MH54 People with Chronic

PEOPLE WITH CHRONIC CONDITIONS

A Discussion Paper

April 2005

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TABLE OF CONTENTS

Purpose of this consultation ...................................................................................2

How to have your say ...........................................................................................2

Section 1: Background ...............................................................................................3

National Health Committee project .......................................................................4

Why look at chronic conditions? ...........................................................................7

Inequalities in health .............................................................................................8

Why it is important to improve support for people with chronic conditions ...........9

Who needs to be involved in supporting people with chronic conditions? ..........10

Section 2: Approaches to supporting people with chronic conditions .....................12

Other countries ...................................................................................................12

New Zealand ......................................................................................................14

Support for self-managing chronic conditions ......................................................16

Role of complementary and alternative care ........................................................19

Section 3: Summary of issues – people with chronic conditions ..............................21

Part 1: Factors that help people with chronic conditions .....................................21

Part 2: Factors that hinder people with chronic conditions ..................................19

Section 4: Summary of issues – practitioners and agencies ......................................27

Element 1: Improved interactions between people and professionals ...................27

Element 2: Redesign of delivery systems and processes .......................................29

Element 3: Workforce planning and development ...............................................32

Element 4: Knowledge management ....................................................................34

Element 5: Partnerships within health, and between health and the community ..35

Appendix 1: Where to go for more information .......................................................38

Appendix 2: Initiatives around New Zealand ...........................................................39

Appendix 3: Contacts ...............................................................................................60

References ...............................................................................................................61

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Purpose of this consultation

This consultation will contribute to the National Health Committee’s (NHC’s) advice to the Minister of Health on how to better support people with chronic conditions.

The NHC seeks your input to help it identify:

• whether the views and key issues from the initial round of meetings reflect wider views

• other key issues that are not presented here

• suggestions for change to help improve how people with chronic conditions are supported.

How to have your say

The NHC is seeking input from a wide range of individuals and organisations – including people with chronic conditions and those who work with them. People working in this area may be in organisations such as District Health Boards (DHBs), Primary Health Organisations (PHOs), Non-Government Organisations (NGOs) or consumer organisations, as well as from other sectors such as housing, transport or social services. If you are representing a collective view (eg, representing the views of an organisation or community), please make this clear in your submission. Please also state if you have a chronic condition/s yourself, or if you are a health professional. If you would prefer to discuss your input, please contact us. All input will be treated in confidence.

Throughout the paper there are questions designed to help you think through your ideas, but please do not feel constrained by them. We welcome your input on any level. However, we would ask that you address the three bullet points above to identify gaps in our analysis and to assist development of a way forward.

The project is focused on people with chronic conditions rather than on specific conditions or diseases. We are not seeking submissions on ‘best practice’ for clinical treatment of particular conditions, but input on the major issues facing people with chronic conditions, and those who work with them.

The NHC acknowledges that on many issues there will not be consensus, but the more submissions it receives, the better able it will be to judge the strength and diversity of views on any particular issue. We therefore encourage you to participate in this consultation.

SUBMISSIONS ARE DUE BY 31 MAY 2005Please send your input to:

Submissions to Chronic Conditions project National Health Committee PO Box 5013 WELLINGTON

Ph (04) 496 2088Or by email to [email protected]

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SECTION 1: BACKGROUND

In New Zealand, as around the globe, the numbers of people living with chronic conditions are on the rise. The World Health Organization has stressed that “chronic conditions will not go away; they are the health care challenge of this century”1.

A fundamental culture change is required to shift our health sector from an acute focus to one that better meets the needs of people with chronic conditions. The health sector has traditionally focused primarily on medical needs, whereas a complex range of social, cultural and economic factors affect people’s health status, many of which lie outside the health sector.

This discussion paper introduces the issue of supporting people with chronic conditions and presents the findings of an initial round of meetings with people with chronic conditions, and those who work with them. Many of the views in this paper reflect those given in focus groups and other meetings and do not necessarily reflect the views of the NHC.

National Health Committee project

The NHC is an independent advisory group to the Minister of Health. It provides advice on a wide range of health and disability issues. The NHC was established in 1992 and is made up of 12 members from around the country who have knowledge of, and experience in, health and disability issues.

This project is looking at people’s experiences of living with chronic conditions in New Zealand, in order to suggest changes to improve the ways that services and professionals support people with chronic conditions. It has links with previous work by the NHC on quality improvement in health care and improving services for adults with intellectual disability.

The project’s objectives are:

1) to find out what helps and what hinders in living with chronic conditions

2) to identify the key issues in supporting people with chronic conditions

3) to advise the Minister of Health on changes to improve how people are supported.

This paper is just one strand of the work. The NHC’s final advice will be based on information collected in case studies involving groups of people with chronic conditions, to be undertaken in 2005, as well as the literature and consultation used to inform this paper and the subsequent submissions.

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Flowchart of project components

NHC interest in people with chronic conditions

Initial round of meetings with providers, NGOs and

government agencies

Initial round of focus groups with people with chronic

conditions

DISCUSSION PAPER

Submissions from people with chronic conditions

Submissions from providers and agencies

Analysis of submissions

Case studies with people with chronic conditions

– people from under-served populations, families with children with chronic conditions, people with depression associated with chronic conditions

Appraisal of findings from submissions and case studies

Final report to Minister of Health

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People with chronic conditions – a defi nitionThe National Health Committee is using a broad defi nition of people with chronic conditions – including people with any ongoing, long term or recurring condition that can have a signifi cant impact on a person’s life.

A wide range of physical and mental health conditions comes under this defi nition, including asthma, arthritis, diabetes, chronic neck or back problems, depression, HIV and cardiovascular disease. It is common for people to have more than one chronic condition, and for others to live with multiple conditions.

The NHC’s work focuses on people in the context of their whole life, rather than taking a disease-based approach. It is appropriate to take a holistic view, as people often live with more than one chronic condition and people’s experiences with chronic conditions are intertwined with their social and economic contexts. People with long-term conditions are often expert at managing their condition/s.

Chronic conditions can affect people’s mental, emotional and spiritual wellbeing as well as their physical health. Depression is a common ongoing condition in itself, and can be associated with many other chronic conditions such as diabetes or cardiovascular disease. For instance, depression is a risk factor for cardiovascular disease, and people with cardiovascular disease have a higher likelihood of experiencing depression than those without cardiovascular disease. In addition, people with mental illness experience relatively high levels of physical illness.2

The NHC believes that spiritual wellbeing should be an integral part of the concept of health and has a role in the support of people with chronic conditions. Our human nature is comprised of both body and soul, and our physical, emotional, and spiritual health are closely intertwined. Times of injury, disease, acute or long-term illness, and their accompanying suffering, often raise profound questions of human meaning, affecting whänau, families and individuals.

In the context of long-term conditions, it is important to address individuals’ spiritual health. An individual’s spiritual state, as expressed through relationships with their Creator, God, ancestors, environment or other people, can support or undermine efforts at maintaining or restoring physical and mental health.

This work by the NHC concerns people with chronic health conditions, rather than people experiencing disability. However, some chronic conditions may result in impairments and some people with chronic conditions may identify as having a disability. There is a need to avoid perpetuating the myth that disabled people are unwell, while recognising that disabled people with chronic health conditions may face similar challenges to others, and must have access to health services without discrimination.

Question for respondents

Do you agree with the NHC’s defi nition of people with chronic conditions?

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Prevention and management of chronic illness

Key elements of better supporting people with chronic illness are to ensure early identifi cation of chronic illness, prevent complications where possible, slow the progression of disease and prevent other conditions from developing. Chronic conditions are largely preventable and share a range of common risk factors – such as inactivity, unhealthy diets, obesity, depression, stress, tobacco use and alcohol misuse.3 Prevention is, therefore, a critical issue in the management of chronic conditions. The World Health Organization promotes a ‘common risk factor’ approach to the prevention of chronic conditions, where a cluster of such factors contributes to chronic conditions.3 The 13 population health objectives in the New Zealand Health Strategy refl ect a focus on prevention.

As chronic conditions share common features both in terms of prevention and management, the NHC believes primary prevention must be considered as an integral aspect of supporting people with chronic conditions. There are still important opportunities for primary prevention once people have been diagnosed with a chronic condition/s. For example, if a person has diabetes, they will be at an increased risk of cardiovascular disease. Support for that person should include preventative measures to reduce their risk of developing cardiovascular disease. Chronic care management programmes present opportunities to encourage primary prevention of a range of related chronic conditions, as well as preventing complications of diagnosed illness. Different conditions will progress along the life course in different ways, with a number of potential intervention points for both prevention and management across the progression of illness.

This paper focuses on supporting people with chronic conditions rather than on prevention, but it incorporates aspects of prevention where relevant to effectively support people with chronic conditions.

What does support mean?Supporting people with chronic conditions (i.e., management) more effectively does not just mean better services or treatment. The NHC sees ‘management’ or support as encompassing everything that people do to live a full life with a chronic condition/s. This may include: • formal and informal social/community support• family/whänau support and involvement in living with chronic conditions• self-management of chronic conditions• prevention of complications• primary prevention of other conditions• access to better information on chronic conditions• access to culturally appropriate services and treatment (including complementary

and alternative health services).

The term ‘support’ is primarily used in this paper to refl ect a broader understanding than the traditional medical term ‘management’. It should not be confused with support services such as disability support.

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Why look at chronic conditions?

In New Zealand and around the world, the numbers of people living with chronic conditions are rising dramatically. People are living longer with chronic illnesses and with more complex co-morbidities. This is due to ageing populations, change in lifestyles and societal factors such as urbanisation and global marketing of unhealthy products.1

Chronic conditions don’t just affect the individuals with the condition, but a much wider group including family members and society as a whole. For instance, family members who give up paid work to care for someone with a chronic condition earn less income and have less opportunity to save for retirement. These issues increase in importance as people survive longer with chronic conditions.

WorldwideNoncommunicable conditions and mental illness accounted for 46% of the global burden of disease in 2000.i By 2020 it is predicted to increase to 60% - with heart disease, stroke, depression and cancer the biggest contributors.1

In New Zealand• most New Zealanders now die of chronic conditions.

Chronic illness accounts for over 80% of all deaths13, ii

• the management of chronic conditions is the leading cause of hospitalisationsiii

• it is estimated that 70 percent of health care funds is spent on chronic disease4

• most of the 13 priority areas in the NZ Health Strategy are either chronic conditions, using the NHC’s defi nition, or risk factors for chronic disease.

The most common chronic conditions (by diagnosis)iv are:• chronic neck or back problems (one in four adults)• asthma (one in fi ve adults aged 15-44 yrs)• arthritis (one in six adults)• heart disease (one in ten adults)• stroke (one in 48 adults).5

i Global burden of disease is a single measure of health status, which combines the number of deaths and the impact of premature death, and disability. (source: http://www.ispn-psych.org/docs/global4_00)

ii Personal communication with Martin Tobias, Ministry of Health

iii Excluding normal pregnancy and childbirth

iv These are people living with chronic conditions, not the most common causes of death (deaths caused by chronic disease are dominated by ischaemic heart disease, stroke and cancers)

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Some key facts on three examples of chronic conditions

Diabetes

• Diabetes is estimated to affect about 118,000 people in New Zealand, with a similar number predicted to have undiagnosed diabetes.6

• The number of new diagnoses of diabetes is predicted to double between 1996 and 2011.10

Mental illness

• Mental illness is experienced by approximately 20 percent of the population. About 3 percent require treatment from specialist services. The remaining 17 percent have less severe conditions that can be well managed in primary health care and do not usually require specialist treatment.

• Mental illness is estimated to cause 25 percent of years lost to disability (premature death). It is argued that, in some cases, the disability associated with mental illness is greater than that which results from major chronic physical diseases, including stroke and diabetes.

• Mental illness is predicted to account for 15 percent of the total ‘global burden of disease’ by 2020.

Arthritis

• One in six New Zealanders have been diagnosed as having arthritis.5

• More than one million New Zealanders will be affected by arthritis at some time in their lifetime.

• Arthritis is a major cause of impairment in New Zealand.7

• People of all ages can have arthritis, including children.7

Inequalities in health

Internationally, it is established that social position and ethnicity affect people’s health outcomes, with socially disadvantaged groups tending to have poorer health status, greater exposure to health risks, and less access to health services. In addition, indigenous peoples tend to experience worse health than other groups. Inequalities in health outcomes are well documented in New Zealand, between ethnic and socio-economic groups, as well as geographic, gender and age disparities. For instance, gaps in life expectancy between Mäori and Pacifi c peoples, and the rest of the population increased markedly during the 1980s and 1990s.8

The NHC argues for a strong focus on people with chronic conditions due to the large contribution of such conditions to health disparities.

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Chronic conditions and disparities in health

• Chronic diseases contribute the major share of the growing disparity in life expectancy between Mäori and Pacifi c, and non-Mäori non-Pacifi c people.8

• In comparison with other groups, Mäori and Pacifi c peoples tend to get chronic disease at a younger age, and to experience more severe illness. In the Decades of Disparity study cited above, the Mäori and Pacifi c 45–64 and 65+ age groups were found to contribute substantially and about equally to the ethnic disparity in life expectancy at birth.8

• Diabetes is about three times more common in Mäori adults than non-Mäori.9 Mäori and Pacifi c people are more than fi ve times more likely to die from diagnosed diabetes than non-Mäori, non-Pacifi c people.10

• Mäori and Pacifi c people tend to be diagnosed with diabetes at a younger age than non-Mäori, non-Pacifi c people. The average age of diagnosis is 47-48 years for Pacifi c peoples compared with 54 years for New Zealand Europeans.10

• Some children have been diagnosed with type 2 diabetes; almost all of these have been Mäori or Pacifi c children.6

As there are signifi cant inequalities in severity and onset of chronic illness, improving how people with chronic conditions are supported is an effi cient way to reduce health inequalities. As Barbara Starfi eld, Professor at John Hopkins University School of Public Health, has stated:

“Personal health services have a relatively greater impact on severity…than on incidence. As inequities in severity of health problems…are even greater than inequities in incidence of health problems, appropriate health services have a major role to play in reducing inequities in health.” 11

Preventing chronic illness (and risk factors such as inactivity and obesity) through a range of primary prevention initiatives and diagnosing people earlier will also play a major part in reducing inequalities in health.

Why it is important to improve support for people with chronic conditions

Chronic conditions affect the lives and wellbeing of many New Zealanders. Living with a chronic condition, or with several conditions, can have a signifi cant impact on peoples’ lives, including family wellbeing and capacity to undertake fulfi lling work and other activities.

Even though the majority of people using the health sector have chronic conditions, our health system is still largely based on an acute model of care. The traditional model of health care is cure-focused, and treats people using a problem-solving approach. This approach is not well suited to people with chronic conditions.

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Instead, a focus on supporting people with chronic conditions emphasises:

• a ‘people-centred’, holistic approach with a focus on self-management

• attention to psychosocial, emotional and spiritual wellbeing

• a greater emphasis on communication, teamwork and integration across services

• ongoing, regular contact between people with chronic conditions and health care services – moving from episodic to continuous care.

As raised earlier, improving how people with chronic conditions are supported is also an effi cient way to reduce inequalities in health.

Who needs to be involved in supporting people with chronic conditions?

People with chronic conditions, and their families, have often lived with the effects of their illness for many years, and have expert knowledge of their own experiences and needs. Efforts to improve how chronic conditions are dealt with must involve people with chronic conditions and family members, and interventions must be planned and coordinated in partnership with the person with chronic illness.

Chronic conditions cannot be prevented or managed by the health sector alone. Many of the factors affecting whether people develop chronic conditions, their risk of developing complications and how effectively they manage lie outside the health sector – for instance, housing, income, transport, local government, education and social services.12 The issue of chronic conditions should be high on the agenda of the whole community. Tackling chronic illness demands an intersectoral approach and strong community engagement.

EXAMPLE OF WORKING ACROSS SECTORSCounties Manukau District Health Board is in the process of producing a fi ve-year, community-owned diabetes plan, “Let’s Beat Diabetes”, in partnership with Manukau City Council and other stakeholder groups. It is aimed at long-term structural changes to prevent, and/or reduce the number of people in the area diagnosed with, Type 2 Diabetes.v

Action areas (being consulted on at the time of writing) include:

• supporting community leadership and action

• enabling vulnerable families to make healthy choices

• changing urban design to support healthy active lifestyles

• developing a Schools Accord to support ‘fi t and healthy’ schools.

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The best place for regular, proactive support of people with chronic conditions is the community setting, which includes primary health care.vi In the UK, people with chronic conditions account for up to 80 percent of primary health care consultations and it is likely that New Zealand would have a similar proportion.15 It has been suggested that up to 30 percent of hospital admissions in New Zealand could be prevented with timelier primary care intervention.13

Primary health care is an appropriate setting for chronic conditions management because it is based in the community, there is regular contact between people and health professionals (often over many years) and most people with chronic conditions can be supported well in primary health care with some specialist input. In addition, many conditions have a spectrum of severity, with most people being at the less severe end. Primary health providers have generalist skills, experience and networks that are useful in supporting people with chronic conditions.

The Primary Health Care Strategy, released in 2001, highlights the central role of primary health care in improving population health. The approach includes:

• a greater emphasis on population healthvii, health promotion and preventative care

• community involvement

• involving a range of professionals and encouraging multidisciplinary approaches to decision making

• improving accessibility, affordability and appropriateness of services

• improving co-ordination and continuity of care

• providing and funding services according to the population's needs as opposed to fee for services when people are unwell.viii

The Primary Health Care Strategy supports the broadening of primary health teams to include allied health professionals such as social workers, pharmacists, physiotherapists, occupational therapists and podiatrists.

v See Counties Manukau DHB website http://www.cmdhb.govt.nz/Counties/LetsBeatDiabetes/Diabetes-Plan/diabetes-plan.htm, accessed 26/1/05

vi The community setting includes the home, community organisations, primary health care, social services, recreational groups, etc.

vii A population health approach is one that aims to improve the overall health of the population. It involves identifying patterns within a population, relating them back to individuals and groups at risk, and identifying a ‘menu’ of broad based and individually tailored interventions that can improve the population’s health over time. Population health must address social, cultural and economic determinants, be multi-disciplinary and multi-agency, and emphasise health promotion, principles of equity, health information systems, and decision-making support.

viii Ministry of Health website www.moh.govt.nz/primaryhealthcare

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SECTION 2: APPROACHES TO SUPPORTING PEOPLE WITH CHRONIC CONDITIONS

Other countries

There are signifi cant moves in many countries to improve how care for people with chronic illness is structured and delivered. At the global level, the World Health Organization has advocated for an innovative approach to chronic conditions based on the ‘Chronic Care Model’, developed by Edward Wagner and used extensively in the United States and increasingly around the world ix.1

The World Health Organization set out eight essential elements for taking action, which build on the Wagner model for chronic care:

1. support a paradigm shift (from an acute to a chronic care model)

2. manage the political environment (to build political commitment for change)

3. build integrated health care

4. align sectoral policies for health

5. use health care personnel more effectively (eg, team models, new training, changing roles)

6. centre care on the patient and family (self-management, patient-centred care)

7. support patients in their communities

8. emphasize prevention

“As its ultimate goal, the chronic care model envisions an informed, activated patient interacting with a prepared, proactive practice team, resulting in high-quality, satisfying encounters and improved outcomes.” 14

The core features of chronic conditions models are similar, but terminology varies slightly across different contexts. Common elements of chronic care models include: changing the patient and carer role, process and system redesign, workforce planning and development, knowledge management, and partnerships between health and the community.15 Some examples of these fi ve elements are given in the following table.

ix The Chronic Care Model is used in over 500 health care organisations in the US and has been shown to have positive effects (Lewis and Dixon 2004 in BMJ Vol 328 24 Jan 2004)

x The elements and examples are adapted from Modernisation Agency 2004 Learning Distillation of Chronic Disease Management Programmes in the UK.

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Elements of chronic conditions models x

Some examples

Improved interactions between people and professionals

Support for self-management, patient-held records, person-centred care, care plan where person with a chronic condition sets their own goals

Redesign of delivery systems and processes

case management, care pathways, medicines management, non-physicians trained to support self-management, arrange for routine tasks (eg. eye exams, foot checks) and ensure follow-up

Workforce planning and development

Use of teams, including allied health professionals (eg, social workers, physios, podiatrists), nurse-led clinics, nurse specialists, GP specialists, salaried GPs, higher ratio of nurses to GPs, incentives for professionals, use of trained volunteers for tasks that don’t require clinical expertise, eg. patient education

Knowledge management

decision support tools, database of key information on all patients, use of clinical data to do risk stratification to better target resources, use of evidence-based guidelines, share information across all relevant health providers (better coordination across primary/secondary)

Partnerships within health and between health and community

an integrated system that works across primary and secondary care, and that works collaboratively with other services such as social services, housing, employment, transport. Formal relationships with the wider community, eg. using a local community centre for older peoples’ exercise classes. Intersectoral collaboration at both local and central government levels.

The UK is beginning to trial and test approaches to supporting people with chronic conditions in the context of the NHS, including key approaches from the US.15, xi Chronic illness, or long-term conditions, has been identified as a national priority in the NHS Improvement Plan.16 In addition, chronic disease is a key focus for several national service frameworks and the Expert Patient Programme is encouraging greater self-care, where patients take a more active role in managing their conditions (see the ‘self-management’ section of this paper). Improving support for people with chronic conditions is a pathway towards a more people-centred health system, and will improve the efficiency and effectiveness of health resources.15

xi A number of Primary Care Trusts in the UK are currently piloting three US models – Kaiser, Evercare and Pfizer.

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The NHS Improvement Plan sets out a three-tiered population management model of service provision for people with chronic conditions.

• Level one is made up of the 70-80% of people who can usually ‘self-manage’ with advice and support.

• Level two consists of higher risk patients who require a more pro-active ‘disease management’ level of service provision (where multidisciplinary teams provide evidence-based care including the use of pathways and protocols).

• Level three consists of a minority of people who require a specialist ‘case management’ approach (active management using case managers).

New Zealand

In New Zealand a wide range of initiatives are occurring at both local and national levels. This section profi les two examples of initiatives to improve how people with chronic conditions are supported within the health sector; the Counties Manukau chronic care management programme and the Leading for Outcomes initiative by the Ministry of Health.

Please refer to Appendix 2 for a list of other current initiatives in New Zealand to improve support for people with chronic conditions.

Counties Manukau Chronic Care Management programme

Counties Manukau DHB is a leader in introducing and evaluating a structured chronic care management programme in New Zealand. The programme has had success in improving health indicators.

Counties Manukau DHB has introduced chronic care management for targeted patients, across community and hospital settings. The disease groups initially included were diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and COPD/asthma. The programme aims to support people in a coordinated care process of partnership with the patient, their whänau/family and the wider community.17

The programme involves quarterly visits with the GP, as well as six hours a year of nursing and health education visits. Electronic decision support based on evidence-based clinical guidelines is used. Information is collected using an electronic template, the data is sent to a central server, and the server sends back reminder information to the GP. For instance, the GP will be sent reminders of people overdue for check-up appointments, and will be notifi ed if current guidelines suggest different forms of treatment. This helps to provide consistency in practice and to promote the use of best practice clinical guidelines. Monthly reports from the server help practitioners to monitor progress and to identify individuals who are only responding slowly.

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The Counties Manukau chronic care management model includes eight core components that inform the negotiation between people with chronic conditions and the health team – (1) culturally competent systems and provider skills, (2) information systems, (3) selection of target groups, (4) clinical guidelines and the education of patients and providers, (5) support from and linkage to secondary care – services and advice, (6) skills in behavioural change, patient care planning, (7) practice systems that encourage proactive care, and (8) evaluation, audit, feedback.

Compared with other models used internationally, the Counties Manukau model has a strong emphasis on cultural competence. This is defi ned as a set of academic, experiential and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within and among groups.xii

Leading for Outcomes

Leading for Outcomes is an initiative within the Ministry of Health that aims to support a ‘whole system’ shift in the focus of health sector activities toward outcomes.xiii Part of this shift is to encourage an agreed approach to supporting people with chronic conditions across New Zealand.

In order to achieve better outcomes for people with chronic conditions, Leading for Outcomes argues for a transformation in the way that health care is delivered in community settings. It suggests, for example, identifying people with chronic conditions earlier using a population health approach, providing continuous rather than episodic care, and encouraging stronger community engagement and self-management.

Leading for Outcomes is a framework to maintain a focus on the overall results of the health sector’s collective actions – on population outcomes. Chronic conditions, starting with diabetes and cardiovascular disease, are presented as a continuum ranging from early risk to end-stage and death. The approach encourages systematic rather than disconnected opportunities for intervention.

Questions for respondents

• What are your views on the best way/s to approach chronic conditions in New Zealand?

• What lessons can we learn from existing models to improve how people with chronic conditions are supported?

• What other key initiatives are going on around New Zealand (that are not included in Appendix 2)?xiv

xii For more information on the Counties Manukau chronic care management programme, see http://www.sah.co.nz/Counties/Service_Areas/Integrated_Care/IntegratedCareframe.htm

xiii See the Leading for Outcomes website www.leadingforoutcomes.org.nz

xiv Responses to this question will be incorporated into Appendix 2, which will be made available on the National Health Committee’s website www.nhc.govt.nz.

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Support for self-managing chronic conditions

Self-management support is a core element of a chronic conditions approach, and is a way to encourage a more patient-centred model. In the New Zealand context, family/whänau involvement in managing chronic conditions is crucial. Some people may prefer the terms ‘shared management’ or ‘shared care’ to avoid implying that it is an individualistic approach.

Defi nition of self-managementThe NHC defi nes self-management as “people with chronic conditions having greater control in looking after themselves, with the support of their families/whänau (where desired), and in partnership with health professionals and community resources.”

It is important to recognise that many people already self-manage to some degree – for instance, in taking a range of medications, obtaining support from family/whänau members and friends or community resources, or by playing a key role in developing a care plan in partnership with health providers.

It should also be emphasised that self-management may not be appropriate for some people, or in some circumstances. For example, some children or people with illnesses such as dementia may not be in a position to self-manage.

Self-management is the norm

“Over 80% of all medical symptoms are self-diagnosed and self-treated without professional care” (David Sobel, Kaiser Permanente) 18

New Zealand’s diabetes consumer organisation has stated that “…for adults with diabetes 99.9% of all their diabetes management choices are made by themselves without the immediate help of their diabetes care team” (Quote from Diabetes NZ website)19

Self-management programmes

While people’s experiences of their chronic condition/s differ according to their symptoms and the treatment they receive, there are commonalities in the day-to-day challenges that people with chronic conditions face. Self-management programmes aim to equip people with the knowledge, skills and support to cope with these challenges and feel confi dent in managing their own lives with a chronic condition/s.

Increasing individuals’ self-effi cacy in managing the effects of their chronic condition/s is a key aspect of self-management programmes. Course participants are introduced to specifi c self-management techniques to this end. Programmes focus on how people manage both the medical aspects of living with chronic condition/s (eg, taking medications), as well as the lifestyle aspects (eg, fatigue, pain management, relaxation, exercise, and healthy eating).

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EXAMPLE OF A SELF-MANAGEMENT PROGRAMME

“Living a Healthy Life With Chronic Conditions” is one of the most long-standing and widely used self-management programmes. Kate Lorig and colleagues at Stanford University developed the programme and it is delivered in groups of 10 to 15 people who have a variety of different chronic conditions.

The “Living a Healthy Life” programme involves one session per week (two and a half hours), for six weeks. The sessions are delivered to groups of 10 –15 people by a lay-leader who has had personal experience of chronic condition/s. People with any kind of chronic condition can attend the course, and many participants have more than one chronic condition. The course leader follows a detailed resource guide to take participants through a range of topics, and encourage the group members to share and learn from each other’s experiences. Topics include exercise, cognitive symptom techniques (eg, relaxation), nutritional change, fatigue and sleep management, use of medications and community resources, managing fear, anger and depression, training in communication with health professionals and others, health-related problem-solving, and decision-making.

The programme has been adapted for various cultures, including minority groups, in the US, and at least 12 countries around the world. Arthritis New Zealand currently provides this programme to groups of people in New Zealand, and trains lay-leaders to deliver the course. There is interest in adapting the programme to be run by Mäori for Mäori. Diabetes New Zealand has also recently started running the programme.

There is a large body of overseas evidence to show that self-management programmes can provide important benefi ts for participants. For example, in a number of evaluations of the Chronic Disease Self Management Programmes developed in the US, sustained improvements were obtained in individuals’ skills in self-management and in disease outcomes.20 In a fi ve-year research project, the programme was evaluated in a randomized study involving more than 1000 subjects. This study found that people who took the programme, when compared to people who did not, improved healthy behaviours (exercise, cognitive symptom management, coping, and communications with physicians), improved their health status (self-reported health, fatigue, disability, social/role activities, and health distress), and decreased their days in hospital.20

The UK has implemented the Expert Patient Programme, based on the Lorig model, as a key plank in their approach to supporting people with chronic disease. This programme has had some success in working with traditionally ‘hard to reach’ groups such as people from deprived areas and people with mental health issues. Participation rates in the Expert Patient Programme for people from black and ethnic groups are almost as high as their proportion of the total population (6.9 percent of those in the Expert Patient Programme are from black and ethnic groups, compared with a national percentage in England of 8 percent).18

Arthritis New Zealand has conducted two post-course evaluations for the “Living a Healthy Life” courses that they have delivered in New Zealand since 1998.21

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These both concluded that the courses were relevant and useful to people with chronic conditions, and that the majority of participants felt they had benefi ted greatly from the course. The post-course evaluation of the courses delivered from 2000 to 2002 also concluded that participants’ self-effi cacy was greatly increased, and they were committed to the continual practice of positive self-management behaviours. Some participants felt, however, that the sessions were rushed.21

EXAMPLE IN NEW ZEALAND

HealthWEST PHO has piloted a self-management programme in West Auckland, which was well attended (no one dropped out of the courses and two extra people joined after hearing about the programme through word of mouth). There was a signifi cant participation by Mäori and Pacifi c people. The programme is led by health professionals and is based on the principles of empowerment. Waitemata DHB is planning to adopt the programme, and Mäori and Pacifi c groups are involved in further developing the programme to suit their needs. The next phase of the programme will be evaluated.

It should be recognised that a self-management programme is only one way to encourage self-management, and that not everyone wants to be part of a group programme. Other self-management interventions that are provided to individuals include patient-led care plans, patient-held records, and asthma self-management plans.


• Do you agree with the NHC’s defi nition of self-management?

• What role do you think self-management has in living with chronic conditions?

• Do you think self-management should be better encouraged and supported in New Zealand, and if so, how?

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Role of complementary and alternative care

A signifi cant proportion of New Zealanders use complementary and alternative health practitioners to help manage chronic conditions.

Use of complementary and alternative health

• The 2002-2003 New Zealand Health Survey showed that one in four people visited a complementary and alternative health practitioner in the previous year.xv

• Almost a third of those who had seen a complementary and alternative health practitioner had a chronic condition or disability.22

The complementary and alternative health paradigm is well suited to people with chronic conditions, as it tends to involve longer, more holistic consultations and is more ‘people-centred’ than the disease-based biomedical approach. The complementary and alternative paradigm has tended to encourage self-management and acknowledge people’s spirituality and religious beliefs as part of holistic care. However, in reality most health practitioners, whether operating within complementary and alternative medicine (CAM) or mainstream health contexts, do not operate solely using one model. Many practitioners use other models as well as the biomedical, such as Mäori or Pacifi c health models, behavioural science or psychological models.

Some practitioners have trained in biomedical and CAM approaches and offer both interventions. A survey of Auckland GPs showed that a third of respondents practised one or more forms of alternative medicine, and two thirds referred patients for CAM therapies.23 Anecdotal evidence suggests a growing number of referrals by GPs to homeopaths for conditions such as glandular fever, chronic fatigue syndrome and recurrent ear/nose/throat infections.xvi However, in many contexts CAM therapies do not have the same status as biomedical interventions in terms of funding or support.

People with chronic conditions may use a combination of CAM products and biomedical pharmaceuticals, without practitioners from either approach being aware of what they are using. New Zealand research has identifi ed occasions where interactions between pharmaceuticals and CAM products have occurred.xvii Presenters to a symposium on the integration of CAM and mainstream medicine, held by the NHC in November 2004, highlighted the need for an adverse events reporting structure, and one presenter suggested doctors need to expand their patient drug histories to include questions on CAM products.

xv This estimate does not include people who buy CAM products from pharmacies or health food shops without seeing a CAM practitioner.

xvi Cited by Nicki Walker and Gwyneth Evans at the National Health Committee’s symposium ‘The Whole Picture: integrated management of chronic conditions in New Zealand’; which explored how mainstream and CAM sectors can work more closely together, 24 November 2004.

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In addition, improving the relationship between the CAM and biomedical sectors may have the downstream effect of improving patients’ confi dence for revealing their use of CAM products to mainstream practitioners.

The development of PHOs with a population health and community focus is an opportunity for allied health professionals (such as physiotherapists, occupational therapists, podiatrists and social workers) to be integrated with primary health care, and ultimately for CAM practitioners to become part of the team.


• What role do you think complementary and alternative medicine has in living with chronic conditions?

• Do you think complementary and alternative medicine should be better encouraged and supported in New Zealand, and if so, how?

xvii CAM symposium, November 2004

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SECTION 3: SUMMARY OF ISSUES – PEOPLE WITH CHRONIC CONDITIONS

The NHC believes it is crucial to canvas the views and experiences of people with chronic conditions to help provide relevant advice to the Minister of Health. People with chronic conditions have extensive experience in living with their conditions and in interacting with health and other services.

The NHC has held four preliminary focus groups with people with chronic conditions in the Wairarapa and Christchurch. More than seventy people were involved. Three groups were associated with Arthritis New Zealand and the Stroke Foundation, and the other was a support and exercise group for Pacific people.

People were asked to highlight the main factors that helped and hindered them in living with chronic conditions. The following information is an initial starting point in identifying the key issues for people with chronic conditions. Further information will be gained from this consultation and from case studies with people with chronic conditions that the NHC will carry out shortly. The views expressed here are reported as they were stated in the focus group context, and are not necessarily views held by the NHC.

Part 1: Factors that help people with chronic conditions

Support from others and self-help groups

Main themesPeople with chronic conditions emphasised that family support is crucial. Many people also highlighted self-management courses as a key factor that helped. Courses helped to provide a safe environment and shared experiences (“knowing you’re not the only one”). Attending courses helped people to be able to ask the ‘right questions’ of health and other professionals. Exercise groups were also helpful in encouraging people to exercise and feel part of a supportive group.

Relationships with health professionals and NGOs

Main themesHaving a good nurse and GP was seen as critical. Direct contact with specialists was appreciated, as well as specialist clinics in rural or provincial areas. For instance, one woman appreciated getting a phone call from her specialist to reassure her that she didn’t have throat cancer. The call helped her feel like “not just a name or number”.

Other commentsPeople said that NGOs and consumer organisations have a key role in providing support and advocacy. Being involved in matters affecting people with chronic conditions also helped, eg, a stroke group appreciated being involved in developing the stroke guidelines. Other factors that helped were occupational therapy and aids, physiotherapy and use of a hot pool, home-help support, use of traditional healing and the accessibility of rural nurses.

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Income, employment and transport assistance

Main themesPeople highlighted the role of work in earning an income and in combating feelings of ‘uselessness’. The 2004 Budget changes to how benefi ts are adjusted in relation to part-time work were seen as helpful in making part-time work more feasible for those receiving a benefi t. Transport assistance such as the Total Mobility Scheme (taxi vouchers), Mobility Parking Permits, and the importance of public transport and ‘kneel-down’ buses were helpful factors for many people in living with chronic conditions.

Individual factors

Main themesMany people said that having a positive attitude and being assertive and independent helped them to manage. It was seen as important for people to accept their condition/s and to feel accepted by others. Interests and hobbies were signifi cant factors that helped, especially keeping physically active.

Other commentsLiving alone was seen as both an opportunity and a challenge for people with chronic conditions. People described using ‘short-cutting’ strategies to make life more manageable (eg, choosing not to dress up or to wear shorts because it’s easier, and wearing shoes with Velcro that are simpler to put on).

Spiritual health

Some people with chronic conditions said that spiritual beliefs and practices helped them in living with ongoing conditions. For example, a service provider talked about one man who had requested a kaumatua to say karakia with him, and the service had arranged for another man with depression to spend two hours with a kaumatua for counselling and support.


• Do you agree that these are the main factors that help people with chronic conditions?

• If not, what other factors are important?

• What suggestions would you make to help improve the ways that people with chronic conditions are supported?

• What is the role of spiritual beliefs and practices in helping people live with chronic conditions? How can these be better addressed by health and other services?

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Part 2: Factors that hinder people with chronic conditions

Lack of coordination (within health and between health and other agencies)

Main themesMany people had experienced a ‘void’ in services after being discharged from hospital. People felt there is poor coordination and communication within the health sector (eg. the Stroke Foundation had only heard about a new hospital wing for people aged under 65 years through the ‘grapevine’). In particular, people thought there is poor coordination between their GPs and secondary/tertiary services.

Other commentsPeople also commented that some health practitioners did not refer people to community support services such as Arthritis New Zealand and Mobility Parking Permits for those with a disability. People often found it difficult to find out what they were entitled to, especially from Work and Income and other support organisations.

Societal attitudes and myths about chronic conditions

Main themesParticipants in the focus groups gave a range of examples where myths about chronic conditions were perpetuated, as well as experiences of discrimination or being misunderstood. These included:

• stroke and arthritis being seen as ‘older person’s diseases’

• feeling stared at or classified as someone with an impairment or problem

• a presumption that if people look ‘normal’ there’s nothing wrong with them (whereas they may be in pain from their condition)

• a young person had friends withdraw because they couldn’t handle the difficulties associated with arthritis

• people felt the public perception of arthritis is to “just get on with it” (whereas they were struggling with pain and depression).

Lack of understanding from health and social support sectors

Main themesIn particular, people talked about health and social services lacking understanding of chronic conditions and their impact on people’s lives. They felt there is limited understanding from health sector and Work and Income staff about the long term, ongoing nature of chronic conditions. People said there was a need for better training of GPs and nurses in specific chronic conditions. An example was given where a Plunket nurse told a young mother she wouldn’t need arthritis services, because she believed that arthritis only affected older people.

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Other commentsSome participants had the experience of other people choosing not to talk directly to a person who had had a stroke. Rather than speaking to the person, they would choose to speak to their partner or carer. Doctors were seen as especially prone to doing this.

Inadequate information for patients

Main themesPeople in the focus groups said they do not consistently get the health information they needed, and that information is not always in an appropriate form. Many people felt that pamphlets are not always the best way to inform people. Information prior to having operations was seen as especially important and people felt that there is a particular lack of information about medicines.

Transport

Main themesParticipants said there is a lack of wheelchair facilities in buses and buildings, and that accessibility to buses is difficult. It was felt that some bus drivers lack awareness of people with mobility problems (if there was no visible indication such as a wheelchair). One focus group talked about difficulties crossing the road at pedestrian crossings, as they found the signals did not allow enough time for people with mobility problems to get across the road. The high cost of transport was a common issue raised, and transport to appointments from rural areas was especially difficult and costly.

Other commentsSome people felt the Total Mobility Scheme (where taxis are subsidised for people whose disabilities prevent them from using public transport) should be more flexible and have a greater entitlement.

Income/employment

Main themesThe limited income on benefits, such as the Invalid’s Benefit, was noted. The effect of shifting from employment to a benefit was cited as particularly difficult, including the effect on the partner and family. Also, people emphasised that when their income does not meet costs of health services and medications it can lead to stress and depression. People said they were unable to afford some treatments to help with living with a chronic condition.

People noted it was difficult to find paid employment when struggling with the effects of living with a chronic condition. People said there was a lack of support from Work and Income. Examples included feeling penalised for choosing to work, and a frequent turnover of case managers. It was felt there is not enough flexibility in Work and Income entitlements. The high costs of heating were raised in the context of cold housing environments affecting people with chronic conditions.

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Problems with support services to help in the home

Main themesParticipants in the focus groups highlighted problems with access to home support and variability of services across the country. People said that carers who come into people’s homes are often untrained and underpaid. One focus group talked about home support carers being unable to accommodate the person’s lifestyle (eg, a woman had a carer who could only arrive at 11am to shower her, whereas the woman wanted to have a shower earlier than that).

People highlighted a lack of support for carers who live at home with people with chronic conditions, and a lack of respite care. People wanted more recognition for families who care for other family members, eg, payment for caring and training for carers who are family or friends. It was felt that there is variability in entitlements and processes regarding equipment to help in the home, eg, one person waited for a shower stool for six months.

Access to services and facilities

Main themesMany people talked about a ‘distrustful environment’ with regard to accessing services, which made people dispirited and aware of a power imbalance. The requirement to see a GP before accessing services was seen as prohibitive, eg, before being able to apply for Mobility Parking Permits.

People felt they did not have access to sufficient time with their GP, due to short appointments. Excessive waiting times to see a specialist were raised, especially at tertiary level. People felt there is a need for more physiotherapists.

Age restrictions for entitlement to services were highlighted as an access problem (eg. there is no facility for younger stroke victims to have respite care so people aged under 65 have to go to rest homes. Also, the falls prevention programme run by ACC is only for those aged over 65 years). Access to some services is only intermittent (eg. a hydrotherapy service was available six weeks on, six weeks off).

Many people talked about variation in entitlements between ACC and disability support (eg. disparities in support for ACC recipients compared with people with a chronic condition or disability, ACC recipients tend to get more home-help and more rapid access to treatment). There was some concern about inequities in how people with different disabilities or conditions are treated (eg. someone may look well but be experiencing debilitating pain).

A lack of flexibility with some entitlements was highlighted (eg. the Workbridge Employment Scheme does not allow use of the funding for transport to get to work). It was felt that the needs assessment process (NASC) favours those who can advocate well for themselves.

The high costs of medication and doctors’ visits, and medical insurance, were seen as barriers to living well with chronic conditions. People highlighted the high cost of some medicines, especially for arthritis, Parkinsons and dementia. They felt that physiotherapy can be expensive and that complementary and alternative treatments had high costs.

26

Other commentsSome people commented that their local hospital lacked a Pacifi c peoples’ chaplain. Some participants found it diffi cult to access a pool and physiotherapy exercise class. They found there was often a lack of facilities to do what the doctor recommended, eg, for being physically active. Physical access problems were also highlighted, for instance, heavy doors, steps that are high, and lack of accessible public toilets.

Mental health and emotional factors

Main themesMany people felt there was a lack of attention at diagnosis on the person’s state of mental and emotional health. The stigma around mental health was emphasised, particularly in rural communities. People with chronic conditions felt there is not enough support for mental health issues, including depression associated with chronic conditions.

Participants talked about the effect of ongoing tiredness, depression and isolation on people’s ability to cope and advocate for themselves. People said they often did not have the strength to be assertive with doctors and other health professionals. Another issue was experiencing grief for what changes in a person’s life when they get a chronic condition.


• Do you agree that these are the main factors that hinder people with chronic conditions?

• If not, what other factors are important?

• What suggestions would you make to help improve the ways that people with chronic conditions are supported?

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SECTION 4: SUMMARY OF ISSUES – PRACTITIONERS AND AGENCIES

The NHC conducted more than 50 meetings to find out the key issues in supporting people with chronic conditions in New Zealand. Interviewees were health professionals working with people with chronic conditions, government policy-makers, and people working in non-government agencies (NGOs).

The issues identified by the people interviewed are summarised here, under the five elements of effective chronic conditions management.15

1. Improved interactions between people and professionals2. Redesign of delivery systems and processes3. Workforce planning and development 4. Knowledge management5. Partnerships within health, and between health and the community

The views outlined are those of the people interviewed and are not necessarily endorsed by the NHC.

Element 1: Improved interactions between people and professionals

Interactions between people and professionals

Main themes■ The importance of a caring relationship between professional and patient,

including culturally appropriate behaviour, was emphasised.

■ Interviewees wanted patient involvement and ‘people-directed consultations’ where both parties jointly plan how to manage chronic illness. Examples were given of differing priorities of patients and practitioners, and the need to start with the patient’s immediate needs or goals.

■ The need for good communication between professionals and patients was emphasised. It was felt that it was particularly important for patients to get the information they needed and that this was not always happening.

■ It was felt that the health sector needed to improve how emotional issues associated with chronic conditions, such as grief and depression, are acknowledged and addressed.

■ The ‘broker’ role of health practitioners was emphasised, for example, negotiating with a hospital, attending appointments with a patient, and advocating on people’s behalf when appropriate.

■ Addressing the emotional and spiritual aspects of health was seen as important. Practitioners at a Mäori service gave an example of a 65-year-old man whose goal was to learn Mäori language, and the nurse linked him up with a course.

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Other comments• The need to work with the whole family of a person with chronic conditions

was stressed. For instance, providing information to the children of people with chronic conditions, in order to encourage prevention among the next generation. Another example was a whänau approach to an alcohol and drug programme for young people where there was a combined outing with older people.

• It was felt there is particular stigma around mental health issues and that GPs need to be supported to feel more confident about treating mental illness.

• It was argued that in particular, children with chronic conditions needed appropriate support. People said that most services are currently aimed at adults and lack expertise in children’s issues.

• Several interviewees said that being a ‘by Mäori for Mäori’ service was important, and that some people chose to travel long distances to use their service.

• Practitioners at a Mäori health service said that providing food played a key role in helping people to feel comfortable. Social events such as a kaumatua Christmas dinner, and provision of transport, were also important.

• Examples were given of times when doctors spoke to the community health worker rather than directly to the patient. There were also instances of receptionists at GP clinics being disrespectful of people who had not paid their bill.

• The use of written letters to advise people of hospital appointments was not always appropriate, for instance, when people could not read them.

Self-management support

Main themes■ A general need for more self-management was highlighted. Interviewees felt that

DHB commitment to self-management was essential, as well as increased funding for patient education.

■ Better coordination to encourage self-management activities/groups was advocated. Consumer organisations and other NGOs need to be coordinated so it is easier to distribute information on self-management.

■ Interviewees felt there is a need for more Mäori and Pacific self-management groups.

■ At the same time, key informants noted that most people with chronic conditions already self-manage to some degree.

■ Interviewees also made the point that not all people with chronic conditions will want to self-manage, and it will not be appropriate or possible in all circumstances. For instance, living on a low income or being homeless may constrain people’s ability to self-manage.

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Other comments• It was felt that the patient should defi ne the level of self-management they want.

• Language and cultural differences between clinician and patient were identifi ed as barriers to self-management.

• It was felt that self-management needed to address the person’s whole life, ie. the ‘non-medical’ aspects of their life as well as medical issues.

• The quality of the training in self-management programmes was seen to be important, therefore planned workforce development is essential.

• There was a view that self-management should be seen as the standard approach, with consultations with professionals added on when needed.

Questions for respondents:

• Do you have any comments on the issues raised in this section?

• What other issues do you think are important to add?

• What suggestions do you have to help improve the ways that people with chronic conditions are supported?

Element 2: Redesign of delivery systems and processes

Funding

Main themes■ People said that administration requirements and compliance costs with

delivering primary health care were currently too high.

■ It was felt that programmes to support people with chronic conditions should be better resourced. One DHB that had implemented chronic conditions management programmes noted that the start-up costs of new programmes are high.

■ Interviewees felt that the time needed for effective interactions with people with chronic conditions should be recognised and adequately funded. One nurse described the one-hour assessment with Care Plus patients as a ‘privilege’ (Care Plus is an initiative that provides funding to PHOs for people who use primary health care frequently due to chronic conditions or other complex needs. More information on Care Plus can be found at http://www.moh.govt.nz/primaryhealthcare and it is included in the list of initiatives in Appendix 2 of this paper). However, it was felt that Care Plus should be monitored to ensure that health practitioners are remunerated for the time they spend with people with chronic conditions.

Other comments• It was noted that the funding system should avoid giving incentives to DHBs to

encourage short stays and regular readmissions to hospital.

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• It was felt that funding should be increased for prevention and early intervention regarding chronic conditions.

• People advocated that the funding for provision of equipment for children with chronic conditions should recognise the increase in complex conditions among children.

• Interviewees said that the funding arrangements do not recognise that it costs more to provide services with people with higher need and those with multiple chronic conditions.

• It was noted that funding for primary health care had not kept pace with the growing IT needs and growth in patient numbers.

• It was suggested that a separate category should be created for people with ‘complex and chronic conditions’, and that specific funding and policy initiatives be designed for this group. There should also be recognition of the higher costs of treatments for rare conditions.

• Work and Income’s approach to people with complex and chronic conditions was criticised as inappropriate, especially for people whose condition will never improve. It was argued that some categories of people with chronic conditions (eg, those with multiple conditions, or those with complex long-term needs) should be treated as a discrete group.

• It was noted that there is little funding assistance to help families where one parent stays home to care for a child with a chronic health condition.

Primary Health Organisations (PHOs)

Main themes■ Key informants felt that people with more than one chronic condition should

not be treated in disease ‘silos’. It was felt that a move away from contracting for disease-specific services was necessary to avoid continued fragmentation of services.

■ Interviewees said that PHO size should be increased to improve effectiveness, including cost-effectiveness.

■ It was felt that expectations of PHOs should be realistic, whereas early expectations had been overly optimistic in terms of what PHOs could deliver.

■ Interviewees asserted that PHOs needed more certainty of long-term funding in order to establish programmes to improve how to interact with people with chronic conditions.

Other comments• There was a view that there should be more flexibility in models for delivering

primary health care, such as a health professional visiting people at home, rather than people always going to a health clinic.

• Interviewees felt that PHO funding should be more flexible and less closely linked to GP registers.

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• Interviewees at one health service said that the taxi chits provided by the PHO were really helpful in assisting people to get to hospital.

Barriers to accessing services

Main themes■ Interviewees stated that some people could not afford to pay for health care visits

or medication.

■ Waiting lists for specialist or allied health professional care were highlighted as a barrier to effective chronic care.

■ It was felt there are barriers to accessing hospital services for some people, as well as a high rate of not attending follow-up appointments after discharge. Social issues and transport difficulties were cited as key issues affecting people’s capacity to access services.

■ Practitioners said that some Mäori and Pacific people could be wary of attending hospital appointments out of fear. For instance, some Mäori may associate hospitals with death, or feel discomfort for ‘wairua’ reasons about people having passed away in the bed they are allocated. People may have had previous experiences in hospitals of misunderstandings or cultural insensitivity.

■ It was felt that variations in entitlements to support and compensation between those on ACC and people using disability support services should be addressed. There are also variations between the support that can be accessed by ACC recipients and people with chronic health conditions.

Other comments• It was noted that ethnic differences in the uptake of home support should be

reduced.xviii

• There was a view that chronic conditions programmes depend on enrolment, which risks putting resources into people who are good at accessing services, rather than those in most need of services. As specific programmes tend to focus on easily measured health outcomes, there is a risk of focusing on narrow outcomes rather than on the patient’s needs. These interviewees felt that it is crucial to strengthen primary health care across the board, rather than focusing on people with chronic conditions.

• Interviewees from one area talked about long waiting lists for GPs that were sometimes up to three days. In some cases the nurses would refer patients straight to hospital because the wait was too long.

xviii For instance, an evaluation found ethnic differences in the uptake of home support (Ne’emia S. 2003. Capital Support in the Lives of Pacific Peoples with Disabilities. Wellington: Capital Support ‘Links for Living’).

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• What other issues do you think are important to add here?


Element 3: Workforce planning and development

Need for improved workforce capacity

Main themes■ Interviewees felt there needed to be more nurses in primary health care in order to

effectively deliver comprehensive support for people with chronic conditions.

■ It was felt that a major problem in supporting those with chronic illness in rural areas is the high use of locums, and high staff turnover, which results in a lack of continuity of care for people with chronic conditions. It also results in limited time for clinicians to spend with people.

■ A greater number of NGOs in some rural areas was seen as a way to improve how people with chronic conditions are supported.

■ A need for more home support workers was also highlighted.

Need for change and innovation in workforce roles

Main themes■ Interviewees talked about the changing roles and skill needs of health care

workers in the new primary care environment – such as needing to look at social issues as well as health, and responding to the increasing numbers of children with complex chronic conditions.

■ It was felt there is a need for more people-directed, multi-disciplinary team approaches, rather than professional silos (where each professional approaches the person within their realm of expertise and seeks out what they can fi x).

■ It was noted that a team approach requires that all professional groups respect and understand each other’s roles.

Other comments• Specifi c roles to help with building and strengthening links across services and

professional groups, such as GP Liaison Offi cers, were seen as important.

• It was felt that both GPs and practice nurses were well placed to take on a ‘caseworker’ role in a more intensive approach to supporting people with chronic conditions.

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• It was advocated that training for health professionals in cultural appropriateness and cultural issues is needed.

• Interviewees said there is an increasing role for the use of complementary and alternative therapies (CAM), including traditional healing, in supporting people with chronic conditions. This growing role has workforce implications, for example, people may request information about complementary and alternative therapies from mainstream health professionals, who may not have this information or be able to refer on to a CAM practitioner.

• Interviewees also raised the question of how to deal with conflicting advice between traditional or complementary/alternative approaches and mainstream medicine.

• It was asserted that greater paediatric expertise in primary health care was needed and that home help services needed to be more appropriate for families with children with chronic conditions.

• Interviewees identified a need for more respite care and carer support.

• Practitioners at a Mäori service emphasised that podiatrist services are important, as people cannot be active if they have problems with their feet. They saw podiatrists as having a key role in preventing and managing chronic conditions.

• Interviewees at one health service said a helpful factor in supporting people with chronic illness was staff working together and not being rigid in their roles.

• People at a Mäori service said that at times they called in a kaumatua to help address people’s spiritual needs.

Role of nurses in supporting people with chronic conditions

Main themes■ Interviewees said that nurses should be upskilled in order to case-manage people

with chronic conditions. The specialist nurse role was seen as important, as well as nurse-led initiatives.

■ It was noted that the nursing role is becoming more like a social work role.

■ A key advantage of the rural nurse model in interacting with people with chronic conditions was flexibility with rural nurses’ time. A rural nurse can spend an hour with people if needed.

Other comments• One Mäori nurse said that working in people’s homes required a different model

of care, where the person and their family are “the boss”. She was aware that she was trained in the mainstream system, and had to learn new ways of operating, such as starting from people’s own goals and priorities.

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Role of community health workers in supporting people with chronic conditions

Main theme■ A need was highlighted for generic community health workers in chronic care to

help connect people to social services and to be an advocate. Community health workers attached to Mäori health providers play a crucial role in working with families and connecting people to other services.

Other comments• Interviewees at one health provider said their community health workers are able

to “pave the way” for nurses to begin working with people. The workers noted that the community health workers “spoke the same language” as their clients, and were already part of the community.

• A similar model cited was the Mäori community welfare offi cer model where one person was selected by their whänau to be trained as a ‘health broker’ for the family.





Element 4: Knowledge management

Main themes■ Interviewees emphasised that the use of decision support is crucial for effective

care for people with chronic conditions.xix

■ It was felt that there should be more standardised technical support for chronic conditions recording and treatment.

■ A need for better sharing of information using technology was highlighted. An example was the idea of having summary clinical information on patients accessible on a central server or a website with password access.

■ Interviewees felt that some rural areas lacked infrastructure for organising clinical information. An example was that some rural nurses did not have computer access.

xix Decision support in the health sector is the use of tools, including information technology, to encourage health practitioners to apply evidence-based practice such as clinical guidelines when working with patients.

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■ Interviewees wanted better coordination of information on chronic conditions and more accurate data.

■ A need for better information for patients on chronic conditions was also identifi ed. In particular, it was felt that there is a lack of information about medications, and that understanding medications is critical for people with chronic conditions.

Other comments• It was felt that appropriate mechanisms for patient education are needed, and that

pamphlets were not necessarily the best way to get information across.

• Management of mixed messages to patients was viewed as important – for example, advice on healthy eating will vary for people with different conditions.

• Greater use of the Internet was advocated, for example, developing one website with key information for people with chronic conditions in a range of languages.

• Some interviewees questioned the use of only measurable health outcomes in working with people with chronic conditions (eg, blood pressure, glucose levels, weight). They felt that using a narrow set of outcomes could miss the patient’s needs, and that outcomes need to be useful to both the person and the health care team.





Element 5: Partnerships within health, and between health and the community

Need for leadership and coordination – partnerships within health

Main themes■ Key informants felt there is a lack of national leadership to drive health

improvement in chronic conditions. It was emphasised that expertise in chronic conditions is fragmented across 21 DHBs and more than 70 PHOs.

■ The importance of key individuals with commitment to ‘make it happen’ in terms of improving support for people with chronic conditions was noted.

■ Interviewees felt there should be better coordination across health services, especially between DHBs and PHOs. People felt that work by some PHOs to improve support for people with chronic conditions was happening in isolation.

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■ Key informants saw the primary/secondary interface as a crucial area for improvement in coordination and integration.

■ People also said that coordination within primary health care could be improved. An example was to ensure that patient information is shared appropriately. Interviewees emphasised the importance of team-based approaches in improving support for people with chronic conditions, such as primary health care teams that include pharmacists, dieticians and social workers.

■ Interviewees said that having a shared vision for supporting people with chronic conditions, and for primary health care overall, is critical.

Other comments• Some practitioners said that a focus on chronic conditions is too narrow, and that

the most important factor is to improve how services (especially primary health care services) are run. Elements such as having a shared vision, a team approach and community involvement were seen as essential.

• The transition from childhood to adulthood was seen as a difficult area – when children with chronic conditions move from paediatrics, where there is a care management system, to adult services where there is not always a structured way of managing care.

• The role of advocacy was emphasised, for example, at one hospital visit the patient, their family and the practice nurse who accompanied them understood the doctor’s explanation differently. Allowing time and space to ask questions was important.

Partnerships between health and the community

Main themes■ Interviewees felt that the transition from hospital to home was an interface that

should be significantly improved.

■ A general lack of coordination between health and community services/NGOs was identified.

■ It was felt that much better coordination across government agencies and NGOs in assisting people with chronic conditions was needed.

■ NGOs were seen as playing a major role in supporting and advocating for people with chronic conditions.

■ Interviewees talked about the role of the church in Pacific communities – both the importance of spiritual beliefs and the potential role of the church in hosting and/or developing initiatives to support people with chronic conditions – such as the introduction of Pacific peoples’ exercise groups in church halls.

■ Interviewees said that housing has a big effect on the health of people with chronic conditions, including overcrowding and the temperature of homes.

37

Other comments• It was felt that NGOs and allied health professionals, such as social workers,

needed more incentives to become part of PHOs.

• It was noted that relationships with other organisations and sectors can play a role in encouraging people to use health services when needed – for example, a person with housing needs may have ongoing contact with a housing worker, who may see that they have chronic health needs and can suggest they go to a health clinic.

• A view was expressed that schools are not good at working with other agencies to help make the transition from school to the community. It was felt that many children with chronic conditions are leaving school without the support of social and employment agencies.

• The interface between health and welfare was highlighted as problematic. For instance, the Work and Income system is based on special benefi ts for illness being temporary, with regular reviews. It was felt this is inappropriate for people with complex and chronic conditions, particularly if severely disabled or in terminal stages.





38

APPENDIX 1: Where to go for more information

The following is a brief list of key websites and other references to find out more information about supporting people with chronic conditions.

New Zealand

Counties-Manukau chronic care website http://www.cmdhb.org.nz/Counties/Service_Areas/Integrated_Care/IntegratedCareframe.htm

Gribben B. 2003. Implementing integrated care in Counties Manukau, Journal of the New Zealand Medical Association, 21 February 2003, Vol 116, No 1169.

Ministry of Health’s primary health care website http://www.moh.govt.nz/primaryhealthcare

Ministry of Health’s website on Care Plus http://www.moh.govt.nz/moh.nsf/wpg_Index/-Primary+Health+Care+Care+Plus

Leading for Outcomes website http://www.leadingforoutcomes.org.nz

International

Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002, Oct 9; 288(14):1775-9.

Centre for Innovation in Primary Care 2003. The future of self-management education for people with chronic conditions; an aid for PCTs and other commissioners, October 2003. (accessed via www.innovate.org.uk)

Chronic care model bibliography (United States) – this website gives a bibliography divided into topics: http://www.improvingchroniccare.org/resources/bibliography/index.html

Department of Health (UK) The Expert Patient; a new approach to chronic disease management for the 21st Century (accessed from Department of Health website)

Expert Patients website (UK) http://www.expertpatients.nhs.uk

Kings Fund 2004. Managing Chronic Disease; What can we learn from the US experience?

Lewis R and Dixon J. 2004. Rethinking management of chronic diseases. BMJ 2004;328;220-222.

NHS Expert Patients Programme 2002. Self-management of long-term health conditions; a handbook for people with chronic disease. Bull Publishing Company.

NHS Modernisation Agency (Matrix Research and Consultancy) 2004. Learning distillation of Chronic Disease Management programmes in the UK, July 2004. (accessed via the internet at: http://www.natpact.nhs.uk/uploads/Matrix%20CDM%20Evaluation%20Report.doc)

Wagner EH. 1998. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4.

World Health Organization 2002. Innovative Care for Chronic Conditions; Building blocks for action. Global Report - Noncommunicable Diseases and Mental Health, WHO.

World Health Organization Observatory on Health Care for Chronic Conditions

http://www.who.int/chronic_conditions/en/

APPENDIX 2: Initiatives around New Zealand The following tables give examples of initiatives around New Zealand to improve support for people with chronic conditions.

The examples included were given in response to a request to DHBs, PHOs, and NGOs for examples of initiatives aiming to improve how people with chronic conditions are supported. The list contains selected examples from the information received, rather than a comprehensive ‘stocktake’.

Initiatives are divided into five categories:

1. Generic initiatives to improve support for people with chronic conditions (across disease groups)

2. Single-disease initiatives to improve support for people with chronic conditions

3. Initiatives aimed at specific groups within the population

4. Self-management initiatives

5. Workforce-specific initiatives.

The following tables will be updated during 2005 and posted on the NHC’s website (www.nhc.govt.nz). You are invited to send in any other examples with your submission.

39

40

1) G

ener

ic in

itia

tive

s to

impr

ove

supp

ort

for

peop

le w

ith

chro

nic

cond

itio

ns (

acro

ss d

isea

se g

roup

s)

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e of

in

itiat

ive

Org

anis

atio

n/s

invo

lved

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tact

per

son

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s/de

scri

ptio

n of

initi

ativ

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orkf

orce

type

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d m

ixEv

alua

tion

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e Pl

usM

inis

try o

f H

ealth

– fo

r im

plem

enta

tion

by P

HO

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istry

of

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lth’s

prim

ary

heal

th c

are

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e Pl

us p

rovi

des

addi

tiona

l fun

ding

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r PH

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to g

ive

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ehen

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ca

re to

peo

ple

who

use

hig

h le

vels

of

care

or h

ave

high

nee

ds b

ecau

se o

f ch

roni

c co

nditi

ons

or te

rmin

al il

lnes

s.

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tice

nurs

es,

GPs

, alli

ed h

ealth

pr

ofes

sion

als

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pend

ant e

valu

atio

n du

e m

id

2006

. Ini

tial p

roce

ss a

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rmat

ive

eval

uatio

ns h

ave

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plet

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and

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labl

e at

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oh.g

ovt.n

z/pr

imar

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lthca

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ntie

s M

anuk

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onic

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e M

anag

emen

t (C

CM

) pr

ogra

mm

e

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ntie

s M

anuk

au D

HB

and

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s

Kim

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us,

Cou

ntie

s M

anuk

au D

HB

Vis

ion

- To

impr

ove

qual

ity o

f life

fo

r peo

ple

with

chr

onic

con

ditio

ns

whi

le re

duci

ng th

e un

nece

ssar

y us

e of

tre

atm

ent s

ervi

ces.

Mis

sion

-To

redu

ce p

rogr

essi

on

and

com

plic

atio

ns in

indi

vidu

als

with

chr

onic

con

ditio

n at

hig

h ris

k by

em

pow

erin

g pa

tient

s an

d th

eir

prim

ary

care

team

s.

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ary

care

in

clud

ing

prac

tices

(G

Ps &

pra

ctic

e nu

rses

, com

mun

ity

heal

th w

orke

rs, a

nd

PHO

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dary

ca

re in

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ing

cons

ulta

nts

and

dise

ase

nurs

e sp

ecia

lists

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pilo

t eva

luat

ions

are

ava

ilabl

e at

ww

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mdh

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g.nz

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er th

e pr

imar

y he

alth

car

e se

ctio

n.

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thla

nd

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onic

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e M

anag

emen

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thla

nd

DH

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, N

orth

land

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Os,

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ntie

s-M

anuk

au D

HB

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ick

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mbe

rlain

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duce

mor

bidi

ty a

nd m

orta

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from

chr

onic

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ract

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nurs

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us a

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h ne

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41

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prev

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mac

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itiat

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anis

atio

n/s

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lved

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tact

per

son

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s/de

scri

ptio

n of

initi

ativ

eW

orkf

orce

type

an

d m

ixEv

alua

tion

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e Pl

usM

inis

try o

f H

ealth

– fo

r im

plem

enta

tion

by P

HO

s

Min

istry

of

Hea

lth’s

prim

ary

heal

th c

are

team

Car

e Pl

us p

rovi

des

addi

tiona

l fun

ding

fo

r PH

Os

to g

ive

mor

e co

mpr

ehen

sive

ca

re to

peo

ple

who

use

hig

h le

vels

of

care

or h

ave

high

nee

ds b

ecau

se o

f ch

roni

c co

nditi

ons

or te

rmin

al il

lnes

s.

Prac

tice

nurs

es,

GPs

, alli

ed h

ealth

pr

ofes

sion

als

Inde

pend

ant e

valu

atio

n du

e m

id

2006

. Ini

tial p

roce

ss a

nd fo

rmat

ive

eval

uatio

ns h

ave

been

com

plet

ed

and

are

avai

labl

e at

http

://w

ww

.m

oh.g

ovt.n

z/pr

imar

yhea

lthca

re

Cou

ntie

s M

anuk

au

Chr

onic

Car

e M

anag

emen

t (C

CM

) pr

ogra

mm

e

Cou

ntie

s M

anuk

au D

HB

and

PHO

s

Kim

Arc

us,

Cou

ntie

s M

anuk

au D

HB

Vis

ion

- To

impr

ove

qual

ity o

f life

fo

r peo

ple

with

chr

onic

con

ditio

ns

whi

le re

duci

ng th

e un

nece

ssar

y us

e of

tre

atm

ent s

ervi

ces.

Mis

sion

-To

redu

ce p

rogr

essi

on

and

com

plic

atio

ns in

indi

vidu

als

with

chr

onic

con

ditio

n at

hig

h ris

k by

em

pow

erin

g pa

tient

s an

d th

eir

prim

ary

care

team

s.

Prim

ary

care

in

clud

ing

prac

tices

(G

Ps &

pra

ctic

e nu

rses

, com

mun

ity

heal

th w

orke

rs, a

nd

PHO

s). S

econ

dary

ca

re in

clud

ing

cons

ulta

nts

and

dise

ase

nurs

e sp

ecia

lists

.

Early

pilo

t eva

luat

ions

are

ava

ilabl

e at

ww

w.c

mdh

b.or

g.nz

und

er th

e pr

imar

y he

alth

car

e se

ctio

n.

Nor

thla

nd

Chr

onic

Car

e M

anag

emen

t

Nor

thla

nd

DH

B/M

APO

, N

orth

land

PH

Os,

Cou

ntie

s-M

anuk

au D

HB

Dr N

ick

Cha

mbe

rlain

To re

duce

mor

bidi

ty a

nd m

orta

lity

from

chr

onic

dis

ease

.G

Ps, p

ract

ice

nurs

es, M

äori

prov

ider

nur

ses,

ho

spita

l spe

cial

ists

, ou

treac

h nu

rses

.

Mon

thly

Rep

ortin

g on

Clin

ical

In

dica

tors

as

per C

MD

HB

CC

M

prog

ram

me.

Inde

pend

ent E

valu

atio

n by

CBG

Re

sear

ch.

Chr

onic

Car

e M

anag

emen

t Pr

ogra

mm

e

[Fun

ded

thro

ugh

Car

e Pl

us a

nd

SIA

(Ser

vice

s To

Im

prov

e A

cces

s)

fund

ing]

ProC

are

Net

wor

k N

orth

(PN

N)

Sarm

ila G

ray

Clin

ical

Pr

ogra

mm

es

Man

ager

To p

rovi

de s

truct

ured

car

e to

all

patie

nts

who

hav

e hi

gher

hea

lth

need

s th

an g

ener

al p

opul

atio

n (a

s de

fined

by

the

MO

H) a

nd h

ence

nee

d to

see

thei

r doc

tors

mor

e of

ten.

Eg.

pa

tient

s w

ith D

iabe

tes,

CV

D, C

HF

and

CO

PD.

Spec

ialis

t nur

ses

Tech

nica

l sup

port

from

Pra

ctic

e su

ppor

t fac

ilita

tors

Pr

ojec

t m

anag

emen

t ex

perti

se.

Det

aile

d ev

alua

tion

will

take

pla

ce

late

r in

2005

. Gre

at e

nthu

sias

m

from

sev

eral

pra

ctic

es. A

s of

14t

h Fe

b 20

05, 5

21 p

atie

nts

enro

lled.

Prog

ram

me

first

targ

eted

to

3 pr

actic

es w

ith h

ighe

st n

umbe

r of

high

nee

ds p

atie

nts.

Upt

ake

not

enco

urag

ing,

due

to b

eing

ava

ilabl

e on

ly fo

r hig

h ne

eds

patie

nts.

42

Nam

e of

in

itiat

ive

Org

anis

atio

n/s

invo

lved

Con

tact

per

son

Aim

s/de

scri

ptio

n of

initi

ativ

eW

orkf

orce

type

an

d m

ixEv

alua

tion

Out

reac

h C

linic

sW

aika

to P

HO

Eric

a A

mon

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prov

e ac

cess

to h

ealth

ser

vice

s in

a to

wn

with

no

GP

serv

ice.

GP,

pra

ctic

e nu

rse,

pha

rmac

ist,

com

mun

ity w

orke

r.

Eval

uatio

n of

impr

oved

acc

ess.

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plia

nce

Pack

agin

gW

aika

to P

HO

Mic

helle

Bay

ley

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prov

e co

mpl

ianc

e, re

duce

ad

vers

e ef

fect

s.Ph

arm

acis

tsBa

sic

eval

uatio

n

Act

ive

Hea

lth

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ram

me

Hea

lthW

EST,

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uckl

and

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onal

Cou

ncil,

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ort W

aita

kere

, W

aita

kere

City

C

ounc

il, S

PARC

Kay

Lind

ley

Offe

rs a

rang

e of

act

ivity

-bas

ed

optio

ns fo

r peo

ple

who

hav

e ch

roni

c co

nditi

ons

and

are

med

ical

ly

stab

le.

Man

aged

thro

ugh

the

Gre

en

Pres

crip

tion

Sche

me

(GRx

) and

co

mm

unity

gro

ups.

Fitn

ess

lead

ers

Lay

lead

ers

and

supp

orte

rs

Hea

lth p

rom

oter

s.

Num

ber o

f ini

tial a

nd o

ngoi

ng

parti

cipa

nts

Life

sty

le c

hang

es a

chie

ved

and

sust

aine

d es

peci

ally

thro

ugh

GRx

an

d G

Rx s

peci

al p

rogr

amm

es.

Gre

en

Pres

crip

tions

(GRx

)

Spor

t and

Re

crea

tion

NZ

(SPA

RC)

Dia

na O

’Nei

llTo

hel

p in

activ

e pe

ople

inco

rpor

ate

activ

ity in

to th

eir l

ives

thro

ugh

refe

rral

s fro

m p

rimar

y ca

re h

ealth

pr

ofes

sion

als

and

supp

ort f

rom

re

gion

al p

erso

nnel

.

Regi

onal

Spo

rts

Trus

ts

PHO

s.

Eval

uatio

ns h

ave

show

n ef

fect

iven

ess

and

cost

-effe

ctiv

enes

s of

GRx

in in

crea

sing

phy

sica

l ac

tivity

and

impr

ovin

g qu

ality

of l

ife

over

12

mon

ths.

GRx

has

pot

entia

l to

hav

e si

gnifi

cant

eco

nom

ic im

pact

th

roug

h re

duct

ion

in C

VD

and

oth

er

mor

bidi

ty a

nd m

orta

lity.

May

200

4 pa

tient

sur

vey.

Nov

embe

r 200

4 G

P su

rvey

(bot

h av

aila

ble

on re

ques

t).

... c

ontin

ued

from

pre

viou

s pa

ge

43

2) S

ingl

e-di

seas

e in

itia

tive

s to

impr

ove

supp

ort

for

peop

le w

ith

chro

nic

cond

itio

ns

Nam

e of

in

itiat

ive

Org

anis

atio

n/s

invo

lved

Con

tact

per

son

Aim

s/de

scri

ptio

n of

initi

ativ

eW

orkf

orce

type

an

d m

ixEv

alua

tion

Wai

rara

pa D

HB

Chr

onic

Dis

ease

M

anag

emen

t D

iabe

tes

Proj

ect

Wai

rara

pa D

HB

The

Doc

tors

M

aste

rton

Dav

id N

ixon

, Th

e D

octo

rs

Mas

terto

n

To im

prov

e ou

tcom

es fo

r a h

igh-

risk

popu

latio

n, d

evel

oped

from

the

Cou

ntie

s-M

anuk

au c

hron

ic c

are

man

agem

ent m

odel

.

Dia

bete

s le

ad

GP

and

prac

tice

nurs

e, d

iabe

tes

nurs

e ed

ucat

or,

Mäo

ri he

alth

car

e w

orke

rs, s

uppo

rt fro

m a

spe

cial

ist.

Impr

ovem

ents

in a

rang

e of

in

dica

tors

eg.

per

cent

age

of p

atie

nts

on c

hole

ster

ol-lo

wer

ing

drug

s an

d de

crea

ses

in b

lood

pre

ssur

e.

Impr

ovem

ents

sim

ilar i

n bo

th M

äori

and

Pake

ha p

opul

atio

ns.

Dia

bete

s Sh

ared

-C

are

Car

d Pr

ojec

tW

aira

rapa

DH

B,

Wai

rara

pa

Loca

lity

Dia

bete

s Te

am,

The

Doc

tors

M

aste

rton

Dav

id N

ixon

, Th

e D

octo

rs

Mas

terto

n

To fa

cilit

ate

chan

ge a

way

from

doc

tor-

cent

red

care

tow

ards

pat

ient

-cen

tred

care

with

a v

iew

to im

prov

ing

patie

nt

unde

rsta

ndin

g an

d cl

inic

al o

utco

mes

.

A p

atie

nt-h

eld

card

to re

cord

targ

et,

resu

lts, a

nd a

ppoi

ntm

ents

.

Mul

ti-di

scip

linar

y te

am

Prim

ary

Car

e IT

So

lutio

ns (I

T fo

r ca

rdio

vasc

ular

di

seas

e ris

k as

sess

men

t)

The

Doc

tors

M

aste

rton,

JESS

Sy

stem

s Lt

d

Dav

id N

ixon

, Th

e D

octo

rs

Mas

terto

n

Kevi

n Pr

esto

n,

JESS

Sys

tem

s Lt

d

Dev

elop

men

t of c

ompu

ting

softw

are

able

to e

xtra

ct d

ata

from

the

data

base

of

var

ious

PM

S sy

stem

s an

d ca

lcul

ate

risk

of C

VD

. To

ena

ble

GPs

to

quan

tify

the

CV

D ri

sk o

f ind

ivid

uals

or

pop

ulat

ions

– to

ena

ble

GPs

to

deve

lop

stra

tegi

es ta

rget

ed a

t hig

her

risk

indi

vidu

als

or p

opul

atio

ns.

Con

tinue

d ov

er...

44

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of in

itiat

ive

Wor

kfor

ce ty

pe

and

mix

Eval

uatio

n

Supp

orte

d di

scha

rge

for

CO

RD

Sout

hern

DH

B m

edic

al in

patie

nt a

nd

com

mun

ity a

llied

he

alth

ser

vice

s

Sue

McN

eill

To m

inim

ise

read

mis

sion

s fo

r pa

tient

s w

ith C

ORD

.

To im

prov

e he

alth

out

com

es a

nd

dise

ase

man

agem

ent.

Alli

ed h

ealth

sta

ff co

ordi

nato

r

Inpa

tient

sta

ff.

Dat

a fo

r 200

2 sh

owed

a d

ecre

ase

in

adm

issi

ons,

read

mis

sion

s an

d be

d ni

ghts

use

d fo

r pat

ient

s w

ith C

ORD

.

Dat

a fo

r 200

3 sh

owed

an

incr

ease

in

adm

issi

ons,

par

ticul

arly

in th

e fir

st 3

mon

ths

of th

e w

inte

r per

iod.

Ra

te o

f rea

dmis

sion

, bed

nig

hts

and

aver

age

leng

th o

f sta

y us

ed

rem

aine

d lo

wer

than

prio

r to

the

impl

emen

tatio

n of

the

prog

ram

me.

Dia

bete

s an

d C

ardi

ovas

cula

r Sc

reen

ing

Nor

thla

nd D

HB/

MA

PO,

Nor

thla

nd G

ener

al

Prac

tices

,

Kia

Ora

Nga

tiwai

M

äori

Prov

ider

, N

orth

land

Pat

holo

gy

Labo

rato

ry, E

nigm

a Pu

blis

hing

(Pre

dict

)

Dr N

ick

Cha

mbe

rlain

To re

duce

mor

bidi

ty fr

om d

iabe

tes

thro

ugh

early

det

ectio

n.G

Ps, p

ract

ice

nurs

es, M

äori

prov

ider

nur

ses.

Mon

thly

repo

rting

of a

ll re

sults

.

Spre

adsh

eet f

orm

at v

ia la

bora

tory

.

Shar

ed c

are

of

patie

nts

livin

g w

ith a

nd

man

agin

g ch

roni

c he

patit

is C

Can

terb

ury

Com

mun

ity

PHO

, Uni

on a

nd

Com

mun

ity H

ealth

C

entre

, Hep

atiti

s C

Re

sour

ce C

entre

Bill

Jang

Man

ager

Hep

atiti

s C

Re

sour

ce

Cen

tre, T

e W

aipo

unam

u

To d

evel

op b

ette

r ser

vice

s to

im

prov

e ac

cess

(man

y pe

ople

di

agno

sed

with

hep

atiti

s C

are

no

t hig

h us

ers

of p

rimar

y he

alth

se

rvic

es).

Soci

al w

orke

r, co

unse

llor,

GPs

, pr

actic

e nu

rses

, pr

actic

e m

anag

er.

Plan

ned

eval

uatio

n fo

r a y

ear’s

tim

e.

Com

preh

ensi

ve

mod

el o

f stro

ke

serv

ices

(CM

oSS)

Stro

ke F

ound

atio

n N

Z In

cBr

ian

O’G

rady

1. T

he re

duct

ion

of th

e in

cide

nce

of s

troke

2. T

he im

prov

emen

t of s

troke

se

rvic

es d

eliv

ery

natio

nally

w

ith b

ette

r clin

ical

and

soc

ial

outc

omes

.

Clin

icia

ns w

ith a

n in

tere

st a

nd

expe

rtise

in s

troke

. M

edic

al D

irect

ors

of th

e St

roke

Fo

unda

tion

and

the

CEO

.

21 in

tegr

ated

pro

ject

s w

ithin

the

thre

e st

rate

gies

bei

ng p

rogr

essi

vely

im

plem

ente

d. T

his

incl

udes

the

esta

blis

hmen

t of o

rgan

ised

stro

ke

serv

ices

.

... c

ontin

ued

from

pre

viou

s pa

ge

45

Rong

oa M

äori

Hua

nga

Ti H

auor

a

Te A

hure

wa

Te K

oper

e

Te R

apu

ora

Te W

hare

Ora

nga

Hin

enga

kau

Mar

ilyn

Vre

ede

Col

in R

icha

rds

Jane

t Roc

kwel

l

Faith

McL

achl

an

Piki

Tai

aroa

Piki

Tai

aroa

To re

duce

sym

ptom

s an

d to

en

cour

age

self

awar

enes

s an

d se

lf m

anag

emen

t of a

sthm

a sy

mpt

oms.

1 FT

E

Tohu

nga

Vol

unte

ers.

Ver

bal F

eedb

ack

Form

al Q

uarte

rly re

ports

Site

Vis

its –

2 m

onth

ly.

Ast

hma

educ

atio

n (3

+ Pl

an)

Ast

hma

Auc

klan

d

Jane

tte R

eid

(chi

ldre

n’s

asth

ma

educ

atio

n)

Ann

Whe

at

(col

lege

ast

hma

educ

atio

n)

Mar

li M

erho

ye

(trai

ning

for G

Ps

and

prac

tice

nurs

es)

To in

crea

se q

ualit

y of

life

issu

es in

ch

ildre

n w

ho h

ave

asth

ma.

To re

duce

hos

pita

l adm

issi

on ra

tes.

To b

ridge

the

gap

betw

een

prim

ary

sect

or a

nd s

econ

dary

se

ctor

to p

rodu

ce s

eam

less

he

alth

care

.

Refe

rral

s fro

m S

tars

hip

hosp

ital

offe

red

hom

e vi

sits

, als

o co

llege

st

uden

ts re

ceiv

e on

e-to

-one

as

thm

a ed

ucat

ion

at c

olle

ge)

Als

o tra

inin

g fo

r GPs

and

pr

actic

e nu

rses

in a

sthm

a an

d its

m

anag

emen

t

Ast

hma

nurs

e ed

ucat

ors.

Patie

nt s

atis

fact

ion

form

s.

Redu

ctio

n in

acu

te a

dmis

sion

s to

ho

spita

l (w

ill ta

ke m

ore

time

to

eval

uate

redu

ctio

n in

adm

issi

ons)

.

Incr

ease

d kn

owle

dge

of a

sthm

a.

Feed

back

from

par

ents

and

ca

regi

vers

is p

ositi

ve.

Qua

lity

of L

ife

Gra

nts

Oth

er e

xam

ples

pr

ovid

ed b

y th

e C

ystic

Fib

rosi

s A

ssoc

iatio

n w

ere

the

Info

rmat

ion

Libr

ary,

Fam

ily

Supp

ort W

orke

r (a

soc

ial w

ork

serv

ice)

and

Fa

mily

Edu

catio

n Pr

ogra

mm

e.

Cys

tic F

ibro

sis

Ass

ocia

tion

of N

ew

Zeal

and

Kate

Rus

sell

To a

ssis

t with

ext

ra c

osts

as

soci

ated

with

impr

ovin

g qu

ality

of

life

. The

se in

clud

e su

b se

ts

– ph

ysic

al a

ctiv

ity g

rant

s, te

rtiar

y gr

ants

, ass

ista

nce

with

med

ical

, ho

spita

l and

pre

scrip

tion

cost

s.

Nat

iona

l offi

ce

and

volu

ntee

r of

fice

hold

ers

at

loca

l lev

el.

Year

ly s

atis

fact

ion

surv

ey.

Con

tinue

d ov

er...

46

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of in

itiat

ive

Wor

kfor

ce ty

pe a

nd m

ixEv

alua

tion

Kidn

ey S

ocie

ty

dial

ysis

hou

seA

uckl

and

Dis

trict

Ki

dney

Soc

iety

and

C

ount

ies

Man

ukau

D

HB

rena

l dia

lysi

s se

rvic

e

Nor

a V

an d

er

Schr

ieck

(Kid

ney

Soci

ety)

Dav

e Li

lley

(Mid

dlem

ore

rena

l ser

vice

)

To p

rom

ote

hom

e ha

emod

ialy

sis

as a

way

for

rena

l pat

ient

s to

man

age

thei

r ow

n he

alth

at h

ome,

and

to

faci

litat

e tra

nsiti

on to

hom

e ha

emod

ialy

sis

by p

rovi

ding

an

unst

affe

d ho

me-

like

com

mun

ity

faci

lity

whe

re p

eopl

e ca

n di

alys

e.

Uns

taffe

d co

mm

unity

ho

use

man

aged

by

off-

site

Kid

ney

Soci

ety

offic

e st

aff.

Patie

nts

com

e an

d go

to

do

thei

r dia

lysi

s, th

ree

times

a w

eek

or a

ltern

ate

days

. D

ialy

sis

equi

pmen

t/su

pplie

s an

d m

edic

al

back

up m

anag

ed b

y M

iddl

emor

e re

nal a

s pa

rt of

hom

e ha

emod

ialy

sis

prog

ram

me.

Form

al e

valu

atio

n - n

ot y

et

carr

ied

out.

Info

rmal

ly, t

he

hous

e is

runn

ing

clos

e to

ca

paci

ty (1

0 pa

tient

s) m

ost o

f th

e tim

e, is

kee

ping

pat

ient

s ou

t of h

ospi

tal d

ialy

sis

units

an

d pa

tient

sat

isfa

ctio

n is

hi

gh. S

ome

peop

le h

ave

take

n, o

r are

pla

nnin

g to

ta

ke, a

mac

hine

to d

ialy

se a

t ho

me.

Vis

ion

New

Ze

alan

dRo

yal N

ew Z

eala

nd

Foun

datio

n of

the

Blin

d, R

etin

a N

ew

Zeal

and,

Dia

bete

s N

ew Z

eala

nd, T

he

Tong

an H

ealth

So

ciet

y, S

ave

Sigh

t So

ciet

y, C

entre

fo

r Citi

zens

hip

Educ

atio

n

Chr

is In

glis

, D

ivis

iona

l M

anag

er,

Blin

dnes

s A

war

enes

s an

d Pr

even

tion,

Ro

yal N

ew

Zeal

and

Foun

datio

n of

th

e Bl

ind

To in

crea

se th

e po

pula

tion’

s kn

owle

dge

abou

t blin

dnes

s, to

pr

omot

e bl

indn

ess

prev

entio

n an

d re

duce

pre

vent

able

bl

indn

ess

in N

ew Z

eala

nd.

Publ

ic h

ealth

spe

cial

ists

, m

edic

al d

octo

rs (G

Ps,

opht

halm

olog

ists

, op

tom

etris

ts),

blin

dnes

s co

nsum

er o

rgan

isat

ions

. W

orkf

orce

dep

ends

on

the

proj

ect d

one.

Eval

uatio

n m

etho

ds to

be

deve

lope

d an

d ta

ilore

d to

sui

t ind

ivid

ual p

roje

cts

unde

rtake

n by

Vis

ion

New

Ze

alan

d.

Hea

rt G

uide

A

otea

roa

Nat

iona

l Hea

rt Fo

unda

tion

(NH

F) a

nd T

e H

otu

Man

awa

Mäo

ri (T

HM

M) i

n pa

rtner

ship

NH

F St

epha

nie

Mun

cast

er

THM

M

Dr G

eorg

e G

ray

To im

prov

e ac

cess

to a

nd

com

plet

ion

of p

hase

II c

ardi

ac

reha

bilit

atio

n fo

r all

peop

le

expe

rienc

ing

hear

t eve

nt

by p

rovi

ding

a h

ome

base

d pr

ogra

m.

Mod

ify ri

sk fa

ctor

s an

d im

prov

es q

ualit

y of

life

.

Targ

eted

to p

eopl

e w

ho a

re

pres

ently

dis

enfra

nchi

sed

by th

e pr

esen

t mod

el o

f car

e.

Prog

ram

faci

litat

or- e

ither

a

Nur

se o

r hea

lth c

are

wor

ker.

Car

diac

car

e st

aff

with

in h

ospi

tal t

o id

entif

y pe

ople

who

will

use

this

se

rvic

e an

d lia

ise

with

pr

ogra

m fa

cilit

ator

.

Gen

eral

pra

ctic

e st

aff

liais

on w

ith fa

cilit

ator

for

ongo

ing

care

.

Aud

it pr

oces

s de

sign

ed to

as

sess

the

impa

ct o

n th

is

prog

ram

with

in p

ilot s

ites

prio

r to

natio

nal r

oll o

ut.

Dem

ogra

phic

det

ails

, ref

erra

l to

and

com

plet

ion

of c

ardi

ac

reha

bilit

atio

n, ri

sk fa

ctor

s m

odifi

catio

n an

d qu

ality

of

life

will

be

mea

sure

d.

... c

ontin

ued

from

pre

viou

s pa

ge

47

Hea

rt Fa

ilure

Proc

are:

Auc

klan

d D

HB:

Pete

r Did

sbur

y

Fellb

rook

M

edic

al C

entre

Vic

toria

Wils

on

Car

diac

Nur

se

Spec

ialis

t

Proc

are

Impr

oved

man

agem

ent o

f he

art f

ailu

re a

nd re

duct

ions

in

adm

issi

ons.

PHO

/IPA

and

DH

B.Fo

rmat

ive

and

outc

ome

eval

uatio

n.

Car

diov

ascu

lar

Proj

ect

Pan

Wai

tem

ata

DH

BD

iana

Nor

thRe

duce

the

impa

ct a

nd b

urde

n of

car

diov

ascu

lar d

isea

se a

nd

redu

ce in

equa

litie

s.

Sub

proj

ects

incl

ude

1. N

ew In

form

atio

n Sy

stem

for

CV

D a

nd D

iabe

tes

2. E

lect

roni

c D

ecis

ion

Supp

ort

for C

VD

, inc

lude

s M

äori

eval

uatio

n of

effe

ctiv

enes

s.3.

Car

diac

Reh

ab p

roje

ct –

the

Hea

rt M

anua

l pilo

t. In

clud

es

a M

äori

and

non-

Mäo

ri pi

lot.

4. P

acifi

c pe

ople

s pr

ojec

t for

C

VD

5. Q

ualit

y U

se o

f Med

icin

es fo

r C

VD

Publ

ic H

ealth

Loca

l Sch

ools

Hos

pita

l

Prim

ary

Car

e/PH

Os

NG

Os.

Mul

tiple

use

d in

clud

ing

quan

titat

ive

and

qual

itativ

e.

Clo

se a

ssoc

iatio

n w

ith th

e U

nive

rsity

and

AU

T fo

r som

e pr

ojec

ts.

Car

diov

ascu

lar

Gui

delin

e Im

plem

enta

tion

proj

ect

Hea

lthW

EST

PHO

an

d pr

actic

esEn

igm

a (P

RED

ICT)

NZ

Gui

delin

es

Gro

upG

reen

Pre

scrip

tion/

SPA

RC

Adr

iann

e A

llen

To id

entif

y, tr

eat a

nd p

rovi

de

supp

ort f

or li

fest

yle

chan

ge fo

r hi

gh n

eeds

peo

ple

enro

lled

in

Hea

lthW

EST

prac

tices

who

are

in

NZ

Gui

delin

es ri

sk ta

rget

gr

oup.

Gen

eral

Pra

ctiti

oner

s,

Prac

tice

Nur

ses,

H

ealth

WES

T Pr

ojec

t sta

ff,

Enig

ma

(PRE

DIC

T)

Gre

en P

resc

riptio

n an

d co

mm

unity

wor

kers

.

Num

ber o

f peo

ple

parti

cipa

ting

Long

er te

rm im

pact

mea

sure

s to

be

arra

nged

.

Car

diov

ascu

lar

Dis

ease

Sout

h Li

nk H

ealth

Ther

esa

McC

lena

ghan

To im

prov

e ou

tcom

es fo

r pa

tient

s w

ith c

ardi

ovas

cula

r di

seas

e.

Gen

eral

pra

ctic

e st

aff

IPA

adm

inis

trativ

e st

aff.

Ong

oing

qua

lity

impr

ovem

ent u

sing

clin

ical

an

d tre

atm

ent e

valu

atio

nsFe

edba

ck d

urin

g pa

tient

pr

actic

e co

nsul

tatio

ns

Con

tinue

d ov

er...

48

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of in

itiat

ive

Wor

kfor

ce ty

pe a

nd m

ixEv

alua

tion

Dia

bete

s w

atch

(e

nhan

ced

“Get

Che

cked

” pr

ogra

mm

e)

Sout

h Li

nk H

ealth

Erin

a Re

wi

To im

prov

e ou

tcom

es fo

r dia

betic

pa

tient

s w

ith e

leva

ted

HbA

1c

leve

ls.

Gen

eral

pra

ctic

e st

aff

IPA

adm

inis

trativ

e st

aff.

Ong

oing

qua

lity

impr

ovem

ent u

sing

clin

ical

an

d tre

atm

ent e

valu

atio

ns.

Feed

back

dur

ing

patie

nt

prac

tice

cons

ulta

tions

Dia

bete

s Ey

e Sc

reen

ing

Wes

t Auc

klan

d PH

Os

Wai

tem

ata

DH

B

Com

mun

ity

Org

anis

atio

ns/v

enue

s

Pasi

fika

Fono

Luck

ens

Rd M

arae

Chr

istin

e Sm

ithPr

ovid

es m

obile

retin

al s

cree

ning

se

rvic

e an

d di

abet

es e

duca

tion

oppo

rtuni

ties.

Retin

al p

hoto

scre

enin

g te

chni

cian

Regi

ster

ed n

urse

(tra

inin

g as

dia

bete

s nu

rse)

TBA

com

mun

ity h

ealth

w

orke

rs.

Num

ber s

cree

ned

and

ethn

icity

DN

A ra

te

Refe

rral

s/Li

nkag

es to

pr

actic

es

Con

sum

er fe

edba

ck.

Let’s

Bea

t Dia

bete

sC

ount

ies

Man

ukau

D

HB

and

partn

er

orga

nisa

tions

Am

anda

D

unlo

p,

CM

DH

B

To b

eat d

iabe

tes

by ta

king

a

“who

le s

ocie

ty-w

hole

life

cycl

e-w

hole

fam

ily a

ppro

ach”

to th

e di

seas

e.

Mul

ti-se

ctor

pa

rtici

patio

n.Se

e w

ww

.cm

dhb.

org.

nz/

Cou

ntie

s/Le

ts B

eat D

iabe

tes.

Dia

bete

s-Pl

an.h

tm.

Dia

bete

s Pr

ojec

tPa

n W

aite

mat

a D

HB

Redu

ce th

e im

pact

and

bur

den

of

diab

etes

and

redu

ce in

equa

litie

s

Subp

roje

cts:

1. R

etin

al E

ye S

cree

ning

pro

ject

2. S

elf M

anag

emen

t Cou

rses

pr

ojec

t

3. E

mpo

wer

ing

prim

ary

care

team

s pr

ojec

t

4. In

divi

dual

ly ta

ilore

d su

ppor

t and

op

tions

for e

xtra

hel

p (e

stim

ated

at

20%

of p

eopl

e) p

roje

ct

5. D

evel

opm

ent o

f ser

vice

s ap

prop

riate

for M

äori

and

othe

r et

hnic

min

ority

peo

ples

pro

ject

6. Q

ualit

y im

prov

emen

t wor

k w

ith

high

nee

d pr

actic

es p

roje

ct.

Publ

ic h

ealth

Hos

pita

l

Prim

ary

care

/PH

Os

NG

Os

Qua

litat

ive

asse

ssm

ent.

... c

ontin

ued

from

pre

viou

s pa

ge

49

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of in

itiat

ive

Wor

kfor

ce ty

pe a

nd m

ixEv

alua

tion

Dia

bete

s w

atch

(e

nhan

ced

“Get

Che

cked

” pr

ogra

mm

e)

Sout

h Li

nk H

ealth

Erin

a Re

wi

To im

prov

e ou

tcom

es fo

r dia

betic

pa

tient

s w

ith e

leva

ted

HbA

1c

leve

ls.

Gen

eral

pra

ctic

e st

aff

IPA

adm

inis

trativ

e st

aff.

Ong

oing

qua

lity

impr

ovem

ent u

sing

clin

ical

an

d tre

atm

ent e

valu

atio

ns.

Feed

back

dur

ing

patie

nt

prac

tice

cons

ulta

tions

Dia

bete

s Ey

e Sc

reen

ing

Wes

t Auc

klan

d PH

Os

Wai

tem

ata

DH

B

Com

mun

ity

Org

anis

atio

ns/v

enue

s

Pasi

fika

Fono

Luck

ens

Rd M

arae

Chr

istin

e Sm

ithPr

ovid

es m

obile

retin

al s

cree

ning

se

rvic

e an

d di

abet

es e

duca

tion

oppo

rtuni

ties.

Retin

al p

hoto

scre

enin

g te

chni

cian

Regi

ster

ed n

urse

(tra

inin

g as

dia

bete

s nu

rse)

TBA

com

mun

ity h

ealth

w

orke

rs.

Num

ber s

cree

ned

and

ethn

icity

DN

A ra

te

Refe

rral

s/Li

nkag

es to

pr

actic

es

Con

sum

er fe

edba

ck.

Let’s

Bea

t Dia

bete

sC

ount

ies

Man

ukau

D

HB

and

partn

er

orga

nisa

tions

Am

anda

D

unlo

p,

CM

DH

B

To b

eat d

iabe

tes

by ta

king

a

“who

le s

ocie

ty-w

hole

life

cycl

e-w

hole

fam

ily a

ppro

ach”

to th

e di

seas

e.

Mul

ti-se

ctor

pa

rtici

patio

n.Se

e w

ww

.cm

dhb.

org.

nz/

Cou

ntie

s/Le

ts B

eat D

iabe

tes.

Dia

bete

s-Pl

an.h

tm.

Dia

bete

s Pr

ojec

tPa

n W

aite

mat

a D

HB

Redu

ce th

e im

pact

and

bur

den

of

diab

etes

and

redu

ce in

equa

litie

s

Subp

roje

cts:

1. R

etin

al E

ye S

cree

ning

pro

ject

2. S

elf M

anag

emen

t Cou

rses

pr

ojec

t

3. E

mpo

wer

ing

prim

ary

care

team

s pr

ojec

t

4. In

divi

dual

ly ta

ilore

d su

ppor

t and

op

tions

for e

xtra

hel

p (e

stim

ated

at

20%

of p

eopl

e) p

roje

ct

5. D

evel

opm

ent o

f ser

vice

s ap

prop

riate

for M

äori

and

othe

r et

hnic

min

ority

peo

ples

pro

ject

6. Q

ualit

y im

prov

emen

t wor

k w

ith

high

nee

d pr

actic

es p

roje

ct.

Publ

ic h

ealth

Hos

pita

l

Prim

ary

care

/PH

Os

NG

Os

Qua

litat

ive

asse

ssm

ent.

Dia

bete

s Ed

ucat

ion

Pilo

t (E

PIC

)

Hea

lth W

EST

(Wai

tem

ata

DH

B no

w ta

king

app

roac

h up

with

long

er te

rm

view

of r

epla

cing

cu

rren

t edu

catio

n fo

r pe

ople

with

new

ly

diag

nose

d Ty

pe tw

o di

abet

es)

Chr

istin

e Sm

ith

Lisa

John

son

To in

crea

se a

cces

s to

effe

ctiv

e di

abet

es a

nd s

elf-m

anag

emen

t ed

ucat

ion

for h

igh

need

s pe

ople

liv

ing

with

Typ

e 2

Dia

bete

s th

roug

h fre

e co

mm

unity

and

pra

ctic

e se

lf-m

anag

emen

t dia

bete

s ed

ucat

ion

and

train

ing

for h

igh

need

s pe

ople

w

ith d

iabe

tes.

(EPI

C p

rogr

amm

e).

Stru

ctur

ed 6

-wee

k co

urse

.

Dia

bete

s N

urse

N

umbe

r acc

essi

ng s

elf

man

agem

ent d

iabe

tes

educ

atio

n co

mpa

red

to

curr

ent s

yste

m

Long

-term

eva

luat

ion

of

patie

nt s

elf-c

ompe

tenc

e an

d cl

inic

al o

utco

mes

.

Dia

bete

s su

ppor

t fo

r hig

h ne

eds

adol

esce

nts

(Mäo

ri Pa

cific

Qui

ntile

5)

Hea

lthW

EST

PHO

Wes

t Kid

s

Futu

res

Wes

t

Tris

h La

wth

erTo

incr

ease

acc

ess

to e

ffect

ive

care

for i

ndiv

idua

l hig

h ne

eds

adol

esce

nts

livin

g w

ith d

iabe

tes

unab

le to

acc

ess

appr

opria

te c

are

from

mai

nstre

am s

ervi

ces.

Yout

h H

ealth

Spe

cial

ist

Paed

iatri

cian

Dia

bete

s N

urse

Spe

cial

ist

wor

king

in a

dvan

ced

self

man

agem

ent s

cope

of

prac

tice.

Indi

vidu

al c

linic

al a

nd

lifes

tyle

out

com

es.

Nat

iona

l M

etab

olic

Ser

vice

Fu

ndin

g is

nat

iona

l vi

a th

e na

tiona

l te

stin

g ce

ntre

and

St

arsh

ip, b

ut th

ere

is n

o m

echa

nism

fo

r var

iatio

n du

e to

th

e na

ture

of D

HB

fund

ing.

Dia

nne

Web

ster

Impr

ovem

ent o

f car

e fo

r peo

ple

with

inhe

rited

dis

orde

rs o

f m

etab

olis

m.

The

Nat

iona

l M

etab

olic

Ser

vice

aim

s to

impr

ove

diag

nosi

s an

d tre

atm

ent o

f peo

ple

with

inbo

rn e

rror

s of

met

abol

ism

.

Met

abol

ic p

hysi

cian

, cl

inic

al n

urse

spe

cial

ist

and

diet

itian

. Bi

oche

mic

al g

enet

ics

labo

rato

ry R

egio

nal

phys

icia

ns a

nd d

ietit

ians

.

Info

rmal

Rong

oa M

äori

Miri

miri

Back

Pai

n

Arth

ritis

Ti H

auor

a

Te A

hure

wa

Te K

oper

e

Te R

apu

ora

Te W

hare

Ora

nga

Hin

enga

kau

Mar

ilyn

Vre

ede

Col

in R

icha

rds

Jane

t Roc

kwel

l

Faith

McL

achl

an

Piki

Tai

aroa

Piki

Tai

aroa

To re

duce

sym

ptom

s

To e

ncou

rage

sel

f car

e an

d m

anag

emen

t

To re

lieve

pai

n

1 FT

E

Tohu

nga

Vol

unte

ers

Ver

bal F

eedb

ack

Form

al Q

uarte

rly re

ports

Site

Vis

its b

y Ta

umat

a H

auor

a 2

mon

thly

.

Con

tinue

d ov

er...

50

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of in

itiat

ive

Wor

kfor

ce ty

pe a

nd m

ixEv

alua

tion

Rong

oa M

äori

Mat

e H

uka

Ti H

auor

a

Te A

hure

wa

Te K

oper

e

Te R

apu

ora

Te W

hare

Ora

nga

Hin

enga

kau

Mar

ilyn

Vre

ede

Col

in R

icha

rds

Jane

t Roc

kwel

l

Faith

McL

achl

an

Piki

Tai

aroa

Piki

Tai

aroa

To in

crea

se s

elf a

war

enes

s

To p

reve

nt h

ospi

talis

atio

ns

To e

ncou

rage

sel

f car

e

1 FT

E

Tohu

nga

Vol

unte

ers

Ver

bal F

eedb

ack

Form

al Q

uarte

rly re

ports

Site

Vis

its 2

mon

thly

.

Car

ePlu

s

Enha

nced

Pa

lliat

ive

Car

e Su

ppor

t Pr

ogra

mm

e

Sout

h Li

nk H

ealth

as

Man

agem

ent S

ervi

ces

Org

anis

atio

n

Prim

ary

Hea

lth

Org

anis

atio

ns

Sara

h Ke

nned

yTo

impr

ove

qual

ity o

f life

for

patie

nts

deem

ed to

be

term

inal

ly

ill.

Car

ePlu

s C

oord

inat

ors,

G

ener

al P

ract

ice

Staf

f, IP

A/M

SO A

dmin

istra

tive

Staf

f

Surv

ey; P

artic

ipan

t fe

edba

ck a

nd re

view

.

Te W

ai O

Ro

na: D

iabe

tes

Prev

entio

n St

rate

gy

30 o

rgan

isat

ions

in

clud

ing

Wai

kato

and

La

kes

DH

Bs, r

esea

rche

rs

from

uni

vers

ities

in

Auc

klan

d an

d W

aika

to,

Spor

t Wai

kato

, priv

ate

labo

rato

ries,

and

oth

ers.

A

ll fiv

e Iw

i and

ten

Mäo

ri he

alth

pro

vide

rs.

Dav

id S

imm

ons

To ta

rget

Wai

kato

Mäo

ri m

ost

at ri

sk o

f dev

elop

ing

Type

2

diab

etes

ove

r a tw

o-an

d-a-

half

year

per

iod.

By

incr

easi

ng a

ctiv

ity

and

impr

ovin

g di

et, t

he a

im is

to

redu

ce th

e nu

mbe

r of n

ew c

ases

of

diab

etes

in th

at p

opul

atio

n by

35%

du

ring

the

perio

d of

the

stud

y.

Mäo

ri C

omm

unity

H

ealth

Wor

kers

, Nur

ses,

ac

adem

ics,

labo

rato

ry

wor

kers

etc

3 yr

rand

omis

ed tr

ial

Wai

kato

DH

B in

itiat

ive

with

W

ork

and

Inco

me

for p

eopl

e in

acu

te

men

tal h

ealth

uni

t

Men

tal H

ealth

and

A

ddic

tions

Ser

vice

,

Wor

k &

Inco

me

NZ

Initi

ativ

e m

ade

poss

ible

th

roug

h th

e W

ork

&

Inco

me

enha

nced

ca

se m

anag

emen

t for

Si

ckne

ss a

nd In

valid

s Be

nefit

s fu

ndin

g.

Chr

is H

arris

To e

nsur

e co

ntin

uatio

n (o

r in

itiat

ion)

of fi

nanc

ial s

uppo

rt w

hile

pe

ople

are

in th

e ac

ute

men

tal

heal

th u

nit,

ther

eby

redu

cing

stre

ss

for t

he c

lient

, and

the

likel

ihoo

d of

read

mis

sion

for s

ocia

l rea

sons

. W

ork

& In

com

e C

ase

man

ager

s ar

e ba

sed

on th

e ho

spita

l cam

pus

and

visi

t clie

nts

in th

e un

it to

add

ress

be

nefit

and

em

ploy

men

t iss

ues.

Clie

nts

MH

nur

ses,

MH

OTs

,

MH

soc

ial w

orke

rs

W&

I cas

e m

anag

ers,

Supp

orte

d em

ploy

men

t ag

enci

es.

Eval

uate

d th

roug

h W

ork

and

Inco

me

enha

nced

ca

se m

anag

emen

t in

itiat

ive.

... c

ontin

ued

from

pre

viou

s pa

ge

51

Hea

lthy

Hea

rts

Act

ion

Plan

ProC

are,

Rot

ary

Clu

b of

O

ne T

ree

Hill

and

the

Hea

rt Fo

unda

tion.

Stew

art E

adie

Car

diac

Car

e M

anag

er

Nat

iona

l Hea

rt Fo

unda

tion

Enco

urag

es ‘a

t ris

k’ a

dults

to v

isit

thei

r loc

al d

octo

r or p

ract

ice

nurs

e fo

r a c

ardi

ovas

cula

r ris

k as

sess

men

t.

PHO

/ NG

O s

ecto

rFo

cus

on s

elf

man

agem

ent,

with

ev

alua

tion

of u

ptak

e pl

anne

d.

Affi

liatio

n Pr

ogra

mm

e -

for c

ardi

ac s

uppo

rt gr

oups

to a

ffilia

te

to N

atio

nal H

eart

Foun

datio

n of

N

ew Z

eala

nd

Not

e:

This

is n

ot a

DH

B in

itiat

ive.

Nat

iona

l Hea

rt Fo

unda

tion

of N

ew

Zeal

and

Use

rs: C

onsu

mer

s liv

ing

with

hea

rt pr

oble

ms

Key

stak

ehol

ders

: GRx

, M

edic

al p

rovi

ders

, Fi

tnes

s pr

ovid

ers,

D

iabe

tes

grou

ps

Nat

iona

l Co

Ord

inat

or:

Gle

nis

Bell,

Hea

rt Fo

unda

tion

To g

ive

supp

ort a

nd e

ncou

rage

men

t to

peo

ple

and

thei

r fam

ilies

, fo

llow

ing

a he

art e

vent

.

The

4 E’

s ar

e en

cour

aged

:

Exer

cise

Educ

atio

n

Emot

iona

l Sup

port

Enjo

ymen

t

And

em

pow

erm

ent o

f clu

b le

ader

s.

2x H

eart

Foun

datio

n C

o-

ordi

nato

r’s to

man

age

the

prog

ram

me

The

actu

al s

uppo

rt cl

ubs

are

mai

nly

volu

ntee

r le

d/ru

n.

Som

e ar

e fit

ness

cen

tre

base

d an

d co

ord

inat

ors

are

paid

. Use

r pay

s.

Inte

rnal

eva

luat

ions

199

9,

2000

. Ext

erna

l eva

luat

ion

2001

.

If fu

ndin

g pe

rmits

, bas

e-lin

e au

dit o

f clu

bs 2

005

Feed

back

from

co

nsum

ers

obta

ined

by

5x a

nnua

l clu

b se

min

ars

(hui

).

Nor

th K

ing

Cou

ntry

Car

diac

Re

habi

litat

ion

Educ

atio

n Pr

ogra

mm

e

Te K

uiti

Hos

pita

l C

omm

unity

Ser

vice

s

Loca

l Pha

rmac

y Pi

nnac

le M

edic

al

Cen

tre

Lesl

ey F

inn

Com

preh

ensi

ve p

rogr

amm

e to

pr

omot

e lif

esty

le c

hang

es fo

llow

ing

a ca

rdia

c ev

ent o

r to

prev

ent f

urth

er

card

iac

epis

odes

.

Car

diac

edu

cato

r Dis

trict

nu

rse

Die

titia

n

Phys

ioth

erap

ist

Soci

al W

orke

r

Phar

mac

ist

Gen

eral

Pra

ctiti

oner

.

Onl

y in

divi

dual

pat

ient

ev

alua

tions

, no

neg

ativ

e fin

ding

s, e

valu

atio

ns s

till

in p

rogr

ess.

Dia

bete

s H

ealth

Pr

ogra

mm

e an

d m

embe

rshi

p ca

rd

Mid

Cen

tral D

HB

Shirl

ey-A

nne

Gar

dine

r

Hea

lth P

lann

er,

Fund

ing

Div

isio

n

Mem

bers

hip

card

for p

eopl

e w

ith

diab

etes

, aim

ed a

t enc

oura

ging

the

pers

on a

nd th

eir f

amily

/whä

nau

to

feel

em

pow

ered

. Th

e ca

rd o

ffers

ac

cess

to c

are

and

ince

ntiv

es (e

g,

redu

ced

cost

foot

wea

r, di

scou

nt

vouc

hers

).

52

3) I

niti

ativ

es a

imed

at

spec

ific

grou

ps w

ithi

n th

e po

pula

tion

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of in

itiat

ive

Wor

kfor

ce ty

pe a

nd m

ixEv

alua

tion

Rura

l You

th

Clin

ics

Wha

ngan

ui R

egio

nal

PHO

Taih

ape

Med

ical

Tr

ust

Mau

rini H

aine

s

To p

rovi

de fr

ee a

cces

s to

yo

uth

med

ical

and

nur

sing

as

sess

men

t, ed

ucat

ion

and

treat

men

t ser

vice

as

an e

arly

in

terv

entio

n st

rate

gy to

offs

et

deve

lopm

ent o

f pot

entia

l ch

roni

c he

alth

issu

es in

hig

h-ris

k yo

uth

parti

cula

rly M

äori

and

Paci

fic Is

land

.

Reso

urce

d by

the

Taih

ape

Med

ical

Tru

st G

ener

al

Prac

tice.

GP

and

nurs

e pr

ovid

ed.

Clin

ics

held

in

out

reac

h se

tting

mos

t pr

efer

red

by y

outh

of t

hat

com

mun

ity.

Eval

uatio

n to

dat

e an

d in

crea

sing

num

bers

at

tend

ing

supp

ort

appr

opria

tene

ss o

f the

se

rvic

e.

Dat

a c

olle

cted

on

ethn

icity

/ di

seas

e co

de /

issu

e id

entifi

catio

n.

198

Yout

h H

ealth

Yout

h H

ealth

Tru

st in

co

ntra

ct w

ith C

ante

rbur

y D

HB

Chr

is W

oods

Pam

Whe

eler

Sue

Bags

haw

To m

ake

heal

th c

are

mor

e ac

cess

ible

to y

oung

peo

ple

‘at

risk’

from

10-

25 y

ears

.

GP,

pra

ctic

e nu

rse,

co

unse

llors

, pee

r co

unse

llors

, soc

ial w

orke

r, m

enta

l hea

lth p

ract

ition

er.

Last

eva

luat

ed in

199

8 - i

nclu

ded

patie

nt a

nd

orga

nisa

tion

satis

fact

ion,

an

d pa

rtici

patio

n ra

tes.

Car

diov

ascu

lar

Scre

enin

g of

Mäo

ri m

ales

in F

ar N

orth

Te T

ai T

oker

au P

HO

Rose

Lig

htfo

ot,

GM

Te

Tai

Toke

rau

PHO

To re

duce

mor

bidi

ty a

nd

mor

talit

y of

car

diov

ascu

lar

dise

ase

thro

ugh

early

det

ectio

n an

d pr

even

tion.

Mäo

ri Pr

ovid

er N

urse

s,

GPs

, Pra

ctic

e N

urse

s.

Mar

ae B

ased

C

linic

sW

aika

to P

HO

Shel

ley

Cam

pbel

lTo

impr

ove

acce

ss to

ser

vice

s.G

P, p

ract

ice

nurs

e.N

ot y

et

Hea

lth P

rom

otin

g C

hurc

hes

Paci

fic Is

land

s H

eartb

eat

(PIH

B).

6 Pa

cific

chu

rche

s &

1

Com

mun

ity g

roup

Hen

ga A

mos

a

Mel

iam

e C

ocke

r

To e

ncou

rage

Pac

ific

peop

le

to a

dopt

hea

lthy

lifes

tyle

s su

ch a

s he

alth

y fo

od c

hoic

es,

phys

ical

ly a

ctiv

e liv

es a

nd

smok

efre

e en

viro

nmen

ts.

Hea

lth/c

omm

unity

w

orke

rs, d

ietit

ians

, nu

tritio

nist

s.

Eval

uate

d in

200

2.

Cer

tifica

te in

Pa

cific

Nut

ritio

n (C

PN)

PIH

B/N

atio

nal H

eart

Foun

datio

n (N

HF)

and

A

uckl

and

Uni

vers

ity o

f Te

chno

logy

(AU

T)

Mar

ia C

assi

dy

Mafi

Fun

aki-

Tahi

fote

To im

prov

e th

e he

alth

and

w

ellb

eing

of P

acifi

c pe

ople

th

roug

h be

tter n

utrit

ion

and

regu

lar p

hysi

cal a

ctiv

ity.

Die

titia

ns, N

utrit

ioni

sts,

H

ealth

Pro

fess

iona

ls,

Med

ical

Doc

tors

/Sp

ecia

lists

Feed

back

giv

en o

n ev

alua

tion

form

s af

ter

each

cou

rse

mod

ule.

53

Smok

ing

Ces

satio

n Tr

aini

ngPI

HB/

NH

F, T

he Q

uit

Gro

up, a

nd H

ealth

Se

rvic

e Pr

ovid

ers

Hai

kiu

Baia

be

(Auc

klan

d &

Nor

ther

n Re

gion

)

Oliv

ia T

usa

(Cen

tral R

egio

n &

Sou

th Is

land

)

To p

rom

ote

the

bene

fits

of b

eing

sm

okef

ree

and

enco

urag

e Pa

cific

sm

oker

s to

qu

it.

Smok

ing

Ces

satio

n Sp

ecia

lists

/Pra

ctiti

oner

s,

Hea

lth P

rofe

ssio

nals

Feed

back

giv

en o

n ev

alua

tion

form

afte

r the

co

urse

– s

ame

as fo

r CPN

ev

alua

tion.

Impr

oved

Prim

ary

Hea

lth A

cces

s fo

r Pa

cific

peo

ple-

le

ader

ship

and

ad

vice

.

Hea

lthW

EST

PHO

SIA

ove

rhea

dTo

incr

ease

acc

ess

to p

rimar

y ca

re b

y Pa

cific

peo

ple

thro

ugh

advi

ce o

n in

crea

sing

acc

ess

for

Paci

fic p

eopl

e to

Hea

lthW

EST

mai

nstre

am p

rimar

y ca

re.

Paci

fic H

ealth

Pro

ject

M

anag

er

Paci

fic L

iais

on N

urse

Incr

ease

d Pr

imar

y D

iabe

tes

Supp

ort

for P

acifi

c Pe

ople

Hea

lth W

EST

PHO

Jenn

ifer T

uaga

luTo

incr

ease

acc

ess

to d

iabe

tes

and

self

care

for P

acifi

c pe

ople

th

roug

h Fu

ndin

g D

iabe

tes

Nur

se S

peci

alis

t and

Sel

f Car

e tra

inin

g fo

r Pac

ific

Clin

ical

Pr

ojec

t Nur

se.

Dia

bete

s N

urse

Spe

cial

ist

Car

ePlu

s

At R

isk

Elde

rly

Sout

h Li

nk H

ealth

as

Man

agem

ent S

ervi

ces

Org

anis

atio

n

PHO

Sara

h Ke

nned

yTo

ols

to a

ssis

t with

ass

essm

ent

and

ongo

ing

man

agem

ent o

f at

risk

eld

erly

pat

ient

s.

Car

ePlu

s C

oord

inat

ors

Gen

eral

Pra

ctic

e St

aff

IPA

/MSO

Adm

inis

trativ

e St

aff.

Parti

cipa

nt fe

edba

ck a

nd

revi

ew

Com

mun

ity F

IRST

an

d In

depe

nden

ce

FIRS

T

Pres

byte

rian

Supp

ort

Nor

ther

nJu

lie M

artin

To m

axim

ise

inde

pend

ence

fo

r old

er p

eopl

e w

ith h

igh

and

com

plex

nee

ds.

To o

ffer a

cho

ice

for o

lder

pe

ople

who

wou

ld o

ther

wis

e be

in re

side

ntia

l car

e. T

o im

prov

e qu

ality

of l

ife fo

r ol

der p

eopl

e an

d ca

rers

To a

void

unn

eces

sary

hos

pita

l ad

mis

sion

s.

Pred

omin

antly

trai

ned

supp

ort w

orke

rs g

uide

d by

mul

tidis

cipl

inar

y te

am in

puts

incl

udin

g a

coor

dina

tor (

regi

ster

ed

nurs

e), p

hysi

othe

rapi

st

and

occu

patio

nal t

hera

py

inpu

ts.

Part

of th

e A

SPIR

E ev

alua

tion

for a

gein

g in

pl

ace

initi

ativ

es. B

eing

un

derta

ken

by A

uckl

and

Uni

vers

ity. S

pons

ored

by

the

Min

istry

of H

ealth

.

Con

tinue

d ov

er...

54

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of

initi

ativ

eW

orkf

orce

type

an

d m

ixEv

alua

tion

Inte

grat

ed h

ome

and

com

mun

ity c

are

for

olde

r peo

ple

and

adul

ts

with

chr

onic

illn

esse

s.

See

web

site

:ht

tp://

ww

w.c

cdhb

.org

.nz

/prim

ary.

htm

Cap

ital &

Coa

st D

HB

Bene

dict

Hef

ford

or

And

rew

D

owne

s

To im

prov

e ca

re,

parti

cula

rly in

the

hom

e,

of a

dults

with

chr

onic

ill

ness

es. T

o en

cour

age

bette

r coo

rdin

atio

n of

car

e; s

tand

ardi

sed

asse

ssm

ent a

nd c

are

plan

ning

pro

cess

for t

his

patie

nt g

roup

.

Mai

nly

seni

or n

urse

s an

d al

lied

heal

th

prof

essi

onal

s.

Form

al e

valu

atio

n of

In

terR

AI a

sses

smen

t too

l (M

oH fu

nded

). A

lso

trend

s an

d in

dica

tors

su

ch a

s ra

te o

f avo

idab

le

hosp

ital a

dmis

sion

; pat

ient

sa

tisfa

ctio

n.

Ass

essm

ent o

f Old

er

Peop

le G

uide

line.

N

ew Z

eala

nd A

ssoc

iatio

n of

G

eron

tolo

gy, A

ge C

once

rn,

Don

ald

Beas

ley

Inst

itute

, G

ener

al P

ract

ition

er, R

NZC

GP,

Te

Ora

nga

Kaum

ätua

Kui

a D

isab

ility

Sup

port

Serv

ice,

C

olle

ge o

f Psy

chia

trist

s (R

AN

ZCP)

, NA

SC, T

e O

rang

a Ka

umät

ua, K

uia

Dis

abili

ty

Supp

ort S

ervi

ce, A

uckl

and

Pres

byte

rian

Supp

ort S

ervi

ces,

G

rey

Pow

er, N

ew Z

eala

nd

Ger

iatri

c So

ciet

y, A

CC

Step

hen

Jaco

bs

Seni

or A

dvis

or,

Hea

lth o

f Old

er

Peop

le

Dis

abili

ty S

uppo

rt Se

rvic

es, M

inis

try

of H

ealth

To re

duce

the

rate

s of

trea

tmen

t and

ho

spita

lisat

ion

for

cond

ition

s id

entifi

ed la

te.

Mul

tidis

cipl

inar

yTh

e to

ols

revi

ew th

at

acco

mpa

nied

the

GL

sugg

este

d In

terR

ai a

s a

poss

ibili

ty fo

r a n

atio

nal

asse

ssm

ent t

ool t

o su

ppor

t th

e as

sess

men

t pro

cess

.

GP

Link

Sout

hlin

k H

ealth

Erin

a Re

wi

To im

prov

e ou

tcom

es

for p

atie

nts

with

men

tal

illne

ss li

ving

in th

e co

mm

unity

.

Gen

eral

Pra

ctic

e st

aff

IPA

adm

inis

trativ

e st

aff.

Ong

oing

qua

lity

impr

ovem

ent u

sing

clin

ical

an

d tre

atm

ent e

valu

atio

ns.

Know

ing

the

Peop

le

Plan

ning

(KPP

)D

HB

men

tal h

ealth

ser

vice

sBa

rry

Wel

sh

To p

lan,

man

age

and

eval

uate

men

tal h

ealth

se

rvic

es fo

r tho

se w

ho

have

con

tact

with

MH

se

rvic

es fo

r mor

e th

an 2

ye

ars.

Con

sum

ers/

case

m

anag

ers/

team

le

ader

s, m

anag

ers/

fu

nder

s an

d pl

anne

rs

and

Min

istry

.

KPP

is a

n ev

alua

tion

tool

in a

nd o

f it s

elf.

An

inde

pend

ent e

valu

atio

n un

derta

ken

by H

RC w

ill b

e co

mpl

eted

by

Apr

il 20

05.

KPP

is th

e su

bjec

t of P

hD

rese

arch

con

duct

ed b

y Ba

rry

Wel

sh a

t Mas

sey

–

due

for c

ompl

etio

n 20

09.

... c

ontin

ued

from

pre

viou

s pa

ge

55

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of

initi

ativ

eW

orkf

orce

type

an

d m

ixEv

alua

tion

Inte

grat

ed h

ome

and

com

mun

ity c

are

for

olde

r peo

ple

and

adul

ts

with

chr

onic

illn

esse

s.

See

web

site

:ht

tp://

ww

w.c

cdhb

.org

.nz

/prim

ary.

htm

Cap

ital &

Coa

st D

HB

Bene

dict

Hef

ford

or

And

rew

D

owne

s

To im

prov

e ca

re,

parti

cula

rly in

the

hom

e,

of a

dults

with

chr

onic

ill

ness

es. T

o en

cour

age

bette

r coo

rdin

atio

n of

car

e; s

tand

ardi

sed

asse

ssm

ent a

nd c

are

plan

ning

pro

cess

for t

his

patie

nt g

roup

.

Mai

nly

seni

or n

urse

s an

d al

lied

heal

th

prof

essi

onal

s.

Form

al e

valu

atio

n of

In

terR

AI a

sses

smen

t too

l (M

oH fu

nded

). A

lso

trend

s an

d in

dica

tors

su

ch a

s ra

te o

f avo

idab

le

hosp

ital a

dmis

sion

; pat

ient

sa

tisfa

ctio

n.

Ass

essm

ent o

f Old

er

Peop

le G

uide

line.

N

ew Z

eala

nd A

ssoc

iatio

n of

G

eron

tolo

gy, A

ge C

once

rn,

Don

ald

Beas

ley

Inst

itute

, G

ener

al P

ract

ition

er, R

NZC

GP,

Te

Ora

nga

Kaum

ätua

Kui

a D

isab

ility

Sup

port

Serv

ice,

C

olle

ge o

f Psy

chia

trist

s (R

AN

ZCP)

, NA

SC, T

e O

rang

a Ka

umät

ua, K

uia

Dis

abili

ty

Supp

ort S

ervi

ce, A

uckl

and

Pres

byte

rian

Supp

ort S

ervi

ces,

G

rey

Pow

er, N

ew Z

eala

nd

Ger

iatri

c So

ciet

y, A

CC

Step

hen

Jaco

bs

Seni

or A

dvis

or,

Hea

lth o

f Old

er

Peop

le

Dis

abili

ty S

uppo

rt Se

rvic

es, M

inis

try

of H

ealth

To re

duce

the

rate

s of

trea

tmen

t and

ho

spita

lisat

ion

for

cond

ition

s id

entifi

ed la

te.

Mul

tidis

cipl

inar

yTh

e to

ols

revi

ew th

at

acco

mpa

nied

the

GL

sugg

este

d In

terR

ai a

s a

poss

ibili

ty fo

r a n

atio

nal

asse

ssm

ent t

ool t

o su

ppor

t th

e as

sess

men

t pro

cess

.

GP

Link

Sout

hlin

k H

ealth

Erin

a Re

wi

To im

prov

e ou

tcom

es

for p

atie

nts

with

men

tal

illne

ss li

ving

in th

e co

mm

unity

.

Gen

eral

Pra

ctic

e st

aff

IPA

adm

inis

trativ

e st

aff.

Ong

oing

qua

lity

impr

ovem

ent u

sing

clin

ical

an

d tre

atm

ent e

valu

atio

ns.

Know

ing

the

Peop

le

Plan

ning

(KPP

)D

HB

men

tal h

ealth

ser

vice

sBa

rry

Wel

sh

To p

lan,

man

age

and

eval

uate

men

tal h

ealth

se

rvic

es fo

r tho

se w

ho

have

con

tact

with

MH

se

rvic

es fo

r mor

e th

an 2

ye

ars.

Con

sum

ers/

case

m

anag

ers/

team

le

ader

s, m

anag

ers/

fu

nder

s an

d pl

anne

rs

and

Min

istry

.

KPP

is a

n ev

alua

tion

tool

in a

nd o

f it s

elf.

An

inde

pend

ent e

valu

atio

n un

derta

ken

by H

RC w

ill b

e co

mpl

eted

by

Apr

il 20

05.

KPP

is th

e su

bjec

t of P

hD

rese

arch

con

duct

ed b

y Ba

rry

Wel

sh a

t Mas

sey

–

due

for c

ompl

etio

n 20

09.

Cou

ntie

s M

anuk

au

Pers

onal

Liv

ing

Solu

tions

(Com

mun

ity

Livi

ng) S

ervi

ces

Cou

ntie

s M

anuk

au D

HB

Con

tract

s w

ith P

enin

a Pa

cific

LTD

, Cha

lleng

e Tr

ust,

Man

itahi

Tru

st, T

e Ko

row

ai

Aro

ha, F

ram

ewor

k Tr

ust

Ross

Phi

llip,

C

MD

HB

To a

llow

men

tal h

ealth

co

nsum

ers

to fi

nd th

eir o

wn

solu

tions

. Ser

vice

s ac

tivel

y as

sist

the

indi

vidu

al b

eing

se

rved

to d

efine

thei

r ow

n ne

eds,

pla

n an

app

roac

h to

mee

t the

m a

nd d

ecid

e up

on m

ore

desi

rabl

e fe

atur

es o

f the

ir liv

es.

Mix

ture

of c

linic

al

and

non-

clin

ical

su

ppor

t sta

ff an

d m

anag

eria

l sta

ff.

In c

olla

bora

tion

with

C

MD

HB

Clin

ical

Pr

ovid

er A

rm

Serv

ices

.

Eval

uatio

n in

futu

re

- ini

tiativ

e co

mm

ence

d m

id-2

004.

Fee

dbac

k al

so th

roug

h re

gula

r m

eetin

g w

ith p

artic

ipat

ing

orga

nisa

tions

and

DH

B cl

inic

al s

taff.

Impr

ovin

g ph

ysic

al

heal

th o

f peo

ple

with

m

enta

l illn

ess

Path

way

s Tr

ust,

Wan

ganu

i

GPs

in W

anga

nui

Mic

helle

G

lenn

y,

Regi

onal

M

anag

er

Empl

oym

ent o

f reg

iste

red

nurs

e w

ith g

ener

al n

ursi

ng

back

grou

nd to

impr

ove

the

phys

ical

hea

lth o

f pe

ople

with

ser

ious

men

tal

illne

ss in

resi

dent

ial a

nd

mob

ile s

uppo

rt se

rvic

es.

Man

y of

thes

e pe

ople

hav

e si

gnifi

cant

chr

onic

illn

esse

s as

wel

l as

a lo

ng-te

rm

psyc

hiat

ric d

isab

ility

.

Regi

ster

ed n

urse

, Pa

thw

ays

men

tal

heal

th c

omm

unity

su

ppor

t wor

kers

. M

ain

inte

rface

is

with

GPs

but

als

o lin

ks w

ith D

HB

Com

mun

ity M

enta

l H

ealth

Tea

m

psyc

hiat

rists

and

co

mm

unity

men

tal

heal

th n

urse

s.

Com

men

ced

in A

ugus

t 20

04 w

ith n

o fo

rmal

ev

alua

tion

yet.

Brie

f Int

erve

ntio

ns fo

r H

arm

ful B

ehav

iour

: Ef

fect

ive

App

licat

ion

of th

e TA

DS

Brie

f In

terv

entio

ns fo

r H

arm

ful B

ehav

iour

Tr

aini

ng P

rogr

amm

e to

PH

Os

in B

OPD

HB

Bay

of P

lent

y D

HB,

Auc

klan

d Sc

hool

of M

edic

ine,

BO

PDH

B PH

Os

Bria

n Po

into

nTo

est

ablis

h a

reso

urce

d w

orkf

orce

with

in p

rimar

y ca

re to

sup

port

the

deliv

ery

of p

rogr

amm

es d

esig

ned

to a

ddre

ss ri

sk b

ehav

iour

s th

at c

ontri

bute

to c

hron

ic

cond

ition

s.

Gen

eral

pra

ctiti

oner

, nu

rsin

g an

d co

mm

unity

wor

ker

wor

kfor

ces.

Brie

f Int

erve

ntio

ns fo

r H

arm

ful B

ehav

iour

: Ef

fect

ive

App

licat

ion

of th

e TA

DS

Brie

f Int

erve

ntio

ns

for H

arm

ful B

ehav

iour

Tr

aini

ng P

rogr

amm

e to

PH

Os

in B

OPD

HB.

Con

tinue

d ov

er...

56

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of

initi

ativ

eW

orkf

orce

type

and

m

ixEv

alua

tion

Prim

ary

Partn

ersh

ips

Men

tal H

ealth

Pro

ject

Hea

lthW

EST

PHO

, GP,

Pr

actic

e N

urse

s an

d re

cept

ion

staf

f

Wai

tem

ata

DH

B Sp

ecia

list

Men

tal H

ealth

ser

vice

s

Com

mun

ity M

enta

l Hea

lth

Serv

ices

Com

mun

ity P

harm

acis

ts

Sara

h H

ughe

sTo

incr

ease

prim

ary

care

ac

cess

and

effi

cacy

for

men

tal h

ealth

pat

ient

s w

ith

seve

re a

nd e

ndur

ing

men

tal

illne

ss.

GPs

, Pra

ctic

e N

urse

s

Psyc

hiat

rists

GP

Liai

son

Spec

ialis

t N

urse

s, C

omm

unity

M

enta

l Hea

lth K

ey

Wor

kers

, Con

sum

ers

and

fam

ily m

embe

rs.

Num

ber c

onsu

mer

s in

tra

nsiti

on o

r tra

nsiti

oned

to

prim

ary

care

.

Parti

cipa

nts

feed

back

(all)

.

Inte

rRA

I MD

S-H

CH

ealth

Wai

kato

,

Dis

abili

ty S

uppo

rt Li

nk,

WD

HB,

Te

Koro

wai

Hau

ora

O H

aura

ki

Jane

Hud

son

Fion

a M

urdo

ch

To s

ee if

this

par

ticul

ar to

ol

coul

d be

use

d to

intro

duce

a

stan

dard

ised

ass

essm

ent

proc

ess,

a n

atio

nal d

ata

set

and

a na

tiona

l ass

essm

ent

tool

sui

tabl

e fo

r old

er

peop

le. W

aika

to D

HB

is

one

of fi

ve D

HBs

pilo

ting

a di

ffere

nt a

sses

smen

t too

l, bu

t is

the

only

one

usi

ng a

M

äori

prov

ider

to tr

ial t

he

tool

.

OPA

T nu

rses

, OT

Com

mun

ity M

äori

Hea

lth N

urse

Eval

uate

d by

MO

H

cont

ract

ed e

valu

ator

s at

th

e en

d of

15

mon

ths

trial

.

... c

ontin

ued

from

pre

viou

s pa

ge

57

4) S

elf M

anag

emen

t In

itia

tive

s

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct

pers

onA

ims/

desc

ript

ion

of In

itiat

ive

Wor

kfor

ce ty

pe a

nd m

ixEv

alua

tion

Can

cerV

oice

s N

ew Z

eala

ndC

ance

rVoi

ces

New

Zea

land

(a

n in

depe

nden

t gr

oup

of p

eopl

e af

fect

ed b

y ca

ncer

)

Judi

McB

ride-

Wils

on

To e

mpo

wer

and

giv

e vo

ice

to th

ose

affe

cted

by

canc

er. T

o in

fluen

ce th

e pr

oces

s an

d en

sure

equ

ality

in th

e pr

ovis

ion

of a

nd a

cces

s to

trea

tmen

ts

for a

ll ca

ncer

pat

ient

s.

Vol

unte

ers,

pat

ient

s an

d ca

regi

vers

mai

nly

- som

e se

rvic

e pr

ovid

ers.

All

have

firs

t han

d ex

perie

nce

of c

ance

r .

Subs

tant

ial i

nfor

mal

fe

edba

ck th

at th

is is

a lo

ng

over

due

deve

lopm

ent.

Hig

h N

eeds

Nur

se

Coo

rdin

ator

role

Wha

ngan

ui

Regi

onal

PH

ORi

hi K

aren

aD

evel

opm

ent o

f ind

ivid

ual c

ase

man

agem

ent p

lans

with

the

patie

nt/

whä

nau

and

GP

team

, aim

ing

to d

rive

self

dete

rmin

atio

n an

d ef

fect

ive

self

man

agem

ent o

f chr

onic

con

ditio

ns

and

addr

ess

barr

iers

to im

prov

ed

heal

th (e

g. h

ousi

ng, t

rans

port)

thro

ugh

advo

cacy

and

pra

ctic

al s

olut

ions

.

Regi

ster

ed n

urse

rece

ives

re

ferr

als

from

the

GP

Team

an

d w

orks

col

labo

rativ

ely

with

the

patie

nt/w

häna

u an

d he

alth

pro

fess

iona

ls a

nd

inte

rsec

toria

l age

ncie

s.

60%

pat

ient

s ar

e M

äori.

C

usto

mer

Sat

isfa

ctio

n Su

rvey

re

sults

are

pos

itive

.

Expe

rient

ial

Patie

nt E

duca

tion

Prog

ram

me

-C

hron

ic P

ain

Ota

go D

HB

Jess

ica

Ath

erto

n-C

linic

al N

urse

Sp

ecia

list

Chr

onic

Pai

n Se

rvic

e

A 6

-wee

k ou

tpat

ient

pro

gram

me.

A

im to

incr

ease

pat

ient

kno

wle

dge

and

appr

opria

te s

elf-m

anag

emen

t te

chni

ques

.

Clin

ical

nur

se s

peci

alis

t,

occu

patio

nal t

hera

pist

,

Clin

ical

psy

chol

ogis

t,

phys

ioth

erap

ist.

Pre

and

Post

test

s

Que

stio

nnai

res

Shor

t ver

bal ‘

debr

ief a

nd

eval

uatio

n’ b

y pr

ojec

t sta

ff m

embe

rs a

fter e

ach

sess

ion.

A1

Serv

ices

to

Incr

ease

acc

ess

to P

rimar

y H

ealth

C

are

for H

igh

Nee

ds P

eopl

e w

ith C

hron

ic

Con

ditio

ns:

Self

Man

agem

ent

Trai

ning

Hea

lth G

reen

Pr

escr

iptio

n

Arth

ritis

Fo

unda

tion

Stan

ford

U

nive

rsity

(H

ealth

WES

T PH

O)

Chr

istin

e Sm

ithTo

incr

ease

effe

ctiv

e se

lf m

anag

emen

t sk

ills

for h

igh

need

s pe

ople

livi

ng

with

chr

onic

con

ditio

ns th

roug

h pa

rtici

patio

n in

”Li

ving

Wel

l with

a

Chr

onic

Con

ditio

n” s

elf m

anag

emen

t tra

inin

g co

urse

. Lea

ders

hip

and

parti

cipa

tion

cour

ses

– fo

cus

on

deve

lopi

ng la

y le

ader

ship

.

Lay

and

staf

f lea

ders

Stee

ring

grou

p –

prov

ides

ac

adem

ic, c

ultu

ral a

nd

cons

umer

gui

danc

e.

Expl

orin

g re

sear

ch,

eval

uatio

n an

d m

onito

ring

optio

ns. S

ome

clin

ical

ou

tcom

es a

s ap

prop

riate

–

livin

g w

ell w

ith a

chr

onic

co

nditi

on is

the

focu

s.

58

5) W

orkf

orce

-spe

cifi

c in

itia

tive

s

Nam

e of

initi

ativ

eO

rgan

isat

ion/

s in

volv

edC

onta

ct p

erso

nA

ims/

desc

ript

ion

of in

itiat

ive

Wor

kfor

ce ty

pe a

nd

mix

Eval

uatio

n

Die

ticia

n w

ith a

Sp

ecia

l Int

eres

t in

Nut

ritio

n an

d G

eron

tolo

gy

(SIN

G)

New

Zea

land

Die

tetic

A

ssoc

iatio

nSa

ndra

Van

Li

l, N

utrit

ion

Serv

ices

, M

iddl

emor

e H

ospi

tal,

Car

ole

Gib

bs, N

ew

Zeal

and

Die

tetic

A

ssoc

iatio

n

To d

isse

min

ate

info

rmat

ion

rela

ting

to n

utrit

ion

and

the

elde

rly.

Die

ticia

nsTh

ere

is in

crea

sing

reco

gniti

on

of th

e im

porta

nce

of n

utrit

ion

in

impr

ovin

g he

alth

out

com

es.

Nur

se L

ed C

linic

s (e

g, d

iabe

tes,

nu

tritio

n, s

mok

ing,

ph

ysic

al a

ctiv

ity)

Haw

kes

Bay

PHO

pr

actic

e - T

he D

octo

rs

Nap

ier a

nd H

astin

gs

Shar

on F

allo

on,

Proj

ect

Coo

rdin

ator

for

Haw

kes

Bay

PHO

Self

man

agem

ent,

educ

atio

n an

d co

ordi

natio

n.Re

gist

ered

Nur

ses

Mon

thly

repo

rts:

- num

ber o

f pat

ient

s re

ferr

ed- e

thni

city

repo

rt- h

ealth

out

com

es

Satis

fact

ion

surv

eyLo

ng te

rm s

trate

gy fo

r the

pro

ject

Car

e Pl

us N

urse

ro

leW

hang

anui

Reg

iona

l PH

ORo

byn

Finu

cane

To a

ssis

t with

any

pat

ient

s w

ith

com

plex

med

ical

/sur

gica

l/m

enta

l pro

blem

s w

ho h

ave

been

enr

olle

d as

Car

e Pl

us

patie

nts;

impl

emen

ting

a ca

re p

lan,

and

invo

lvin

g th

e pa

tient

/whä

nau/

fam

ily w

ith

obje

ctiv

es/g

oals

to im

prov

e th

eir h

ealth

.

Regi

ster

ed N

urse

w

ho w

orks

alo

ngsi

de

GP

Team

s.

Role

com

men

ced

early

in

Nov

embe

r 200

4

Eval

uatio

n ye

t to

occu

r.

Gen

eral

feed

back

from

rura

l pr

actic

es v

ery

favo

urab

le.

Hom

e V

isiti

ng

Nur

se (p

ilot i

n Te

Ku

iti)

Wai

kato

PH

OEr

ica

Am

onTo

tria

l the

role

of a

nur

se

atta

ched

to a

med

ical

cen

tre,

doin

g ho

me

base

d as

sess

men

t an

d co

ordi

natio

n w

ith e

lder

ly

to re

duce

risk

.

Prac

tice

nurs

e w

ithin

a

rura

l pra

ctic

e.Ev

alua

tion

unde

rway

in fo

rm o

f RC

T.

Dis

ease

Sta

te

Man

agem

ent

Nur

se

Wai

kato

PH

O, R

auka

wa

Hau

ora

Tang

aroa

W

hitio

raTo

impr

ove

care

of M

äori

patie

nts.

Nur

se w

ho li

nks

with

lo

cal G

Ps.

Vol

umes

, sat

isfa

ctio

n

59

Mob

ile N

urse

C

oord

inat

or

Wha

ngan

ui R

egio

nal

PHO

Judi

th

Mac

Don

ald

To c

oord

inat

e ca

re fo

r co

mpl

ex h

igh

need

pat

ient

s.Re

gist

ered

nur

se

Targ

et g

roup

s

Ethn

icity

Dem

ogra

phic

pro

file

Refe

rral

s pe

r qua

rter

Dis

char

ges

per q

uarte

r

Dis

ease

sta

tes

Hea

lth p

lans

Inte

grat

ion

and

coor

dina

tion

with

oth

er s

ervi

ces

Barr

iers

to a

cces

s

Con

sum

er e

valu

atio

n.

60

APPENDIX 3: ContactsThis list of contact people for organisations involved in chronic conditions work was compiled from responses to the NHC’s request for information.

Organisation: Name: Position:

Counties Manukau DHB Chris Mules Chief Planning & Funding Officer

Waitemata DHB Dr Dale Bramley Manager of Health Gain and Public Health Physician

Southland DHB Sue McNeil Coordinator physiotherapy

Health Waikato: Provider Arm of the Waikato DHB_

Chris Higgins Manager: Service Development Unit

Cancer VOICES New Zealand Judi McBride-Wilson Trustee & acting Executive Officer

Hawkes Bay PHO Dr Sanja Sajatovic-Majstorovic General Manager

Asthma Auckland Janette Reid National Asthma Educator

Cystic Fibrosis Association of New Zealand

Kate Russell General Manager

The Auckland District Kidney Society Inc.

Nora Van der Schrieck Manager

Hauora Taranaki PHO Pauline Cruickshank Manager Clinical Projects

Royal New Zealand Foundation of the Blind

Chris Inglis Divisional Manager, Blindness Awareness and Prevention

SPARC Diana O’Neill Senior Advisor Health

Whanganui Regional PHO Rihi Karena High Needs Nurse Coordinator

PACT Anna Frost Service Manager Intellectual Disabilities

Te Hotu Manawa Mäori (THMM)

Dr George Gray

The National Heart Foundation of New Zealand

Stephanie Muncaster Phase I &II National Cardiac Rehabilitation Coordinator

The National Heart Foundation of New Zealand

Glenis Bell National Phase 3 Cardiac Rehabilitation Coordinator

New Zealand Guidelines Group

Catherine Marshall CEO

Ministry of Health Barry Welsh Senior Advisor

South Link Health Richard Whitney General Manager

Pinnacle Erica Amon Clinical Services Manager

Pacific Islands Heartbeat, The National Heart Foundation

Iutita Rusk Programme Manager

Presbyterian Support Northern Julie Martin General Manager, Services for Older People

Analysis, Planning and Service Development Unit

Faye Ryan Manager Qualitative Information

Pathways Trust Michelle Glenny Regional Manager

Taumata Hauora Trust Mars Delamere Clinical Manager

61

1 World Health Organization. 2002. Innovative Care for Chronic Conditions: Building Blocks for Action. Global Report. Noncommunicable Diseases and Mental Health.

2 Handiside A. 2004. ‘Our Physical Health…Who Cares? Occasional Paper No. 5. Wellington: Mental Health Commission.

3 World Health Organization. 2003. Diet, nutrition and the prevention of chronic diseases; Report of the Joint WHO/FAO expert consultation. WHO Technical Report Series No.916 (TRS 916). Accessed March 2005 at http://www.who.int/dietphysicalactivity/publications/trs916/en/gsfao_background.pdf

4 New Zealand Guidelines Group. 2001. Chronic Care Management: Policy and Planning Guide. Compiled by the Disease Management Working Group.

5 Ministry of Health. 2004a. A Portrait of Health. Accessed November 2004 at www.moh.govt.nz.

6 Ministry of Health. 2004b. The Health and Independence Report 2004; Director-General of Health’s annual report on the state of public health. Wellington, December 2004.

7 Arthritis New Zealand website, accessed February 2005 at www.arthritis.org.nz

8 Ajwani S, Blakely T, Robson B, Tobias M, Bonne M. 2003. Decades of Disparity: Ethnic mortality trends in New Zealand 1980-1999. Wellington: Ministry of Health and University of Otago.

9 Ministry of Health. 2003a. Diabetes Toolkit. Only available on the web. Accessed December 2004 at http://www.newhealth.govt.nz/toolkits/diabetes/introduction.htm#burden.

10 Ministry of Health. 2002. Diabetes in New Zealand; Models and forecasts 1996-2011. Wellington: Ministry of Health. March 2002.

11 Department of Health. 2004a. Improving Chronic Disease Management. Accessed November 2004 at http://www.dh.gov.uk/assetRoot/04/07/52/13/04075213.pdf.

12 National Health Committee. 1998. The Social, Cultural and Economic Determinants of Health. Wellington.

13 Ministry of Health 1999. Our Health, Our Future: the health of New Zealanders 1999. Wellington: Ministry of Health.

14 Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002, Oct 9; 288(14):1775-9.

15 Modernisation Agency. 2004. Learning Distillation of Chronic Disease Management Programmes in the UK. July 2004. Accessed March 2005 at http://www.natpact.nhs.uk/uploads/Matrix%20CDM%20Evaluation%20Report.doc.

16 Department of Health. 2004b. The NHS Improvement Plan: Putting People at the Heart of Public Services.

REFERENCES

62

17 Wellingham J, Tracey J, Rea H, Gribben B. The development and implementation of the Chronic Care Management Programme in Counties Manukau. NZMJ 2003;116. 21 February 2003. Accessed March 2005 at http://www.nzma.org.nz/journal/116-1169/327/.

18 National Primary Care Trust Development Programme. 2003. The Connectors publication, Episode 15, 11 November 2003. Accessed March 2005 at http://www.natpact.nhs.uk/engaging_communities/the_connectors/episode_15/episode15.pdf

19 Diabetes New Zealand website. Accessed November 2004 at http://www.diabetes.org.nz/managing/.

20 Department of Health. 2001. The Expert Patient: A New Approach To Chronic Disease Management for the 21st Century. London: Department of Health.

21 Arthritis New Zealand. 2003. Arthritis New Zealand Self-Management Course ‘living a healthy life’: course evaluation report 2000 –2002. Wellington: Arthritis New Zealand.

22 Ministry of Health. 2003b. A Snapshot of Health; Provisional results of the 2002/2003 Health Survey. Wellington: Ministry of Health.

23 Marshall R, Gee R, Israel M et al. 1990. The use of alternative therapies by Auckland general practitioners. NZMJ 1990:103(889)L213-15.

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