continuation of work commenced to refocus district nursing, allied health and Needs Assessment and Service Coordination teams to work effectively within the locality model. The reablement service has been launched in Manukau, and will look to expand to other localities rapidly. A reablement response for younger people has been defined – this is unique to Counties Manukau in response to our population needs. Home and community based support providers continue to be engaged in this development, with operational staff joining Counties training sessions.


2. Integrated Home and Community Support Services Workstream This workstream will redesign and procure contracted long term home and community support services under a restorative services model. A detailed model of care has been developed, which will inform a planned Expression of Interest and competitive dialogue process, with implementation planned for July 2016. A draft service specification, quality framework and procurement plan have been developed, and a patient experience/ service user feedback tool has been developed. This will be disseminated through existing community networks and inform the ongoing design of the model. 3. Community Central Community Central will provide seamless access and intake for CM Health community services, enabled by a technology solution that supports a ‘first response’ request for services, triaging, allocation of resources and capacity planning. A business case is currently being prepared for submission to board (9th September) to procure a service offering from Homecare Medical Ltd and Primary Options for Acute Care to extend the existing service co-ordination function currently provided by Primary Options for Acute Care and utilise technology used by Homecare Medical Ltd to provide this service. Subject to board approval, initial functionality is planned for late September 2015 with a rolling implementation as described below.


Quality and Safety – Safety in Practice The first of our Year two Learning Sessions was held at Ko Awatea on Wednesday 17 June 2015. The programme included a mix of session breakouts into audit bundles, specific focused sessions for both year one and two practices as well as a focus on starting off the year with an introduction to the model for improvement tool kit and information. The feedback on the learning session programme and delivery, particularly from those who were part of the year one project was very positive in terms of how much the programme has evolved and how the sessions have been designed to deliver maximum benefit in a very small timeframe available. This year sees Auckland District Health Board providing an Improvement Facilitator to join the Safety in Practice project team to work with Auckland District Health Board practices.

The external evaluation of Year one Safety in Practice programme has been presented to the Safety in Practice Advisory Group and Operational Group by Price Waterhouse Cooper and has since been released on our website http://koawatea.co.nz/project/safety-in-practice/. The evaluation report findings were encouraging as to the success of the inaugural year of the programme and provided constructive recommendations regarding Safety in Practice’s management approach towards Year two. Many of the report’s recommendations had already been taken on board for improvement changes in planning for Year two. The scheduled programme of Improvement methodology masterclasses are well underway for the Primary Health Organisation Quality Facilitators and attendance at these teaching sessions has been excellent. The coaching is provided by the CM Health Improvement Advisors with the support of Ko Awatea’s external improvement advisor, Brandon Bennett. Practice visits by the core Safety in Practice project team across the three District Health Board areas have been progressing well and the approach of visiting collaborative team members following the first learning session is seeing a positive uptake in terms of understanding of the audit bundles and monthly audit data submitted great engagement of teams with the programme.

http://koawatea.co.nz/project/safety-in-practice/


5.9 Primary & Community Finance Report This report highlights net exceptions from agreed budget with a focus on full year variances.

CPHAC Financial Report Mth Mth Mth

FY 14/15

FY 14/15

FY 14/15

As at 30 June 2015 Actual Budget Var. Actual Budget Var.

$000 $000 $000 $000 $000 $000

Total Revenue 40,512 32,513 7,998 399,479 390,158 9,322

Expenditure

Pharmaceuticals 7,991 8,337 347 101,348 100,050 (1,298)

PHO/GMS/Rural Retention 7,269 6,902 (368) 83,711 82,818 (893)

Primary Care & Service Development 780 318 (462) 4,650 3,812 (838)

Planning & Funding - Governance 1,094 138 (956) 3,119 1,658 (1,461)

Primary Care NGOs 1,810 914 (895) 12,009 10,972 (1,037)

Chronic Health Conditions Programme (ARI and Health Targets) 1,300 923 (377) 11,353 11,079 (275)

After Hours Regional Service 554 566 12 7,307 6,797 (509)

Child, Youth & Mortality 1,705 588 (1,117) 9,584 7,055 (2,528)

Oral Health 488 464 (24) 5,594 5,570 (24)

Localities/20k initiatives 1,232 575 (657) 7,328 6,902 (426)

LTS - Chronic Health Conditions 415 347 (69) 4,332 4,159 (173)

Immunisations 47 246 199 2,747 2,947 200

Primary Options for Acute Care (POAC) 329 181 (147) 2,201 2,178 (23)

Intersectorial 207 110 (97) 1,116 1,320 204

Healthy Lifestyles 1,643 91 (1,552) 2,427 1,091 (1,335)

> 65 Home Based Support Services 2,634 1,715 (919) 20,864 20,582 (282)

> 65 Aged Residential Care 2,727 6,038 3,311 67,463 72,452 4,989

> 65 Other 295 441 146 4,207 5,295 1,088

Mental Health NGOs 2,219 4,194 1,975 44,610 50,333 5,724 Other - incl. Budget Savings Target 1,996 (699) (2,695) (4,019) (8,387) (5,261)

Total Expenditure 36,736 32,391 (4,345) 391,951 388,686 (3,265)

Net contribution 3,776 123 3,653 7,529 1,472 6,057

Summary Primary & Community came under budget for the year by $6m mostly driven by reduced demand for aged Residential Care relative to a budget set to an over 65 population growth of 4%. While achieving a surplus, the year saw a number of offsetting variances as Localities and Community Integration activity increased more organically rather than to strict budget lines. The variance in the table above are largely offsetting with notable exceptions listed below. Community Pharmaceuticals (FY $1.298m unfavourable variance) 40% of the $100m pharmaceuticals budget consists of pharmacy funding relating to drug dispensing and added value services. This expenditure has been under constant change over the last couple of years as we


move from a pure volume dispensing arrangement to a hybrid of volume dispensing coupled with greater patient health management. This transition has been a complex programme of ensuring consistent pharmacy income, maintaining access to appropriate drugs and implementing greater managed healthcare for patients with long term conditions. Under the implementation, managed by the Ministry of Health the total country dispensing cost has been controlled and capped but that has not prevented variation at District Health Board level. CMH is one District Health Boards with forecasted dispensing growth greater than average and greater than our budget. Complexity of the changes have meant forecast detail was not available at budget time. Reasons why we differs from the average District Health Board are complex but relate to the extent how well District Health Boards’ have managed their pharmacies dispensing activity. District Health Board’s with pharmacies with historically excessive repeat dispensings have seen their costs reduce as the incentive for dispensing volume decreases. Consequently, District Health Board’s like CMH with well managed dispensing have had to take an increased share in maintaining the total capped dispensing budget.

Health of Older People (FY $6m favourable variance) These costs include Home Based Support and Aged Residential Care for over 65s. CMH over 65s population is growing at over 4% pa and Health of Older People budgets have been fixed to this growth. Recent forecasts have revealed growth, however utilisation of these services are below population growth. Reasons why this is happened are a combination of controllable and uncontrollable variables. Variables like;

- Winter severity - Net worth threshold for rest home subsidy has been impacted by Auckland house price increases

resulting in a reduced number of clients receiving a subsidy - Economic family hardship - Managed strategies to keep the aged well and more self-managing. - InterRAI assessments and reassessments have been resulting in reduced Home Based Support Service

cost.

Other A number of priority issues arose during the year that required unbudgeted spend they include:

- Increasing Oral Health – Relief of Pain volumes due to meeting a large increase in demand - Further investment into achieving health targets - Palliative care – GP training

The above plus additional external costs in relation to Localities and Community Integration activity have been absorbed within the total surplus.


5.10 Locality Reports

Eastern Locality

General Manager Integration, Eastern Locality Penny Magud – the newly appointed General Manager Integration, Eastern Locality will start on 31st August 2015. Reablement Service This service will be managed through the Integrated Coordinator in the Eastern Locality which like Franklin Locality’s Rapid Response is an existing service, making Reablement an extension of business as usual. At the end of July systems were poised for the first patients to be enrolled for both Eastern and Franklin Localities.

1. Acute Demand

Indicator Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

CMDHB Avg Last 12 mths

1.1 Unplanned readmissions (28 days) 5.3% 5.7% 5.2% 5.2% 5.7% 5.1% 6.4%1.2 ASH rate (per 1,000 enrolled patients) 0.5 0.6 0.8 0.9 0.7 0.7 1.41.3 Average bed day usage in last 6 months of l ife 11.2 9.9 6.8 8.0 15.5 13.7 11.8Notes : Numbers for previous months may change as additional morta l i ty data i s received for 1.3 and as coding i s modi fied for 1.1 and 1.2.Aged Res identia l Care Bed Days in Pukehoke and Frankl in Memoria l Hospi ta ls are included in the figures for 1.3 - this wi l l primari ly a ffect Frankl in as ARC faci l i ties are independently located in a l l other loca l i ties .

2. Quality



2.1 Children fully immunised at 8 months (Target = 90%) 95.4% 94.9% 95.1% 94.7% 95.5% 94.9% 94.1%2.2 Children fully immunised at 24 months (Target = 95%) 97.4% 96.7% 97.5% 96.2% 96.6% 94.7% 95.5%2.3 Middlemore Radiology < 6 week wait time for GP Referrals 87.0% 92.6% 92.2% 89.8% 88.8% 91.6% 91.4%

3. Shared Accountability Services

Item Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15Last 12

Mths3.1 ED presentations not admitted 245 223 214 236 227 200 28543.2 Acute medical bed days 1061 1093 1278 1358 1371 1262 168323.3 Acute casemix-funded non-medical bed days 806 774 963 1080 900 884 116033.4 Medical outpatient attendances 1691 1739 2221 2053 1968 2045 25023Note : Al l SAS volumes for previous months may change as IDF updates are received and coding i s modi fied

4. Other



4.1 E-referrals as % of all referrals 21.0% 24.8% 23.3% 24.2% 26.3% 27.0% 19.5%4.2 Medical Outpatient DNA rate 2.1% 1.2% 3.5% 3.6% 2.2% 3.5% 8.7%Note : Numbers for previous months may change as coding i s modi fied for 4.2 , and additional referra ls are included for 4.1


Mangere/Otara Locality

Vision: People living in Mangere-Otara Locality are Well A key population health measure is Ambulatory Sensitive Hospitalisations which indicates the number

of preventable admissions to hospital. Ambulatory Sensitive Hospitalisation rates are slowly declining. In June 2015 the Ambulatory Sensitive Hospitalisation rate was 2.1 per 1000 enrolled patients. This compares favourably to the same period last year when the Ambulatory Sensitive Hospitalisation rate was 2.6 per 1000 enrolled patients. A small group is working on improvements to the Locality performance monitoring framework “Dashboard”.

Goal: Promote Healthy Environments & Lifestyles The Healthy Families Initiative targeting people living in Otara-Mangere is in the planning phases. There

has been an approach from the Locality Leadership Team to the Auckland Regional Public Health Service to explore ways of working on initiatives that improve the local environment, for Health benefit. Otara Health’s “Housing Action Tank” continues to be supported by members of the Locality Leadership Team and provider network an intersectoral process that will drive action to resolve some of the complex variables creating high risk housing problems for local people. Poor housing feeds poor health and high hospitalisation rates.

1. Acute Demand



1.1 Unplanned readmissions (28 days) 8.1% 7.0% 6.5% 6.8% 5.9% 6.8% 6.4%1.2 ASH rate (per 1,000 enrolled patients) 1.8 1.8 1.7 1.8 1.7 1.8 1.41.3 Average bed day usage in last 6 months of l ife 9.5 10.1 9.8 10.9 9.7 11.0 11.8Notes : Numbers for previous months may change as additional morta l i ty data i s received for 1.3 and as coding i s modi fied for 1.1 and 1.2.Aged Res identia l Care Bed Days in Pukehoke and Frankl in Memoria l Hospi ta ls are included in the figures for 1.3 - this wi l l primari ly a ffect Frankl in as ARC faci l i ties are independently located in a l l other loca l i ties .

2. Quality






Mths3.1 ED presentations not admitted 767 611 703 672 643 650 83763.2 Acute medical bed days 1994 1721 1745 1865 2054 1804 263663.3 Acute casemix-funded non-medical bed days 1612 1334 1700 1316 1589 1539 187123.4 Medical outpatient attendances 2442 2763 3141 2634 2688 2720 36113Note : Al l SAS volumes for previous months may change as IDF updates are received and coding i s modi fied

4. Other





Strengthen and Integrate Self-Management support

Drop in Tapuaki pregnancy and parenting classes started on 18th June and occur weekly in Otara town centre, with referrals promoted through local self-employed midwives. The Infant nutrition and breastfeeding workforce development workshops commenced in June. A community integrated self-management support initiative has started. In collaboration with the Ko Awatea Hauora Manaaki Campaign this initative aims to get all providers of self-management support services targeting people living in Otara-Mangere to come together with the Locality Leadership Team to answer the question “how can we work together better to better support the self-management of people living in this place, across their life-course?” A stakeholder workshop is being planned for 2nd September, an action plan for self-management support service development will come out of this.

Integrated Health & Social Care - Risk stratification, Assessment, Diagnosis, Care Planning, Treatment / Therapy / Care

Pharmacy free pregnancy test pilot - A ‘second phase’ of the pilot was run until the end of June. The pilot’s objective of getting significant proportions of women attending their GP was not achieved and the pilot has been wound up. An Otara self-employed midwives directory has been printed and 400 copies distributed to local general practices, Non-Government Organisations and other potential referrers. A clinical audit has been developed for general practices to use for assessing their practice’s maternity care. An initiative that targets our high risk youth is in the early planning phases under the leadership of the CMH Youth Health Leadership Team. Adults of high risk of disease progression causing hospitalisation continue to be enrolled by their General Practices on the At Risk Individuals Programme. Service level integrated Multidisciplinary Teams continue to develop around the four clusters of General Practices and are strengthening their ways of working. Taikura Trust has agreed to join in meaning each general practice will have a named contact person in Taikura Trust who can help with assessment and planning where patient / family whaanau cases are complex and involve a disability issue for under 65 year olds. We are expecting this model of integrated care to benefit from CMH’s roll-out of it’s “Community Central” initiative in September. A working group has formed to develop an action plan to strengthen the provider network’s focus on better management of people living with Chronic Kidney Disease. This is part of a wider agreement to work with CMH in a portfolio approach to strengthen the focus on diabetes prevention and better management, as proposed by Danny Wu. Recommendations on how to strengthen foot care of local people living with diabetes were received by the Leadership Team from the Integrated Foot Care Working Group, led by Alan Greenslade. The aim is to reduce the rates of lower limb amputations in local people. ProCare and East Health indicated their support for a locally co-ordinated model of podiatry service delivery to increase podiatry interventions, a key recommendation of the working group. Once a decision is received from Alliance Health Plus PHO, Total Healthcare PHO and the National Hauora Coalition,


next steps on this initiative will be taken. The proposal to divert simple wound care from District Nurses to Practice Nurses has been well received by the primary care nurse and GP clinical leads. Enable System Integration

Strengthen Provider Networks

• A Midwife “mix and mingle” lunch meeting was held in June. Objectives were to form a local network, share experiences and educate the midwives on the project’s integration initiatives. It was attended by 21 midwives.

• Approximately 20 Nurses working in Otara met as a network group and shared ideas on how to work together better for shared benefit. Information sharing and learning together was a common interest.

• Doctors networks are strengthening as a network by way of the integrated clinical governance groups which is re-engaging local GP’s and SMO’s in a meaningful dialog about care of people with diabetes, among other things.

Design, Develop and Implement Shared Services Hubs

• The Locality Leadership Team received the report commissioned by CMH from Sapere on Facility Planning for Otara-Mangere. They have agreed to reconvene the small group that worked on the Facilities planning 12 months ago to progress planning to the next stage. The aim is to have shared services hubs up and running in 12 months in Mangere, and Otara respectively. A sum of money has been allocated to facility fit out by CMH in it’s capital planning & prioritisation process. The next step is to agree the details of service mix with CMH.

• CMH General Medicine and a third Party continue to negotiate on the establishment of a haemodialysis unit in the Mangere shared services hub area. Once concluded the Locality will have some certainty around whether that facility will operate in Mangere.

Share Information

• Handheld pregnancy journey cards to record pregnancy care milestones and share that information between GPs and midwives are now used in six general practices, by local self-employed and DHB midwives and Non-Government Organisations.

• E shared care continues to be implemented under the At Risk Individuals Programme, as an electronic means of sharing assessment and care planning information between some members of the multidisciplinary teams.

• The availability of Vivid Technology to Multidisciplinary Teams is progressing well and it seems like a solution will be available soon.


Manukau Locality

Winter Wellness Health Promotion in Manukau Locality – May - June 2015 In May and June the Manukau Locality developed and circulated two health promotion resources focusing on Winter Wellness. • A Poster covering Flu immunization, Smoking cessation, options for seeking health advice and information on the Warm up Counties programme. The poster was shared with GP Practices, Community Centres, Libraries, Early Childhood Education Centres, Social Services, Marae, Churches, Home Based Care Providers, Libraries, Pharmacies, Outpatient clinics and a Pacific Health Expo. • A double sided information sheet covering topics such as Immunisation, Importance of Warm housing and insulation, Smoking Cessation and what to do when people are unwell including Primary Care and telephone advice available. These resources were shared with over 60 different services in the Manukau Locality. GP practices/organisations/businesses offered these resources were happy to share with their clients, patients, customers. This initiative supported increased health literacy and shared practical ways of keeping well in the winter months. It also provided opportunities for an unexpected increase in networking with a range of health and socials services within the Manukau Locality. These included: • Identification of possible venues for collocated health clinics and venues for education sessions

for clinicians and patients • Opportunities to collaborate in health education e.g. requests for support with contraceptive

education by one social service organisation

1. Acute Demand



1.1 Unplanned readmissions (28 days) 6.2% 6.5% 6.0% 5.5% 5.1% 6.5% 6.4%1.2 ASH rate (per 1,000 enrolled patients) 1.5 1.5 1.7 1.4 1.6 1.5 1.41.3 Average bed day usage in last 6 months of l ife 13.8 10.2 9.5 9.8 8.7 10.1 11.8Notes : Numbers for previous months June change as additional morta l i ty data i s received for 1.3 and as coding i s modi fied for 1.1 and 1.2.Aged Res identia l Care Bed Days in Pukehoke and Frankl in Memoria l Hospi ta ls are included in the figures for 1.3 - this wi l l primari ly a ffect Frankl in as ARC faci l i ties are independently located in a l l other loca l i ties .

2. Quality






Mths3.1 ED presentations not admitted 759 617 685 672 653 613 85203.2 Acute medical bed days 2413 2197 2596 2347 2454 2425 325053.3 Acute casemix-funded non-medical bed days 1800 1819 2024 1944 1877 1937 244033.4 Medical outpatient attendances 3195 3613 4069 3525 3948 3957 49326Note: Al l SAS volumes for previous months June change as IDF updates are received and coding i s modi fied

4. Other





• Opportunities for linking with youth services through YouthLine. This resulted in a representative form Youth line joining the At Risk Individual Phase two work stream and representatives from Youthline attending General Practitioner Cell Group meetings in the locality.

• Opportunities for future linking with migrants and refugees through the English Language Partners Auckland South (formerly ESOL Home Tutors). This organisation is keen to explore ways in which they can link with the locality and improve health status/ health literacy for their clients. Conversations are continuing with the coordinator of this organisation.

• Linking with the Manukau Kindergarten Association Play Truck staff and identifying ways in which this service could also support future locality health education in low decile areas.

• Identification of community groups (e.g. Early Childhood Education centres, Workskills organisations) who can share health promotion information for future initiatives.

Healing at Home - Self-Management Project – Manukau Locality 2015-2016 The Manukau Locality team members at the Papakura Home Health Care base have committed to a two year self-management project. The service’s vision for this project focuses on inspiring and enabling high service reliant patients with long term conditions, to self-manage in partnership with their primary care team. This project will support patients to spend more time well in the community and experience less service inputs. The project’s aim is to ensure that at least 500 high service reliant patients, with long term conditions in the Manukau locality, will have a personal self-care plan by 1st December 2016. Background to the Project The District Nursing service at Papakura has a large number of high reliant patients (patients requiring more than one home visit a week over the last 12 months) within their case load. A data search identified referrals for wound care were one of the key reasons for patients to require high service inputs. A survey assessing the current self-management skills and practice of the Home Health Care Team (District Nurses, Allied Health and Needs Assessment clinicians) highlighted a number of deficiencies in practice which could be improved by training staff and providing resources to support better patient focused goal setting, improved care planning and patient health literacy. Outcome measures will include number of home visits and Emergency Department presentations, time between home visits, change in patient and clinician self-assessment scores and number of patients with personal care plans. Progress Process charting and driver diagrams have identified a list of change ideas, and the testing of PDSA cycles is underway. Fifty high reliant patients will complete self-assessment surveys in the next few weeks after which clinicians will start to work differently support improved patient self-management in a number of different ways, which will be guided by the results of regular PDSA cycles. Clinical Priorities Diabetes Collaborative The locality clinical team including GP lead, senior medical officers and nurse lead continue to work with Ko Awatea on the clinical priority of patients, aiming to review 200 patients with HBA1C over 100.


Practice teams are showing interest in: • identifying patients with high HBA1c who have the “potential” to become self-managing (complex and severe cases may need to be looked at separately), • Learning more about the role of Multi-Disciplinary Team meetings and how they can be of value to the patient and practice. The group has developed the change ideas demonstrated below to support a range of response and interventions to support patients to achieve their goals. Multi-Disciplinary Team meetings are planned in three practices in the coming weeks. The first Multi-Disciplinary Team review has been held with 10 patients on the list and seven reviewed. Some of the change ideas below (see boxes) were generated following this first Multi-Disciplinary Team review.


Locality Co-ordinators The locality co-ordinators are leading the winter reablement pilot for Manukau. Training is complete and the first two patients have been assessed and commenced on the service. The co-ordinators continue to review frequent presenters and support practice teams with At Risk Individuals as well as testing the reablement processes. Their role with reablement is an interim measure until capacity within the system is released and the full roll out of the reablement service is enabled using district nursing as the key clinical leads. The front door combined triage process continues with a workshop planned to review the process and achievements to date. So far the combined process is working to minimise time spent between


individual teams to review similar lists and to ensure a co-ordinated response for each frequent presenting patient requiring follow up. Analysis is also underway to review effectiveness of the interventions with patients following the triage process. Opportunities for sharing resources and support are being utilised with a combined approach from Maori and Pacific teams with a clinical VHIU team member for patients with complex health and social needs. A member of the community geriatric service will join the workshop to better understand the services that support frail elderly in the community in particular. Locality Co-ordinators continue to support the clinical priorities diabetes project as well. Huff and Puff Collaborative This collaborative includes a Respiratory Consultant, Locality Nurse Lead and the Respiratory Physiology team based at the Manukau Super Clinic. The aim of the chronic obstructive pulmonary disease collaborative (AKA Huff and Puff) is to design a reliable screening, referral and intervention pathway for 50 people who smoke aged 35 plus in the Manukau Locality to enable early diagnosis of breathing problems and the support of self- management by June 2016. Participants are identified from within community groups; workplaces and business’s using posters and e mails to recruit with support from management within the organisation. Spirometry testing is offered with letters and lung function results sent to patients General Practitioner with the participant’s consent. Within 4 weeks of testing, a member of the collaborative group will contact the GP for feedback. Smokefree advice and support is offered at time of testing. On July 20th the collaborative group took the opportunity to link into the Respiratory Consultant’s outpatient Clinic (also the clinical lead for this collaborative). This was a trial run of the actual process (engaging patients; practicality of spirometry testing) as well as capturing early diagnosis of chronic obstructive pulmonary disease. The group successfully completed seven spirometry tests on members of the public attending the Clinic and in doing so, gained a number of new learnings. Over a three hour period, 14 potential participants were approached regarding the free spirometry test. Seven participants declined and seven were tested. Of note, participants were very willing to share their reasons for taking part (quit smoking due to expense; family persuasion to quit; keen to be part of a trial). Following this trial, minor changes have been made to the patient information sheet and data capture sheet. The group are in discussions with two potential community settings (Papakura Marae and Vodafone) who have shown interest in supporting the next phase.


Franklin Locality

Dementia Pathway Outreach Pilot - Waiuku Medical Centre The pilot is set to commence with Practice champions in early August. It will be based on the findings from the Waitemata Primary Pilot and the dynamic clinical pathway integrated with the At Risk Individual Programme Videoconferencing – implementation at Franklin Community Health Services A trial of the virtual conferencing process was held on Monday 20th July across the four Locality Community Teams using Real Presence software. The trial using the Localities Virtual Meeting Room, with connections through the CMH intranet was successful. This communication system will be used to connect clinicians from community health bases, as required for redesigned working groups. Work is continuing to rectify some technical issues with the Vivid Solutions software which will support video conferencing for Multi-disciplinary meetings in Primary Care. Help You, Help Me The work in this collaborative is slowly progressing with the first cohort now live on the web site. A valuable meeting with a local literacy group has demonstrated the need for testing assumptions made on key words for searching electronically. Winter Planning A review of lessons learnt and on the progress achieved was held at the end of July. A member from the Communications Team was invited as a regular attendee to assist with the formatting of

1. Acute Demand



1.1 Unplanned readmissions (28 days) 8.2% 4.9% 6.2% 6.2% 7.4% 6.3% 6.4%1.2 ASH rate (per 1,000 enrolled patients) 0.8 1.1 1.2 1.0 1.0 0.8 1.41.3 Average bed day usage in last 6 months of l ife 24.5 16.3 20.3 9.8 14.4 15.0 11.8Notes : Numbers for previous months June change as additional morta l i ty data i s received for 1.3 and as coding i s modi fied for 1.1 and 1.2.Aged Res identia l Care Bed Days in Pukehoke and Frankl in Memoria l Hospi ta ls are included in the figures for 1.3 - this wi l l primari ly a ffec Frankl in as ARC faci l i ties are independently located in a l l other loca l i ties .

2. Quality






Mths3.1 ED presentations not admitted 132 110 120 103 82 101 14003.2 Acute medical bed days 707 703 667 700 721 937 106273.3 Acute casemix-funded non-medical bed days 548 536 560 619 626 548 78423.4 Medical outpatient attendances 862 1075 1178 1131 1213 1076 14557Note: Al l SAS volumes for previous months June change as IDF updates are received and coding i s modi fied

4. Other





publications and written messages. In general most of the initiatives are progressing well and the early stages of the dashboard are heading in the right direction. Discussions were held regarding whether another boost of the message would be beneficial in September, and a more targeted approach was decided within the Pukekohe North area.

Clinical Advisory Networks Locality progress with Enuresis, Diabetes, and Palliative care discussions are under way each with champions and across sector engagement.

Social Services Integration in Otara-

Mangere Locality July 2015

093

Outcome Accountable Care

Coordinated Seamless Healthcare System 2.0

• Patient/Person Centered

• Transparent Cost and Quality Performance

• Accountable Provider Networks Designed Around the patient

• Shared Financial Risk

• HIT integrated

• Focus on care management and preventive care

Community Integrated Healthcare

● Healthy Population Centered

● Population Health Focused Strategies

● Integrated networks linked to community resources capable of addressing psycho social/economic needs

● Population based reimbursement ● Learning Organization: capable of rapid deployment of best practices ● Community Health Integrated ● E-health and telehealth capable

• Episodic Health Care

• Lack integrated care networks • Lack quality & cost performance transparency

• Poorly Coordinate Chronic Care Management

Acute Care System 1.0

US health care delivery system evolution

Community Integrated Healthcare System 3.0

Health Delivery System Transformation Critical Path

Episodic Non-Integrated Care

094

Locality Structure

095

Locality Structure cont.

096

Integration work in the locality

Keeping people well

Identifying people at risk

Better integrated care

Monitoring the impact of care

• Healthpoint website profiles

• Social service provider forums

• Social service network coordination contracts

• MDT meetings • Network of

providers for pregnant women and whanau with young children

• Leadership and monitoring performance

• Developing an integrated dashboard

Population health approach: the continuum of care

097

Keeping people well

Social service provider forums

Series of forums for providers working in secondary and community, across the whole DHB region

Objectives are to: strengthen relationships across the sector; and have a common understanding of funding streams and referral criteria; with a view to improving use of resources

Housing Hui

DHB represented at local hui to address housing shortage issues, and committed to working collaboratively on solutions

Healthpoint website profiles

Work in partnership with Healthpoint to profile Otara and Mangere based social service organisations on the Healthpoint website.

The Healthpoint website is popular with health providers looking for information on other health services; this initiative makes information on local social services more readily available to clinicians.

098

Identifying people at risk

Social service network coordination contracts

Take referrals from local clinical teams, make assessments, triage according to need and refer to appropriate social service providers

Establish and provide leadership of local social services networks

Lead engagement and active networking with local people, ensuring their views are represented at a locality governance level

099


Multidisciplinary team meetings First established in Mangere in 2013 to provide a regular forum /

opportunity for General Practices to get multidisciplinary team input into care of people “At Risk” of disease progression causing hospitalisation

7 General Practices across three of the four Clusters of general practices in the Mangere Otara Locality, participate and present cases at MDT meetings

As new service providers have joined the MDT environment they bring with them greater knowledge and access to resources and programmes to support general practice in meeting the needs of the patient and whanau.

Meetings are generally well attended and feedback is positive in terms of the learning, networking and integrating opportunities the forums present.

A CMH wide MDT charter has been agreed and this underpins MDT processes.

100


Multidisciplinary team meetings continued Two tiers of “MDTs”:

1. Practice specific, generalist MDTs. Generally nurse led and focusing on issues of a less clinical nature. Multidisciplinary team comprises practice staff, community social service providers, community pharmacists, Home Health Care, District Nurses and Allied Health, NASC, SME coordinators, PHO social workers and mental health workers.

2. Combined practice, specialist, MDTs. GP led and involve clinically complex cases. Team includes practice teams, SMOs and clinical nurse specialists, secondary mental health, secondary care social workers, VHIU and secondary care pharmacists.

101


Mangere social service provider network

Series of workshops held with community providers and service users in 2014

Co-design sessions to develop the processes for service integration for whanau in the Mangere area

Network of providers for pregnant women and whanau with young children

Local integration project in Otara has been the vehicle for building an intersectoral network of primary care providers and community based social services organisations.

Bi-monthly meetings and various small co-designed initiatives have built trust and knowledge between midwives, general practice staff, well child providers and key social service and mental health NGOs.

Referral pathways are understood and better utilised, information sharing has improved

102

Monitoring the impact of care

Leadership and monitoring performance

Chief Executives of two key social service organisations have been appointed to the locality leadership team

Developing an integrated dashboard

The locality is currently revising the monthly dashboard to incorporate a social services indicator

Signals a commitment by the Locality leadership team to work intersectorally on improving the overall wellbeing of the population

May be in the area of housing, employment or education (TBD).

DHB data analyst trained in the area of measuring collective impact

103


Counties Manukau District Health Board 6.0 Resolution to Exclude the Public Resolution: That in accordance with the provisions of Schedule 3, Clause 32 and Sections 6, 7 and 9 of the NZ Public Health and Disability Act 2000: The public now be excluded from the meeting for consideration of the following items, for the reasons and grounds set out below:

General Subject of items to be considered

Reason for passing this resolution in relation to each item

Ground(s) under Clause 32 for passing this resolution

7.1 Minutes of CPHAC meeting 27 May and 8 July 2015 with public excluded

That the public conduct of the whole or the relevant part of the proceedings of the meeting would be likely to result in the disclosure of information for which good reason for withholding would exist, under section 6, 7 or 9 (except section 9(3)(g)(i))of the Official Information Act 1982). [NZPH&D Act 2000 Schedule 3, S32(a)]

Confirmation of Minutes For the reasons given in the previous meeting.

counties manukau district health board community & public ... · resolution (moved mr john...

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