QUARTERLY REPORT APR – JUN 2015 · HEALTH CARE HOMES 3728 B4 SCHOOL CHECKS COMPLETED All under 6s...

1

QUARTERLY REPORT

APR – JUN 2015

ISSN-2463-2740

Contents

Quarter 4 Highlights ...........................................................................1

CEO Introduction ................................................................................2

Getting the Job Done .........................................................................3

Pinnacle by the Numbers ..................................................................5

Locality Insight - South Taranaki ......................................................7

No Gaps ................................................................................................9

Health Care Home ..............................................................................11

Healthy Tamariki and Rangatahi ......................................................15

Living with a Long Term Condition ..................................................20

Supporting People with Mild Mental Health conditions ................27

Smokefree Midlands ...........................................................................30

Detailed Contract Reports .................................................................33

1

Quarter 4 Highlights

First network to launch Rheumatic Fever Response

Primary Options relaunched to ensure

better access

In Lakes 98% of our target 24 month old Maori

children were immunised.0ffered

240 primary health

consultions to refugees

100% ADOPTION OF

ZERO FEES FOR UNDER 13s

37,645 Smoking Cessation Brief Advice Provided

ALL PRACTICES IN TAUPO AND TURANGI ARE BECOMING

HEALTH CARE HOMES

3728 B4 SCHOOL

CHECKS COMPLETED

All under 6s in Waikato now on NCHIP

2

CEO Introduction

This quarter we have marked a major development in the future of primary care in New Zealand, with the creation of a business case that enables the adoption and development of the Health Care Home model of care across much of New Zealand.

With our N4 Partners Procare, Compass Healthcare and Pegasus, we have put a compelling case to the Minister of Health outlining the way in which we can ensure the future sustainability of primary care and help deliver on the government’s promise of better, sooner, more convenient healthcare.

Moving to the model of care enables new levels of agility and efficiency for the sector; it will enable us to increase access to local community secondary services and in the long term improve demand on tertiary services and, most importantly, improve the health of all New Zealanders. It’s a message that’s now getting through to the Ministry.

Between the four networks, we are responsible for the health needs of nearly two million people, and we’re in a great position to transform things for the better.

The power of the primary section in improving overall health can’t be underestimated, and at MHN we’re helping equip our practices with technology and information to help them tackle some of the toughest health issues we face.

This work is beginning to bear fruit, we’re beginning to close the gaps between our high need communities and the general population. For instance, latest figures coming out of Taranaki this month show that Pinnacle practices are helping close the gaps in health outcomes for Maori, with a huge increase in provision of cardiovascular risk assessments.

Cardiovascular disease is the leading cause of death for Maori, so identifying the risk and offering support at an early stage is a key step for increasing health and life expectancy in this group.

As we come to the end of the quality year, you tend to get a bit reflective about the organisation and its members, what we’ve achieved and what we’ve not, what we’ve taught and what we’ve learned.

We like to pride ourselves in our agility and creativity, but we’ve got to ensure that we bring the sector with us, so in the coming year we’ll be focusing on offering bespoke services and tools to our practices to ensure they all benefit from membership.

The review of the New Zealand Health Strategy has underlined the important job that a refocusing of our system into preventative and long term conditions management can deliver on the overall goals of the Ministry, whether that’s supporting vulnerable children, helping people with mental health problems to even helping us get over the smokefree line by 2025.

If the funding streams follow the clear intentions of this review, this could be a transformative time for the whole sector, we have to ensure that we’re agile and prepared to take the opportunity.

John Macaskill-Smith

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11 July - 31 December 2014

2

1 January - 30 June 2015

4


5

1 July - December 2016

3



Getting the job doneWhat we’re doing to ensure we achieve our strategic goals

6


2


4


5

1 July - December 2016

3



1 July to 31 December 2014

1. Dynamic Locality profiles in place for 11 localities2. Enhanced Quality Plan v1 implemented3. Shared care records available across the network4. Enhanced funding model to incentivise change in

line with the network's objectives5. Waikato DHB wide roll out of NCHIP6. NIR Co-located within MHN Hamilton Offices7. 100% of Waikato DHB providers on MedTech PMS

able to refer patients to PMH service via electronic system

8. 100% of Tairawhiti DHB providers on MedTech able to refer patients to PMH service via electronic system

9. Virtual CVRA version 2 established10. Implementation of a centralised telephone catch

up service for those smokers who have not attended practice in the past 12 months

1 January to 30 June 2015

1. Locality plans developed for 11 locations2. Workforce strategy developed, assessed and signed

off for each workforce category3. Education strategy developed for each

workforce category4. Patient safety programme fully implemented5. SEHR available to all GPs6. MoC Roll out and aligned funding model launched 7. First phase evaluation of NCHIP8. 100% usage of Patient Prompt by other providers of

child healthcare services 9. Waikato diabetes service integration project steering

group established10. Network smokefree champions in place to work with

patients outreach services and NGOs

1 2

3

4

5

6


1. PO for acute and non-acute Care accessible to all practices

2. Taranaki, Lakes and Tairawhiti DHB project plans developed for the integration of district nursing with the general practice core team

3. Work with Waikato, Taranaki and Lakes DHBs to assess Midlands rollout potential of ETER

4. Terms of reference established for Waikato and Taranaki review of current PMH service


1. Education plan developed which reflects the education strategies for each workforce

2. SPOA accessible to all community health services3. PO Plans integrated with the development of PAC

and SPOA 4. Taranaki and Tairawhiti B4 School service coordination

and provision, NIR, outreach and mobile imms transferred to the network

5. Waikato, Taranaki and Lakes integrated service plan implemented including SPOA

6. Taranaki DHB current PMH services review completed and recommendations available

7. Recommendations implemented from the Waikato, Taranaki and Tairawhiti SLATs on the impact of implementing the stepped-care and shared-care model

8. Workforce and education annual plan completed which includes the specific LTC covered during that period


1. Integration plan for specialist and generalist Model of Care in place

2. NCHIP extended coverage to 18 year olds3. Recommendations implemented from Taranaki DHB

current PMH services review


1. Education plan developed which reflects the education strategies for each workforce

2. Incentive framework developed to bring 10% of practice income within the framework

3. 50% of the network operating in the HCH model4. SEHR available to allied health providers5. All network practices have DNs as members of the

core team6. 60% of enrolled population using patient portal7. PO standardised across the region

✓✓✓✓

✓

✓✓

✓✓✓

✓✓

✓✓✓

✓✓✓

Key ✓✓

AchievedPartly Achieved

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Waikato52 practices

259,715 patients

136,864 GP consults

16.6% of patients are Maori

Almost 1 in 3 patients is eligible for

a cardiovascular risk assessment.

Taranaki31 practices

106,796 patients

68,414 GP consults


More than 10% of patients smoke

Taupo4 practices

34,110 patients

19,592 GP consults


14.6% of patients smoke

4 out of 100 patients is living

with diabetes.

* Figures relate to April-June 2015

Pinnacle General Practice Network

By The Numbers*

Tairawhiti3 practices

26,092 patients

17,375 GP consults


1,128 patients are living with diabetes

Locality Insight – South Taranaki

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Locality Insight – South Taranaki

South Taranaki is situated between two secondary hospitals; Wanganui in the south and Taranaki Base in the north, creating unique patient flows.

The main towns of Eltham, Hawera, Patea, and Opunake make up a distinctive social picture with their combined demographics, employment and economic development.

The population of the locality at the last census was 22,080, which is expected to decline slightly to around 21,240 by 2016. The locality is served by four Pinnacle medical practices with a combined enrolled population of 20,671.

The locality has a higher than average Maori enrolled population at 27% compared to 19% over our whole region, and has a larger proportion of 5-14 year olds.

Pinnacle Medical practices

• Eltham Health Centre

• Mountain View Medical – Manaia and Hawera

• Patea & District Community Medical Trust

• Opunake Medical Centre

GPs across the four practices carried out 18,360 consults over the first quarter of 2015, with those in the 45-64 and 65+ age group being the highest users.

There are

20,671enrolled patients

25%of patients are 45-64

years old

30%of patients are eligible for a cardiovascular

disease risk assessment

We estimate there will be

24,996people living in the

locality by 2021

The majority of enrolled patients

live within 2km of a practice.

The number of enrolled patients has

been increasing across all age groups.

5

out of 100 patients are

living with diabetes

GP’s performed

18,360consults in the first quarter

of 2015

27%of patients are MaoriKey Statistics

NO Gaps

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NO GapsThe Midlands Health Network NO GAPS policy aims to achieve equal health outcomes for all patients from all work carried out across the network.

Rather than developing separate Maori, high needs and rural health plans, the network is focused on producing superior health outcomes from every aspect of the core work programme. Every team responsible for a programme or initiative seeks to improve the effectiveness and quality of its work in these areas in order to comply with the NO GAPS policy.

The success of the NO GAPS policy and activities will be measured by the regular analysis and reporting of the Network’s performance – and of the corresponding health status or outcome measures – in all areas of healthcare.

Collaboration boosts Pasifika B4 School check performance

To ensure more Pacific Islands families receive critical B4 School checks, a new partnership was set up with K’aute Pasifika Trust (KPT) and South Waikato Pacific Islands Community Services (SWPICS). These providers have spent time promoting the programme and are using resources specifically targeted at PI families. PI coverage this quarter has gone from 73% of children having the check to 92%.

This quarter we also ran three Saturday clinics and home visits for hard to reach kids, which meant an extra 54 checks were completed.

Taranaki closing the gaps in CVRA assessment for Maori

Primary care is closing the gaps in healthcare provision in Taranaki, and is set to be leading the country with provision of cardio vascular risk assessments for Maori.

Achievement in this links back to the tools and long term conditions program put in place through the MHN Alliance. As part of the Long Term Condition program each practice has an electronic tool set that prompts both at a personal health level but also at a population level who is eligible and when they are due. This includes targeting for Maori.

Practices are funded on a stratified population level where funding is targeted at those practices with populations in need. They are also funded on outcomes against the target populations.

Cardio vascular disease is the leading cause of death for Maori, so identifying the risk and offering support at an early stage is a key step in increasing good health and life expectancy in this group.

Collaborative action for greater impact on smoking in Tokoroa

In April, MHN initiated a joint meeting with other entities active in Tokoroa to explore interest in a joined-up approach to tackling smoking. MHN is interested in improving coverage and effectiveness of Brief Advice and Smoking Cessation support for enrolled patients at the Tokoroa Medical Centre, particularly for Maori, and sees benefit in joining forces with other parties active in the ABC and Smokefree space.

Representation included MHN, MHN’s Tokoroa Medical Centre, Waikato DHB, Hauraki PHO, South Waikato District Council, Raukawa Charitable Trust, South Waikato Pacific Islands Community Services (SWPICS) and Unichem Pharmacy. There was full support for working together on a more aligned approach.

Helping our newest New Zealanders

Midlands Health Network is contracted to provide primary health care for newly arrived refugees in Waikato. This year has seen a 57% increase in demand for interpreting services at medical centres and hospital appointments in Waikato. Over the same period last year 288 interactions were captured, this period it has increased to 502 interactions.

The demographics of the refugees has also seen a shift with the majority of arrivals being female and children. Many of these families come with very high medical and psychological support needs which has been a challenge to deliver for the service.

The refugee community were noticed to be very transient across practises but this period has seen many of the families staying enrolled and engaged with their home practice.

Transport closing the gaps

In Gisborne, MHN negotiated an agreement with a commercial transport operator to provide a transportation service which would enable rural patients from the East Coast, who had no transport options, to attend the Caridac Rehab programme. The service worked well and 4 patients were able to attend who would otherwise not have had access to the programme

Health Care Home

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Health Care Home

The Health Care Home is about creating sustainable general practice through new models of care. Through it we equip general practice with tools to enhance development of proactive integrated care.

Key to this is the development of new professional roles to expand the capacity and capability of primary care, as well as the promotion of patient self-management through effective use of technology.

Taking the Health Care Home national

Four of New Zealand’s biggest primary care groups – Midlands Health Network, Compass Health, ProCare and Pegasus – have come together to seek government support to take the Health Care Home nationwide.

The Health Care Home harnesses the strength and agility of primary medicine to its full potential, and is the prescription for sustainable high-quality care now, and in the future.

The Network 4 and our members nationwide are ready, willing and able to transform primary health care for the better, and offer every New Zealander the high quality healthcare they deserve through their Health Care Home. They are now working with the government to investigate ways they can work together to make this a reality and harness the power of primary care.

Network 4 is responsible for the primary care needs of 1,930,915 New Zealanders, including 226,545 Māori (36% of Māori enrolled in PHOs), 140,503 Pacific Island people (44% of Pacific people enrolled in PHOs), 162,531 non-Māori/Pacific Quintile 5 people (43% of non-Māori/Pacific people enrolled in PHOs) and 172,568 New Zealanders living rurally (31% of rural New Zealanders enrolled in PHOs).

Network 4 collectively manages, as providers and commissioners, public and private funding exceeding $500 million, placing the group among the ranks of middle to larger DHBs and as key change agents for the New Zealand health sector.

Taupo and Turangi to become first Health Care Home towns

The way health care is provided by medical centres in Taupo and Turangi is about to change for the better.

Taupo Medical Centre, Taupo Health Centre, Lake Surgery and Pihanga Health will be moving to the Health Care Home model of care in the coming months, offering their combined 34,000 patients access to the benefits of the system and the flexibility and convenience it offers.

Taupo Health Centre GP David Nixon acknowledges that medical centres across New Zealand are getting busier and the exciting changes will ensure patients receive high quality health care for future generations.

“The average patient is seen twice a year, which increases to about eight times a year for 65-70 year olds. With patients getting older, it will result in four times the workload, and the way things are currently, we are not going to cope. We need to shift to working smarter and targeting expertise to where it is needed the most.” says Dr Nixon.

The introduction of the new way of working is being supported by Midlands Health Network. Eight medical centres across the midland region are already offering these services to patients.

Target practices by June 2017

45No of practices

operating 12+ months

No of practices operating MOC 18+ months

7

1

No of practices moving into MOC this quarter

4

No of practices operating < 6 months

1

Total population covered

No of practices in next quarter pipeline

85k 2

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Patient Access Centre

A key part of the Health Care Home is the Patient Access Centre, which enables patients quicker telephone access to their practice as well as freeing up reception staff to help patients better. Having access to the Patient Access Centre also enabled MHN to provide practices in Waikato and Taranaki with a short term telephone campaign to deliver brief smoking cessation advice to those patients who have not been seen in practices in the past twelve months. This final quarter in the Waikato has seen the most successful result ever against the ‘Providing Brief Advice’ target.

Call Volumes Average Speed To Answer Abandon Rate

April 18164 32 Seconds 4.24%

May 18596 16 Seconds 1.48%

June 21952 19 Seconds 2.04%

Administration

Call Volumes

April May June Total

Credit control

Current 678 637 632 1972

30 Day 284 273 236 793

60 Day 131 175 154 460

90 Day 126 111 121 358

120+ Day 158 177 207 542

Business 110 128 154 392

Smear

Current 481 520 447 1448

1 Month 328 368 307 1003

2 Month 249 245 233 727

Immunisation

Current 201 194 194 589

1 Month 113 87 74 274

2 Month 54 54 39 147

2.X Not Seen 165 183 124 472

B4 School 130 130 117 377

NHI Lookup 120 100 110 330

Call volumes have been steady this quarter and abandonment rate on average across all practices has been quite low. For the month of April we can see that speed to answer and abandon rate increased, this would have been due to some staff movement and the retraining of a number of staff in preparation for the Taupo sites coming on board.

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Other key statistics

• 3.5% - Abandonment Rate

• 65% of patient calls managed in PAC

• 13 FTE Staff providing coverage for 36,000 ESUs.

Flu Campaign:

For this year’s Flu Campaign PAC were required attempt to make contact with 792 patients, each of these patients would have received a minimum of x3 attempts to call, making our outbound call number approximately 2376. In some cases to assist some of the sites we made more outbound attempts.

Smoking Cessation:

To assist the wider network PAC undertook a smoking cessation campaign to attempt to offer brief advice to smokers.

PAC did outbound calling for 10 practices, and attempted to make contact with more than 4,300 patients, each patient had x3 call attempts made, this meant approximately 9,000 outbound calls were made, however this would be dependent on reliable contact information.

Healthy Tamariki and Rangatahi

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Healthy Tamariki and Rangatahi

Pinnacle Practices are the region’s front door for coordination of community and primary care based health services for children and young people. We have been amongst the first to deliver the government’s Rheumatic Fever Rapid Response service, and our B4School checks doesn’t face any health hurdles before reaching school.

Our Child Health Coordination Service will ensure that all the information from these services is stored in one central, secure database and that no child falls through the gaps and misses out on the healthcare they are due.

100% sign up for zero fees under 13s

Pinnacle is one of the leading networks in delivering the government policy to offer free care to enrolled under 13s during standard consulting hours.

Every Pinnacle member practice across Waikato, Taranaki, Tairawhiti and Taupo/Turangi signed up and was ready to provide the service from 1 July.

Pinnacle practices first off the mark for Rheumatic Fever Rapid Response

Practices throughout Waikato spearheaded a government-backed response to eradicate rheumatic fever and heart damage by offering free throat swabs.

The Pinnacle Practices were ready to offer the service from the 16 March launch date. They offered free throat swabs eligible populations with suspected Group A Streptococcal throat infections as part of the Rheumatic Fever Prevention Programme. Primary Options was used to enable an efficient straightforward claims process for practices.

The scheme has seen nearly 1,000 swabs taken across Waikato, with nearly 150 showing positive for Group A Streptococcal infection.

Every under 6 in Waikato now on Child Health Coordination Service

Midlands Health Network this quarter wrote to all parents of children six years old and under in Waikato to inform that their child’s details were being added to the database held by the Child Health Coordination Service.

With the addition of around 20,000 children to the service, a copy of every child’s health check and immunisation status will be securely stored in one place. It will only be accessed by those involved in that particular child’s care.

Chief Executive John Macaskill-Smith stressed the importance of the service in ensuring all under sixes can get the healthcare they are entitled to.

“The CHCS works with parents, caregivers and health providers to ensure children access the right health providers and receive all of their checks on time,” he said.

“These checks include birth checks, Well Child/Tamariki Ora checks, immunisations, dental checks, vision and hearing checks, and the B4School check.”

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Waikato NIR Colocates with Midlands Health

Waikato DHB’s National Immunisation Register team (NIR) recently moved into the Midlands Health Network Hamilton office to sit alongside the mobile immunisation team.

Bronwen Warren, team lead for immunisation and child health champion at Midlands Health Network says there is a lot of scope for practices to use this information.

”While practices and the mobile immunisation team are doing a great job of protecting patients from preventable diseases, the relocation of the NIR team to Midlands Health Network will help us better connect the dots between the services,” says Bronwen.

“Co-locating the NIR team with the mobile immunisation team, which also moved here from Waikato DHB two years ago, will help get things done quicker and more efficiently. What would have been a game of phone tag or faxing between the two teams is now a one-to-one conversation”

Ensuring no child is left unimmunised

MHN has been contracted in Waikato to provide mobile immunisations to the under 2 year old age group. The service continues to perform above target whist also supporting co-operative work arrangements with Hauraki PHO.

A newly established immunisation huddle has enabled everyone working with immunisation to identify gaps, duplicates and issues. This has resulted in some early gains but there are further improvements to be explored.

Making sure kids are ready for school

MHN is contracted to provide 5216 B4SCs in Waikato as well as 1337 high deprivation checks. This is a key health milestone as it identifies and addresses any health, behavioural, social, or developmental concerns which could affect a child’s ability to get the most benefit from school, such as a hearing problem or communication difficulty.

To engage more Pacific Island families a new partnership has been set up with K’aute Pasifika Trust (KPT) and South Waikato Pacific Islands Community Services (SWPICS). These providers have spent time promoting the programme and are using resources specifically targeted at PI families and coverage this quarter has gone from 73% of children having the check to 92%.

In Lakes the practises completed 397 for the year. The service has visited several children this year who are without proper housing (e.g. living in caravans, porta-cabins, dilapidated houses) without services such as running water. Now these children are identified, the service will continue to prioritise these children/families, who often have multiple issues.

School Based Health Services (SBHS)

MHN runs Registered Nurse led school clinics in 13 decile 1-3 schools, including 2 teen parent units (TPU) and 4 alternative education programmes.

To ensure youth voice is captured in the development of the service, focus groups were held in 1 high school and 2 area schools as well as whole of Year 7-11 written surveys in Paeroa and Waihi Colleges. This will continue into the next quarter.

Work in progress to open a RN lead clinic in Te Wharekura o Maniapoto, Te Wharekura o Te Kaokaoroa o Patetere and Te Wharekura o Nga Purapura o Te Aroha and undertake scoping to develop a whanau centric model of care applicable to Wharekura, whaanau and hapuu (school community).

GP lead School based health services

An inter-professional meeting and SBHS GP peer group evening were held this quarter, co-ordinated by SBHS GP Lead Dr Bronwyn Campbell. The GPs have identified ways to remove barriers to long term contraception and Jadelle insertions funded by SBHS are now in place across participating school clinics.

In partnership with Midlands Community Pharmacy Group, a script fund has been developed to remove the barrier of cost of treatment.

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The Waikato Mobile Immunisation service has given more than 3000 immunisations across the whole region since the programme began.

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HEALTHY TAMARIKI & RANGATAHI

Project

Community Nursing

Service - Mokau335977/04 Taranaki NA NA 33

After Hours Primary

Medical & Nursing Services

(+ under six)336138.05 Waikato ✓ ✓ 33

Free After Hours GP Care

for Under 6 Year Old

Children347313.02 Tairawhiti ✓ ✓ 33

After Hours Primary Health

Services for Under Six342416.03 Lakes ✓ ✓ 33

Free After Hours Care for

Children Under Six344112.04 Taranaki ✓ ✓ 33

B4 School Check 685858/336153/04 Waikato ✓ ✓ 35

Child Health

Co-ordination ServiceWaikato NA NA 35

Immunisation

Coordination341396-02 Waikato NA NA 36

Mobile Immunisation

Service345778 Waikato ✓ NA 36

Maternal Child and Youth

Health Nurse347936/00 Lakes x ✓ 37

B4School 347936/00 Lakes x x 37

School based health

Service: RN and GP336548 Waikato NA NA 38

Youth Sexual Health

Services

Waikato/Taranaki/

Lakes/Tairawhiti

✓ ✓ 39

Contract Number DHB Volumes Demographic Targets Status Page number

Living with a Long Term Condition (LTC)

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Living with a Long Term Condition (LTC)

Long Term Conditions are the leading cause of hospitalisations, account for most preventable deaths and are estimated to consume a major proportion of our healthcare funds. They are also a barrier to independence and participation in the workforce and society in general.

Long Term Conditions also account for a higher proportion of illness and deaths amongst Maori, people on low incomes and Pacific peoples than amongst the general population. Many people with a Long Term Condition don’t fit neatly into a single disease state or system within the current configuration of the health system.

This is where it is important to establish a multi-disciplinary team around them to offer more patient-centric support to maintain better health.

• Podiatry services are available in all DHB regions.

• Services for dietetics and social workers are available in all DHB regions.

• A pharmacy pilot is occurring in Huntly and Te Awamutu and the results from this will form the basis for developing

services further in the Waikato region.

• The clinical pharmacy service in Taranaki continues to make good progress.

• The clinical pharmacist position at Tokoroa continues to develop in a positive direction. This initiative is designed to

enhance the colocation and integration of general practice with Tokoroa Hospital and provides support to both general

practices in the health hub.

• Positive discussions with the various DHBs are leading to an increasing variety and levels of additional services.

Points of note

• The volume of referrals to Green Rx are significantly higher than other services

• Volume of referrals to Social Work and Dietician services continue to grow as awareness of the services grows

2014/15 YTD EREFERRALS TO MDT !

!

BoP$DAR$detail$201415$year$end.pdf!

DAR$201415$year$end $Waikato .pdf

Lakes&DAR&detail&201415&year&end.pdf!

Tairawhiti(DAR(detail(201415(year(end.pdf

Taranaki'DAR'detail'201415'year'end.pdf!

!

0200400600800100012001400160018002000

Q1 Q2 Q3 Q4

eReferrals0to0MDT

Taranaki Tairawhiti0 Waikato0 Lakes0 Total

21

Podiatry service saves lives, and limbs

A ground breaking service started by Midlands Health Network is improving the lives of hundreds of people with diabetes and helping reduce the number of amputations.

The service, which started in December 2012, enables those with the risk of foot disease to be treated for free by specially accredited podiatrists. To date nearly 2,000 people have been treated through the service, which is delivered in partnership with PodiatryNZ.

The aim of the service is the early detection and treatment of foot problems that can lead to lower limb amputations, as well as providing education for people on how to better look after their feet and prevent problems in the future.

Initial results from the service shows a 15% drop in amputations, some of the best results from any area in the country.

Treating more people, at an earlier stage, in the community, reduces demand on secondary services and allows them to focus on more complex needs.

Primary Options

Following feedback from primary care providers, Primary Options has undergone a redesign to create more robust governance and clinical audit structures as well as improving the ease of access from primary care. This will ensure that more people get easier access to the secondary services they need, delivering on the promise of better, sooner, more convenient healthcare for people throughout the Midlands region.

Clinical Pharmacy making its mark in Taranaki

This clinical pharmacy role in Taranaki is making a difference to patients with long term conditions that require ongoing education and support around their medications. Having the flexibility to offer this service in the home or at the practice allows access for many patients who otherwise would not have benefitted from the service. The service is preventing admissions to hospital, reducing the numbers of medicines being prescribed where appropriate therefore reducing medication costs, falls risk, medication related adverse effects and inappropriate polypharmacy.

Tairawhiti falls prevention

The Falls Prevention service is now receiving referrals from St Johns, with 48 referrals being received in the last quarter. Weekly clinics have been implemented for the service, which are working well. There has been strong support for this service from all General Practitioners within the three medical centres involved in this project which is contributing to the good results being seen so far.

Lakes outreach

This quarter has seen improved patient outcomes through implementation of Xcrania in a practice to give remote access which allows holistic management of care by being able to complete outstanding health tasks for patients in regards to bloods, health apt bookings and flu vaccinations.

Lakes MDT Social work

Further promotion of the social worker role is planned for the next quarter to ensure practitioners are more aware of the improved outcomes for clients with long term conditions when positive social and psychological determinants of health are addressed. This will hopefully help to increase referral numbers.

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LONG TERM CONDITIONS

Project

Minor Surgery & Skin Lesions

Flexible Funding

NA NA 45

Very Low Cost Access Sustainability Initiative

Services349849 Waikato NA NA 45

Nurse Practitioner / Family Nurse

329336/00 Lakes NA ✓ 47

Primary Options 349538-02 Tairawhiti x NA 47

Primary Options Lakes x NA 48

Primary Options Taranaki x NA 48

Primary Options 345057 Waikato x NA 49

Cervical Smear Services To Priority Women in

Waikato DHB3336/15.02 Waikato ✓ ✓ 46

Breast screening and Cervical Screening

339453 and 685858

Lakes NA NA 50

Post-Acute Community Cardiac and Pulmonary

Rehabilitation685858/347260/01 Tairawhiti ✓ NA 50

Clinical Pharmacist Taranaki NA NA 51

Community Outreach Nurse - Waikato

Flexible funding

NA NA 51

Long Term Conditions MDT

Lakes x ✓ 52


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Project

Nurse Practitioner / Family nurse 329336/00 Lakes NA ✓ 47

Kawhia Lifestyle Coach and Diabetes Education

and ManagementKAWHI-11.14 Waikato ✓ ✓ 60

Long Term Conditions Management

Programme – access to MDT and DCiP

management

Lakes NA NA 41



management

Tairawhiti NA NA 41



management

Taranaki NA NA 41



management

Waikato NA NA 41



management

Bay of Plenty

NA NA 41

Primary Care LTC Management Program

MDT349173100 Lakes NA NA 54

Cervical Smear-taking Services MID-VAR-05518.00 Taranaki ✓ ✓ 61

Nurse Practitioner and Clinical Nurse Specialist

Falls Prevention685858/349587/01 Tairawhiti NA NA 62

Nurse Practitioner Mangakino 336128/04 Lakes NA ✓ 55

Outreach Nurse 351574/00 Lakes NA NA 56


24


Project

Palliative Care

Waikato/Taranaki/

Lakes/Tairawhiti

✓ ✓ 63

More Heart and Diabetes checks

348796 Lakes ✓ ✓ 58


348935 Tairawhiti ✓ ✓ 58


348766 Taranaki ✓ ✓ 58


349401Waikato – including

BOP✓ ✓ 58

Refugee Primary Health Care

336154 Waikato NA NA 56

Primary Care Long Term Conditions Management

Programme Multi-Disciplinary team

349173/00 Lakes NA NA 57

Community Nursing Services - Inglewood

348373/01 Taranaki NA NA 62

Cervical Smear Priority Women - Taupo

TCSPW-00.14 Lakes ✓ ✓ 61

Cervical Smear Service for Priority Service in

Tairawhiti

TDH-MRHNCT-CS2.15

Tairawhiti ✓ ✓ 61

Primary Care Long Term Conditions Allied Health

MDT348027 Taranaki x NA 59

Whanau Co-Ordinator 336549 Waikato NA NA 57


25

Project

Telephone Nurse Triage 336136 Waikato NA NA 64

After hours Under 6s 336636.04 Lakes NA NA 64

Kai-a-te-mata Marae Outreach Clinic

Waikato ✓ ✓ 65

Otawhiwhi Marae Outreach Clinic

WAIHB-90.00 Waikato ✓ ✓ 64

Meremere Outreach Pharmaceuticals /

Meremere Outreach Clinic

WT-MORP-01.13 / WP-

TEKHSMOC-02.13Waikato ✓ ✓ 65



Supporting people with Mild Mental Health conditions

27

Supporting people with Mild Mental Health conditions

Midlands Health Network aims to provide services that best support the needs of mental health patients. We are working to ensure patients have access to interventions that best meet their needs and that, in turn, providers are aware of the interventions available to patients.

MHN support the development of youth focused providers of primary mental health services, ensuring that PMH contracted providers have the capacity and capability to deliver youth focused PMH services.

Adult Services

Adult PMH services continue to be well supported by referrals from general practice with referral numbers slightly increased from the same period last year. As is expected in this quarter, the service saw an increased number of missed appointments due to seasonal illness and reluctance to travel in bad weather.

In Taranaki, primary connect co-ordinators have utilised their new placement within the DHB mental health clinical team office to better the transition from primary to secondary mental health services, where these are more appropriate for a patient. It has also introduced a new level of safe practice with co-ordinators being able to discuss complex referrals in the multi-disciplinary team forum in order to receive input from the clinical team.

Youth Services

Referral numbers to the Youth PMH service have already shown an increase and we expect that this will continue as referrers become more familiar with the service options and the stepped care approach to supporting youth experiencing mild to moderate mental health or addiction issues.

A youth group therapy programme was started this quarter with Opunake High School and Hawera Intermediate to provide those youth living with mild to moderate mental health and addiction issues support to learn skills including emotional regulation distress tolerance and interpersonal effectiveness skills.

Observations of therapists delivering the youth group therapy included:

• Growth in confidence from the quieter students

• Growth in care and support from the more outgoing students

• More awareness of their impact on others

• Improvement in their efforts to demonstrate respect

• Improved problem solving skills

• The speed at which the group formed and the students took ownership of the therapeutic milieu

• Cohesive group bond that extended to outside the group times and setting

• Students allowing each other time and space to take centre stage when discussing their issues, without judgement

• Growth in their help-seeking skills

• ‘Slow to warm up’ students talking more from session 8-9

• Development of adult problem-solving skills

• Increase in self-confidence and self-belief

28

Project

Primary Mental Health Extended GP consult

348469 Lakes x NA 69

Sexual Abuse Assessment and

Treatment336152.03 Tairawhiti NA NA 69

Primary Mental Health Initiatives Service

685858/343947/03 Tairawhiti NA NA 68

Primary Mental Health Initiative

348290 Taranaki NA NA 68

Primary Mental Health Service- Youth


Primary Mental Health- Adult


MILD MENTAL HEALTH


Smokefree Midlands

30

Smokefree Midlands

Primary Care is a major part of helping achieve the government aim of a Smokefree New Zealand by 2025.

Electronic tools, administrative resources and extra support have been contributing factors in a region wide improvement towards achieving the health target.

Call campaign helps push advice further

In Waikato and Taranaki, MHN provided practices with a short term telephone campaign through the Patient Access Centre to deliver brief advice to those patients who have not been seen in practices in the past twelve months. This final quarter in the Waikato has seen the most successful result ever against the ‘Providing Brief Advice’ target.

Of the fifty two practices, forty eight achieved 90% plus of both quality goals, forty of those had maintained their achievement from the previous quarter. Of the remaining four practices, three utilise non Medtech practice management systems therefore results of their achievements are not yet known, so the potential for a higher achievement is possible.

Supporting World Smokefree Day

To support World Smokefree Day, promotional resources and materials were distributed to those practices who ran competitions for staff to work through their national health target lists, those who completed the highest number of calls could win lunch and dinner vouchers as well as winter gift baskets.

Helping practices to help people quit

A key part ensuring that we meet our aims of reducing smoking is to ensure those working in practices have a sound knowledge of Smoking cessation techniques. Refresher training organized by MHN and delivered by National Heart Foundation was attended by 65 clinical staff and 21 practice administrators and receptionists in New Plymouth and Hawera.

Tui Ora Stop Smoking Service presented on their programmes for patients at the New Plymouth sessions and engaged with general practice staff on individual cessation support, group therapy and cessation support for pregnant women including how to refer, carbon monoxide monitoring and nicotine replacement therapy.

31

Project

Better Help for Smokers to Quit Health Target –

Primary Care Waikato NA x 73

Tobacco Health Target and Stop Smoking

352201/00 Taranaki x x 73

Tobacco Control Services –

Aukati Kai Paipa Service 347261.01 Tairawhiti ✓ ✓ 74

Tobacco Control Services –

Hapu Women Smoking Cessation Service

347261.01 Tairawhiti x ✓ 74

SMOKEFREE


Healthy Tamariki & Rangatahi Contract Reports


33

CONTRACTING DHB: TARANAKI DHB

CONTRACT NUMBER: 335977/04

HAS MET: VOLUMES: NA DEMOGRAPHIC TARGETS: NA

All schools and preschools in the Mokau area were visited or contacted by the nurse during the quarter with no

education sessions requested.

No new Well Child/Tamariki Ora referrals received this quarter. Currently one infant is receiving appropriate age

related core visits and one child has completed a three year core visit.

Two children from Mokau primary school received their year seven immunisation, tetanus booster vaccinations

at the school. Six consent forms were sent home with children who met the criteria. Four declines were returned

as the children had received their 11 year old immunisations at their GP. Appropriate cold chain and immunisation

processes were followed according to the immunisation guidelines.

PREVIOUS QUARTER ACHIEVEMENT:

Q1 Q2 Q3 Q4

Patients 68 75 62 43

Contacts 233 201 216 115

EXPLANATION IF NOT ACHIEVED: 43 people were seen by the service during the quarter. This is a decrease on previous quarters.

CONTRACT NAME: CONTRACTING DHB: CONTRACT NUMBER:

AFTER HOURS PRIMARY MEDICAL & NURSING SERVICES (+ UNDER SIX)

WAIKATO 336138.05

FREE AFTER HOURS GP CARE FOR UNDER 6 YEAR OLD CHILDREN

TAIRAWHITI 347313.02

AFTER HOURS PRIMARY HEALTH SERVICES FOR UNDER SIX

LAKES 342416.03

FREE AFTER HOURS CARE FOR CHILDREN UNDER SIX

TARANAKI 344112.04

HAS MET: VOLUMES: YES DEMOGRAPHIC TARGETS: YES

The Free under 6 programme is to be extended to under 13 at 1 July 2015.

Volumes for the Under 6 programme are consistently high; at year end Tairawhiti and Lakes were over expected

utilisation ($1465 and $3757). Waikato and Taranaki were within budget.

Community Nursing Service - Mokau

After Hours Under 6

*Continued on next page


34

* Continued from previous page

AFTER HOURS UNDER 6 APRIL - JUNE 2015

WAIKATO

Coromandel Family Health Centre 3

Health Te Aroha 20

Mahoe Med 627

Te Kuiti Medical Centre 58

Tokoroa Medical Centre 152

Waihi Beach Medical Centre 16

Hauraki Plains Health Centre 1

Total Waikato 877

LAKES

Taupo Health Centre 133

Taupo Medical Centre 159

The Lake Surgery 61

Total Lakes 353

TAIRAWHITI

City Medical Gisborne Ltd 121

Three Rivers Medical Centre 248

Total Tairawhiti 369

TARANAKI

Carefirst Medical Centre 110

Dr R G Radich 1

Medicross Taranaki Ltd 640

Phoenix Urgent Doctors 571

Total Taranaki 1322


35

CONTRACTING DHB: WAIKATO DHB

CONTRACT NUMBER: 685858/336153/04


The B4SC programme is contracted to provide 5216 B4SCs and we have met this contract. 1337 high deprivation

checks were contracted to be delivered and this has also been met.

MHN’s target was 3708 and we completed 3728 B4 school checks

Three Saturday clinics and home visits were provided in the last quarter and 54 checks were completed. Most of

these children were from Beerescourt medical centre (who do not provide the check).


Q1: 25% Q2: 50% Q3: 75% Q4: 100%

B4 School Check

CONTRACTING DHB: WAIKATO


MHN has been responsible for the roll out of NCHIP and the Child Health Co-ordination Service (CHCS), with

supporting funding coming from the DHB and Hauraki and National Hauora Coalition PHOs. Reporting templates

are being developed to address the needs of each of these funders. The service is now moving to a business as

usual phase although there is work remaining in terms of engaging with providers and supporting the data feeds

from them.

A backload of children in May 2015 has resulted in close to 30,000 children now on the system.

CHCS continues to monitor the data and follow with providers as needed.

Child Health Co-ordination Service


36


CONTRACT NUMBER: 341396-02


The facilitation role is a region wide resource for immunisation within the Waikato providing support and expert

advice to all immunisation stakeholders. Clinical assessments of vaccinators and cold chain accreditation enable

stakeholders to store and deliver immunisations.

Over the past six months 24 nurses and 25 pharmacists have had a clinical assessment. Twenty cold chain

accreditations have been completed. Sixty-five premises have had their vaccine fridge temperatures audited.

In collaboration with IMAC the facilitator has attended and provided education at a two day vaccinator training

course, an immunisation information course and one vaccinator update course. The facilitator has also provided

education to midwives regarding cold chain management.

The facilitator attends the regular immunisation stakeholder meetings.

Following a diagnosis of measles at an intermediate school, the facilitator assisted with the immunisation of the

teachers at the school to prevent further infections.

Immunisation Coordination


HAS MET: VOLUMES: 488 immunisations required – 557 achieved

DEMOGRAPHIC TARGETS: Continue to work across the Waikato DHB region. Reciporcal agreement with Hauraki PHO – we do their Tokoroa referrals they do our Coromandel referrals.

MHN has been contracted to provide mobile immunisations to the under 2 year old age group. The service

continues to perform above target whist also supporting co-operative work arrangements with Hauraki PHO. The

service have taken all Tokoroa referrals for at least 12 months. The team has recently been supplied with Surface pro

devices to maximise the time they spend in the community and reaching families.from them.



Q3

Jan – 55 children, injections - 152 required / 148 achieved, 97% for month

Feb – 74 children, injections – 152 required / 203 achieved, 134% for month

March – 78 children, injections - 176 required / 213 achieved, 121% for month Quarter target 480 required / 564 achieved – 118%

Q4

April – 68 children, injections - 152 required / 179 achieved, 118% for month

May – 78 children, injections – 168 required / 205 achieved, 122% for month

June – 61 children, injections - 168 required / 173 achieved, 103% for month

Quarter target 488 required / 557 achieved – 114%

Mobile Immunisation Service


37


HAS MET: VOLUMES: 488 immunisations required – 557 achieved

DEMOGRAPHIC TARGETS: Continue to work across the Waikato DHB region. Reciporcal agreement with Hauraki PHO – we do their Tokoroa referrals they do our Coromandel referrals.

MHN has been contracted to provide mobile immunisations to the under 2 year old age group. The service

continues to perform above target whist also supporting co-operative work arrangements with Hauraki PHO. The

service have taken all Tokoroa referrals for at least 12 months. The team has recently been supplied with Surface pro

devices to maximise the time they spend in the community and reaching families.from them.



Q3

Jan – 55 children, injections - 152 required / 148 achieved, 97% for month

Feb – 74 children, injections – 152 required / 203 achieved, 134% for month

March – 78 children, injections - 176 required / 213 achieved, 121% for month Quarter target 480 required / 564 achieved – 118%

Q4

April – 68 children, injections - 152 required / 179 achieved, 118% for month

May – 78 children, injections – 168 required / 205 achieved, 122% for month

June – 61 children, injections - 168 required / 173 achieved, 103% for month

Quarter target 488 required / 557 achieved – 114%

CONTRACTING DHB: LAKES


HAS MET: VOLUMES: NA DEMOGRAPHIC TARGETS: YES

We achieved 93% with 7 declines (6%) for the 8 month Imms target, with 119 imms given. We also achieved 93%

with 2 declines for the 24 month target.The number of declines affect our coverage rates. The Child and Youth

team have spent considerable time looking for children who are currently included on our target stats but have

moved out of the area. Contacting many agencies to find these children is very labour intensive

EXPLANATION IF NOT ACHIEVED

The target was not met due the number of declines this quarter with the majority coming from the same

practice. This is a community issue not a practice issue. The team spent considerable time and effort discussing

Immunisation with declining families. This strategy has helped as a number of children who were originally declines

have been completed or have started their immunisations with 2 children who will be completed but outside the 8

month target.

Maternal Child and Youth Health Nurse



HAS MET: VOLUMES: NO DEMOGRAPHIC TARGETS: NO

The service is contracted to deliver 400 B4 school checks in the practices. The practices completed 397 for the

year. It needed to deliver 100 high dep checks and only delivered 80 high dep checks

Although not part of the target numbers, the Maternal child team completed 78 checks with 42 high dep checks.

Total B4 school checks completed were 475 with 122 high dep checks.

The service has visited several children this year who are without proper housing (e.g. living in caravans, porta-

cabins, dilapidated houses) without services such as running water. Our service will continue to prioritise these

children/families, who often have multiple issues.


Q1 Q2 Q3 Q4

Practices Only 397 80 93 18

CCHN 78 42 13 4

Total Of Both 475 122 106 22

B4School


38


CONTRACT NUMBER: 336548


RN LEAD SCHOOL BASED HEALTH SERVICES

1. 13 decile 1-3 schools, including 2 teen parent units (TPU) and 4 alternative education programmes have a RN

service in place.

2. RN education this quarter included triage, standing orders, mental health and suicide prevention.

3. To ensure youth voice is captured in the development of the service, focus groups were held in 1 high school

and 2 area schools as well as whole of Year 7-11 written surveys in Paeroa and Waihi Colleges. This will

continue into the next quarter

4. This coming quarter (July-September) Work in progress to open a RN lead clinic in Te Wharekura o Maniapoto,

Te Wharekura o Te Kaokaoroa o Patetere and Te Wharekura o Nga Purapura o Te Aroha and undertake scoping

to develop a whanau centric model of care applicable to Wharekura, whaanau and hapuu (school community).

GP LEAD SCHOOL BASED HEALTH SERVICES

1. An inter-professional meeting and SBHS GP peer group evening were held this quarter, co-ordinated by SBHS

GP Lead Dr Bronwyn Campbell.

2. GPs identified ways to remove barriers to long term contraception and Jadelle insertions funded by SBHS are

now in place across participating school clinics.

3. In partnership with Midlands Community Pharmacy Group, a script fund has been developed to remove the

barrier of cost of treatment 4) WIP contract GP from Coromandel Family Health to underwrite standing orders

for new RN clinic in Coromandel Area School.

School based health Service: RN and GP


39

CONTRACTING DHB: WAIKATO/TARANAKI/LAKES/TAIRAWHITI

CONTRACT NUMBER:


The programme is a free primary care based sexual health and contraception service to improve the sexual and

reproductive health of young people in the target age group(s), under 25s.

The aims are to improve access to first level general practice services and include facilitating:

• A reduction in unwanted pregnancies amongst the target group

• A reduction in STIs amongst the target group

• A reduction in infertility amongst the target group

The service can be delivered by GP and/or suitably qualified practice nurses

Access criteria, e.g. target age, differ slightly across the DHB area, but intent of the service aligns.

MHN is undertaking a review of the services to align the access criteria and standardise general practice claiming

processes.

The service is available in Taranaki, Tairawhiti, Taupo and Waikato rural practices, but not Hamilton.


Q1: Q2: Q3: Q4: 4583

Youth Sexual Health Services

WAIKATO:

Full data at http://www.pinnacle.co.nz/q4/q415

Total consults: 2833

Sexual health GP consultation: 1,847

Sexual Health Nurse consultation: 986

TARANAKI:

Total consults: 1,164

Sexual health GP consultation - Adult: 524

Sexual Health Nurse consultation – Adult: 296

Sexual health GP consultation – Youth: 245

Sexual Health Nurse consultation – Youth: 99

LAKES:

Total consults: 271





TAIRAWHITI:

Total consults: 315





Long Term Conditions Contract Reports


41

CONTRACTING DHB: LAKES TAIRAWHITI TARANAKI WAIKATO BAY OF PLENTY


This programme is focused on patients with diabetes, those eligible for cardiovascular risk assessments and in

20114/15 those patients with chronic obstructive pulmonary disease (COPD).

General practices are being provided resourcing to:

• support long term conditions management through providing clinical best practice advice and guidance

• greater workforce development

• comprehensive long term conditions management planning for patients

• performance based funding to recognise improvements achieved for patients chronic disease states

• development of a toolkit to support the practice to manage the patient’s needs

• better identify patient needs within the programme

HISTORICAL OVERVIEW

The following demonstrates the growth in eReferrals as eReferrals are ‘turned on’.

2014/15 YTD EREFERRALS TO MDT



Long Term Conditions Management Programme – access to MDT and DCiP management

!

!






!

0200400600800100012001400160018002000

Q1 Q2 Q3 Q4

eReferrals0to0MDT


!

!






!

0200400600800100012001400160018002000

Q1 Q2 Q3 Q4

eReferrals0to0MDT



42


Multidisciplinary teams (MDT) coordinated in primary care, using shared care processes and pathways (integrated

with allied health and secondary care providers) to provide timely wrap around services to patients.

Practices are further supported in their long-term condition management by access to externally provided services,

which complement those available from the core practice team.

• Podiatry services are available in all DHB regions.

• Services for dietetics and social workers are available in all DHB regions.

• A pharmacy pilot is occurring in Huntly and Te Awamutu and the results from this will form the basis for

developing services further in the Waikato region.

• The clinical pharmacy service in Taranaki continues to make good progress.

• The clinical pharmacist position at Tokoroa continues to develop in a positive direction. This initiative is

designed to enhance the colocation and integration of general practice with Tokoroa Hospital and provides

support to both general practices in the health hub.

• Positive discussions with the various DHBs are leading to an increasing variety and levels of additional services.

POINTS OF NOTE

• The volume of referrals to Green Rx are significantly higher than other services

• Volume of referrals to Social Work and Dietician services continue to grow as awareness of the services grows

Diabetes Care improvement Program - Supporting our MHN Practices in Diabetes Management

The following reports demonstrate the clinical indicators around the DCiP care delivered to our patients with

diabetes.

*Full data at https://www.pinnacle.co.nz/qr/q415



43



!

!


44


!

!

Highlights:!

(One%bullet%point%with%a%highlight%of%the%previous%quarter%or%a%particularly%good%result%which%can%be%featured%in%the%overall%aims%report)%%

!


45

CONTRACTING DHB: NONE (FLEXIBLE FUNDED)


The service is available only in Lakes and some Waikato practices.

Delivery, eg access criteria and price, is not consistent across the two localities. A revised programme is under

development and is expected to replace the current programme.

MINOR SURGERY APRIL - JUNE 2015

LOCALITY CONSULTATION DESCRIPTION NUMBER

LAKES Minor Surgery - Simple - Lakes 120

Minor Surgery Complex 52

Total - Lakes 172

WAIKATO Skin Lesions 129

Total - all 301

CONTRACTING DHB: WAIKATO (OTHER DHBS DO NOT CONTRACT – STRAIGHT PASS THROUGH OF FUNDING FROM MOH)

CONTRACT NUMBER: 349849.00


Practices receiving VLCA Sustainability funding in 2014/15 are

Delivery, eg access criteria and price, is not consistent across the two localities. A revised programme is under

development and is expected to replace the current programme.

LOCALITY PRACTICE ANNUAL ALLOCATION 2014/15

WAIKATO DHB Kawhia Health Centre $3,298.00

Hakanoa Health Centre $4,865.00

Avalon Medical Centre $37,104.00

Tokoroa Primary Care $55,108.00

Te Kuiti Medical Centre $44,972.00

Taumarunui Medical Centre $17,445.00

Huntly West Medical Centre Ltd $19,286.00

TAIRAWHITI DHB Waikohu Health Centre $8,098.00

Three Rivers Medical Centre $100,453.00

LAKES DHB Pihanga Health $21,522.00

TARANAKI DHB Tui Ora Family Health $18,053.00

Waitara Health Centre $33,263.30

Ruanui Health Centre $25,247.50

Patea & District Community Medical Trust $13,665.00

All practices have submitted and are working on Sustainability plans

Minor Surgery & Skin Lesions

Very Low Cost Access Sustainability Initiative Services


46


CONTRACT NUMBER: 3336/15.02


MHN is contracted to manage the demand for cervical screening relating to priority women. Midlands Health

Network are required to report back to Waikato DHB at the earliest opportunity if there is likelihood that the

volumes may exceed the agreed volume of 3,000 smears.

MINOR SURGERY APRIL - JUNE 2015

SMEAR VOLUME

Reporting Unit: Incognito

Women

Incognito Women

Number of cervical smears taken (European) (20-69) 8

Number of cervical smears taken (European) (NO-AGE) 3

Number of cervical smears taken (Maori) (NO-AGE) 1

Number of cervical smears taken (Asian) (NO-AGE) 1

Total number of cervical smears for Incognito Women 13

Reporting Unit: Priority

Group Women NZ

Maori, Pacific or Asian

women, 20-69 years of age

who are not un-screened or

under screened

Number of cervical smears taken (Asian) (20-69) 203

Number of cervical smears taken (Maori) (20-69) 460

Number of cervical smears taken (Other) (20-69) 11

Number of cervical smears taken (Pacific Islander) (20-69) 72

Total number of cervical smears for Priority Group Women 746

Reporting Unit:

Under-screened women

(women who haven’t had

a smear in 5 years or more,

30-69 years of age)





Total number of cervical smears for Under-screened women 117

Reporting Unit:

Un-screened women

(women who have never

had a smear, 30-69 years

of age)





Number of cervical smears taken (Pacific Islander) (30-69) 1

Total number of cervical smears for Un-screened women 21

GRAND TOTAL 897


Q1: NA Q2: NA Q3: NA Q4: 897

Cervical Smear Services To Priority Women in Waikato DHB


47




The primary focus of this contract is to improve access to health care for those with complex chronic conditions.

This has been achieved by providing clinic based consults in Turangi at Pihanga Health to 168 Maori people, 139

Pakeha people and 20 other ethnicities. An outreach home based case management service has been delivered

to 29 people (see appendix). This is an increase of 60 clinic and 11 home based clients on quarter 3. To maintain

sustainability some people have participated in group based education and exercise and this will continue as

an ongoing option in partnership with MDT, DHB nurse specialists and mental health, Lifestyle potential and

Tuwharetoa health service providers.

This contract also contributes to achievement of influenza outreach vaccination and promotion as well as

pneumovax, high risk cardiovascular and diabetes management. Insulin initiation, monitoring and maximising

control and self- management are a key focus and four people have been started on insulin. Access to medicines in

the high risk group is improved for people with chronic conditions with prescriptions for 167 people.

Nurse Practitioner / Family Nurse

CONTRACTING DHB: TAIRAWHITI DHB

HAS MET: VOLUMES: NO DEMOGRAPHIC TARGETS: NA

Midlands Health Network is contracted to provide 498 Primary Options referrals per year. In the 2014/15 contract

year 463 referrals were received with a variance of 35.

In Quarter 4 the Primary Options team visited all practices (regardless of PHO alignment) to relaunch Primary

Options resulting in significantly higher referral numbers compared to previous quarters and last year (Q4 2013/14 =

43). The proportion of referrals successfully managed in Primary Care remained constant in Q4 at 91% (Q3 = 91%).

Top pathways continue to be Cellulitis (18%) and DVT (14%), however it has been refreshing to see the Q4 growth

driven by increased utilisation of other ways such as respiratory and gastroenterological conditions.

PREVIOUS QUARTER ACHIEVEMENT: THE QUARTERLY TARGET IS 125

Q1: 116 Q2: 65 Q3: 59 Q4: 203

EXPLANATION IF NOT ACHIEVED: When compared to Q4 2013/14 (referrals = 85) Primary Options has continued to experience significant growth.

Work is progressing to develop pathways for ED to actively refer into Primary Options as a means of avoiding ED

presentations and follow ups.

Primary Options


48

CONTRACTING DHB: LAKES DHB


Midlands Health Network is contracted to provide 492 Primary Options referrals per year. In the 2014/15 contract

year 191 referrals were received with a variance of 301.

A slight decline in the percentage of referrals successfully managed in primary care was experienced with 85% in

Q4 (Q3 = 87%).

Top pathway continues to be Cellulitis (38%), however increased utilisation of other pathways has seen Renal/

Urological now making up 15% of all referrals while DVT has dropped to 10%.


Q1: 32 Q2: 58 Q3: 57 Q4: 44

EXPLANATION IF NOT ACHIEVED: Primary Options referrals have remained relatively flat in 2014/15. A major communications push aimed at

revitalising practitioners interest in Primary Options is planned for Q1 2015/16.

Primary Options



Midlands Health Network is contracted to provide 744 Primary Options referrals and 3180 ED Redirects per year.

In the 2014/15 contract year 700 Primary Options referrals were received (variance of 44) and 220 ED Redirects

(variance of 2,960) were received.

In Q4 Primary Options referrals continue to grow and exceed contracted volumes, however a lower per unit cost

than anticipated has offset the increased numbers.

A slight decline in the percentage of referrals successfully managed in primary care was experienced with 93% in Q4

(Q3 = 95%). This is still well above other MHN regions.

Top pathways continue to be DVT (30%) and Cellulitis (22%) however it has been refreshing to see the Q4 growth



PRIMARY OPTIONS: THE QUARTERLY TARGET IS 186

Q1: 153 Q2: 133 Q3: 190 Q4: 224


Primary Options


49

CONTRACTING DHB: WAIKATO DHB


Midlands Health Network is contracted to provide 8,091 Primary Options referrals per year. In the 2014/15 contract

year 5,807 referrals were received with a variance of 2,284.

A slight decline in the percentage of referrals successfully managed in primary care was experienced with 89%

in Q4 (Q3 = 90%), this is in part due to an increase in the number of primary options referrals from ED that were

returned to ED following unsuccessful treatment (16% of all ED initiated referrals).

Top pathways continue to be Cellulitis (22%) and DVT (12%), however it has been refreshing to see the Q4 growth


PREVIOUS QUARTER ACHIEVEMENT: THE QUARTERLY TARGET IS 2,022

Q1: 1,448 Q2: 1,402 Q3: 1,357 Q4: 1,600

EXPLANATION IF NOT ACHIEVED: When compared to Q4 2013/14 (referrals = 1,024) Primary Options has continued to experience significant growth.

On 1 June 2015 additional pathways for ED to refer into Primary Options were established. Reengaging with St John

Ambulance in Q1 next year is also likely to increase referral numbers going forward.

Primary Options


ED REDIRECTION: THE QUARTERLY TARGET IS 795

Q1: 57 Q2: 17 Q3: 44 Q4: 102 EXPLANATION IF NOT ACHIEVED: Primary Options referrals have remained relatively flat in 2014/15. A major communications push aimed at

revitalising practitioners interest in Primary Options is planned for Q1 2015/16.


50


CONTRACT NUMBER: 339453 AND 685858


Breast Screen Aotearoa mobile breast screening unit visited Turangi this year and are scheduled to visit Mangakino

in the next month. This will see an increase in the breast screening rates of Maori women due to the high Maori

population in these areas. Even though there were women that failed to book appointments in Turangi 351 women

were screened out of the 506 that are enrolled on the programme. This is a 69% screening rate which is 1% below

the national target. There is an opportunity for women who missed the bus to attend an appointment in Taupo

within the next 2 months which will hopefully bring the screening rate to the meet the national target.

340 referrals from Breast Screen Midland, 147 (47%) of these referrals went on to have mammograms, 5 of which

required Support to service. BSM regional plan target is 50% of referrals go on to have mammograms.

165 cervical screening referrals who are high needs women that don’t respond to cervical screening recalls. These

are received from GP practices, Anamata CAFÉ and Taupo community services staff – 32 went on to have smears

which is a 19% screening rate from these referrals.

9 colposcopy referrals from Rotorua Gynaecology Outpatients and GP practices, 2 of which required support to service.

Breast Screening and Cervical Screening

CONTRACTING DHB: TAIRAWHITI


HAS MET: VOLUMES: YES DEMOGRAPHIC TARGETS: NA

There were 18 participants in the programme for this quarter from a total of 28 referrals (61% Maori). 12 people

attended at least 75% of the sessions and completed the course.

Of the people who did not attend: three had returned to work and were unable to attend a daytime programme,

one had become too unwell, six did not give a reason. Six people did not complete the course, four due to illness,

one due to family responsibilities and one person did not give a reason.

Participants recorded an average improvement in Sit to Stand of 4.02 seconds and Up and Go of 1.88 seconds.

82% of participants agreed or strongly agreed that the programme had helped them to better manage their health.

The exercise component was the most appreciated aspect of the programme.

All participants who completed the programme left with agreed goals and forward care plans.

Post-Acute Community Cardiac and Pulmonary Rehabilitation


51

Clinical Pharmacist

CONTRACTING DHB: TARANAKI


April to June has been a busy quarter for the chemical pharmacist, with 86 complex patients being referred and a

mixture of home and clinic visits. She has received 2 referrals from 2 different GP practices who prior to this period

had not accessed the clinical pharmacist service. She presented at the MHN GP locality conference which covered

innovation in primary care on “The Clinical Pharmacist Role, the move from secondary to primary care”. The

presentation was well received, gathered very positive feedback and was a great opportunity to promote the service

to the practices.


Q1: 54 Q2: 83 Q3: 94 Q4: 86

CONTRACTING DHB: NONE (FLEXIBLE FUNDED)

CONTRACT NUMBER: FLEXI FUNDED


The outreach nurse service has had a caseload of 63 patients this quarter. 8 new patients were enrolled. 30 patients

are over 65 years old. There are 19 diabetic and 16 cardiac patients in the service. The mobile medication clinic has

been used more this quarter than before indicating a level of trust in the service. 70 home visits were provided and a

number of transport to services were delivered.

Community Outreach Nurse - Waikato


52



HAS MET: VOLUMES: NO DEMOGRAPHIC TARGETS: YES

MHN is contracted to provide dietetic service to 55 initial patients, 119 follow ups and 6 group education sessions

per quarter. The follow up volumes and group sessions were met, with 133 follow up consults and 6 group sessions

delivered this quarter. The initial consult volume was not met as only 54 patients were seen. Dietetic patients are

seen on a 1:1 basis as well as group education sessions and cooking demonstrations. The dietetic service works

closely with the exercise consultant, with the majority of patients being seen by both services. Likewise, clients that

are referred for dietetic service often have other issues going on in their life that require social work input so they

are referred to that service.


Q1: 38 INITIAL CONSULTS, 163 FACE TO FACE F/U, 8 GROUP SESSIONS




EXPLANATION IF NOT ACHIEVED: Initial consult volume was not met, it was one short. This may be due to a new Dietitian coming into the role and

GP’s not being familiar with me at the start of the quarter.

* Continued on next page


53



DIETITIAN QUARTERLY NUMERICAL REPORT:

NEW REFERRALSCumulative total of referrals for the contract:

Total number of new referrals in the quarter 54

Referral Source:

General Practice teams 50

Internal 0

Lakes District Health Board Staff 3

Other community providers 1

Number of new referrals by domicile:

Taupo 35

Turangi 18

Mangakino 1

New referrals by age: < 5 years 0

5-11 years 0

12-24 years 2

25-44 years 14

45-64 years 23

65-74 years 11

75-84 years 3

85 + 1

New referrals by ethnicity:

Maori 20

Pacific Peoples 1

NZ European 30

Other 3

New referrals by gender:

Male 26

Female 28

WORK COMPLETED

Total number of INITIAL CONTACTS made with clients during quarter 54

Total number of TELEPHONE client contacts in the quarter 98

Total number of FACE TO FACE follow-ups in the quarter 133

Total number of LETTERS sent to clients in the quarter 16

Total number of GROUP SESSIONS in the quarter 6

CURRENT CASELOAD AND DISCHARGES

Total number of active clients enrolled with service at the end of the quarter 94

Total number of clients discharged in the quarter 11


54




The Living Well exercise consultant works within the MHN’s LTC management team providing patients with

individually designed exercise options appropriate for their medical condition/s. 43 new referrals were received this

quarter with a total of 113 clients receiving exercise support. 65 (inclusive of pulmonary, cardiac & diabetes) group

sessions were held with over 377 face to face consults held with clients. 27 clients achieved a “fit 2b discharged”

status and as such have clearly demonstrated a higher level of exercise tolerance and an understanding of their

condition to now be able to exercise independently.

LIVING WELL SERVICE QUARTERLY NUMERICAL REPORT:

Total number of new referrals in the quarter 44

Referral Source:

General Practice teams 25

PHO Clinical Team 6

Lakes District Health Board Staff 12

Other community providers 1

Number of referrals by domicile:

Taupo 44

Turangi 12

Number of referrals by age:

12-24 years 3

25-44 years 8

45-64 years 16

65-74 years 13

75-84 years 4

85 +

Number of referrals by ethnicity:

Maori 17

Pacific Peoples 2

Non-Maori/ non-Pacific 25

Number of referrals by gender:

Male 51

Female 62

Total number of clients supported in the quarter 113

Total clients supported by domicile

Taupo 83

Turangi 30

Primary Care LTC Management Program MDT



55

Total clients supported by age

12-24 years 3

25-44 years 16

45-64 years 38

65-74 years 30

75-84 years 21

85 + 5

Total clients supported by ethnicity

Maori 43

Pacific Peoples 2

Non-Maori/ non-Pacific 68

Total clients supported by gender

Male 51

Female 62

Total number of group sessions held in the quarter 65

Total number of first face-to-face contacts with clients / whanau in the quarter 17

Total number of follow-up face-to-face contacts with clients / whanau 377

Total number of telephone follow ups in the quarter 180

Total number of referred clients discharged in the quarter 27


Nurse Practitioner Mangakino




This 0.4Fte contract is to deliver clinical care to adults with complex chronic conditions in their homes/community.

In Mangakino this is delivered on an individual/whanau and group style. Liaising between secondary and

primary care for integration and improved outcomes for people alongside individual care planning, medication

management and monitoring continues to be a big part of the role. The np is regularly utilised as a resource for

information for the wider whanau.

There are 25 individuals/whanau being case managed and 14 of these identify as maori. The gender split is

reasonably even. The np had 12 direct contacts in April, and 17 each in the months of May and June. Smoking

cessation, smear and breast screening are highlighted with patients as part of encouraging health promotion and

regular engagement with screening programs. Health promotion group sessions have been successful in targeting a

demographic not previously seen (see highlights).

Accessibility to specialist services continues to be a challenge.


56

Outreach Nurse

Refugee Primary Health Care




This role focuses on an integrated and systems approach to achieving the primary health targets: ‘more health and

diabetes checks and better help for smokers to quit’. This quarter has seen an increase of patients in the service by

80 from the previous quarter and an increase in referrals for patients 12-24 years.

At the end of the financial year practices Best Practice reports sit between 94% and 95% for meeting smoking

cessation brief advice. Continual support has been given to smoking leads in practices to support them in meeting

their targets and support with best practice education. Further assistance in achieving smoking stats this quarter

was provided by MHN Patient access centre phoning clients not seen with the additional data being updated on

PMS by self.

Indicators Q1 Q2 Q3 Q4

Smoking High Needs 77.40% 88.58% 93.02% 93.29%

Smoking Total Pop 75.80% 88.67% 93.60% 94.43%

CVRA High Needs 85.78% 87.15% 88.79% 89.52%

CVRA Total Pop 90.30% 91.00% 91.75% 91.83%



HAS MET: VOLUMES: NA DEMOGRAPHIC TARGETS: Y

This year has seen a 57% increase in demand for interpreting services at medical centres and hospitals

appointments. Over the same period last year 288 interactions were captured, this period it has increased to 502

interactions. The demographics of the refugees has also seen a shift with the majority of arrivals being female and

children. Many of these families come with very high medical and psychological supports needed which has been a

challenge to deliver for the service.


Q1: 135 Q2: 105 Q3: 177 Q4: 115


57

Whanau Co-Ordinator

Primary Care Long Term Conditions Management Programme Multi-Disciplinary Team




There are three community providers delivering services as part of this contract. In the last quarter the Kaumatua

Nursing service- (Rauawaawa) enrolled 27 new clients taking the total number of clients to 266. 295 nurse

consultations were delivered with 130 in clinic, 102 clients were seen in the community.

Healthright- Whanau household (Ngati Maniapoto Marae Pact Trust) enrolled 5 new clients this quarter. The total

number of clients in the service is 13. The lifestyle programmes provide educational opportunities for clients to self-

manage their conditions better with the assessments identifying barriers and then providing support and plans to

break the barriers down.

Chronic care management- SWIPICS have 58 clients in their service with 1 new enrolled patient. The service was

provided by phonecall (216) homevisits (77) and 40 office consults. 9 patients were hospitalised this quarter. A

variety of education sessions were delivered including a Mens focus Group with guest speaker and medication

education.




The Social worker has provided social work assessment and intervention across the LTCM multidisciplinary team

within a case management approach.

11 new referrals were received this quarter with 13 being discharged. Active clients enrolled with the service

presently sits at 13.

There were 29 face to face appointments with 40 contacts made with clients over the quarter.

Clients are referred from general practice via e-Referral and from within the MDT. Needs are regularly identified

within the longer consultations provided by the multidisciplinary care teams planning process. Attendance at

the MDT fortnightly meetings in Turangi also support referrals and promotion of this service. Clients’ needs are

complex.

Support has been given to Pulmonary Care and Cardiac community support programmes across Turangi and

Taupo.


58

More Heart and Diabetes Checks

CONTRACTING DHB: AS BELOW...

CONTRACT NUMBER: LAKES DHB – 348796

TAIRAWHITI DHB – 348935

TARANAKI DHB – 348766

WAIKATO DHB – 349401

Includes BoP DHB performance


Our internal calculations (as at 30/06/2015) are shown below. All localities have achieved the More Heart and

Diabetes Health Target of 90%.

!

!

80%

82%

84%

86%

88%

90%

92%

94%

Q4!end!2013/14 Q1 Q2 Q3 Q4Lakes 89% 91% 91% 92% 92%Tairawhiti 85% 88% 88% 89% 90%Taranaki 88% 91% 90% 92% 93%Waikato 86% 89% 89% 90% 91%MHN 87% 90% 89% 91% 91%Target! 90% 90% 90% 90% 90%

More!Heart!and!Diabetes!Checks!2014/15


59

Primary Care Long Term Conditions Allied Health MDT




Multidisciplinary teams (MDT) coordinated in primary care, using shared care processes and pathways (integrated

with allied health and secondary care providers) to provide timely wrap around services to patients

Practices are further supported in their long-term condition management by access to externally provided services,

which complement those available from the core practice team. Midlands Health Network contracted with Taranaki

DHB Hospital and Specialist Services to provide the community dietetics and social work services. Access to the

service is via an eReferral from a MHN GP practice in the Taranaki region.

To ensure a sustainable service was developed, initial efforts were centred on the establishment of a patient

and family/whanau-centred model of care. With the aim of integrating treatment, education and motivation to

support healthy lifestyle changes for high risk/high needs patients who have long term conditions (diabetes and/or

cardiovascular disease).

PERFORMANCE


To increase service utilisation further work is required to understand demand, raise awareness within general

practice, and consider how it may further align the Social Worker and Dietician resource to general practice.

As a new service referral volumes have been slowly increasing as awareness is raised. Insights gained to date

include:

1. Establishing relationships across the many health care professionals is key to a successful program. These

relationships generate referral volumes

2. The Podiatry service reach expected service levels over a two year period

3. Making it easy to refer within the MDT would be beneficial

4. Creating volume flexibility within the contract would be beneficial

5. There is a need to continually promote the program, within general practice and the wider community to drive

referral volumes

6. Joint MDT visits have worked well

!

!

0

500

1000

1500

2000

2500

3000

Total+Social+Worker Total+Dietetics Total+Pharmacy

MDT!Utilisation!

Target Actual+


60

Kawhia Lifestyle Coach and Diabetes Education and Management


CONTRACT NUMBER: KAWHI-11.14


The provider reports that

During the above period we have had 5 new referrals to Sport Waikato and are working alongside their new Active

and Well Coordinator for this area.

We have also been supporting and following up clients from the Diabetic Nurse Educator and Podiatrist and

Dietician as well as linking with the local School and other agencies in the community.

I have had 3 new referrals for Smoking Cessation, but continue to follow up and support previous clients.

Our Diabetic Health workers are trying to visit clients in their homes and helping set up exercise circuits and going

walking with them when can, as well as supporting any problems they may be having with their diabetes (including

testing).

Building relationships with our clients in the community is really important in helping them with their Diabetes and

healthy lifestyle changes and challenges. We work really hard at trying to make this happen – relationships and

building trust are a huge key in walking alongside our clients.


Q4:

Number of new Participants during this Quarter

AGE

0 – 14 0

15-24

25-34 0

35-44 1

45-54 3

55+ 15

GENDER

Male 13

Female 6

ETHNICITY

Maori 11

European 8

Asian -

Pacific -

PLUS SMOKERS

Male 0

Female 3

Maori 1

European 2


61


CONTRACT NUMBER: MID-VAR-05518.00


This agreement aims to improve coverage of eligible women having a Cervical Smear every three years. In particular

Priority Women who are aged 20-69 and either Maori, Asian or Pacific Islander or any other woman aged 30-69

who has never had a smear or is overdue a smear for 5 years.

TARANAKI CERVICAL SMEARS APRIL – JUNE 2015 154


Q1: NA Q2: NA Q3: NA Q4: 154

Cervical Smear-taking Services


CONTRACT NUMBER: TCSPW-00.14


This agreement aims to improve coverage of eligible women having a Cervical Smear every three years. In particular

Priority Women who are aged 20-69 and either Maori, Asian or Pacific Islander or any other woman aged 30-69

who has never had a smear or is overdue a smear for 5 years.


Q1: NA Q2: NA Q3: NA Q4: 155

Cervical Smear Priority Women - Taupo


CONTRACT NUMBER: TDH-MRHNCT-CS2.15


This agreement aims to improve coverage to move towards DHB and National Target of 85% of eligible women

having a Cervical Smear every three years. In particular Priority Women who are aged 20-69 and either Maori, Asian

or Pacific Islander or any other woman aged 30-69 who has never had a smear or is overdue a smear for 5 years.


Q1: NA Q2: NA Q3: NA Q4: 78

Cervical Smear Service for Priority Service in Tairawhiti


62




Both the Nurse Practitioner and the Clinical Nurse Specialist continue to make good progress against the

contracted objectives. Statistics are being collected which will provide evidence over time of reduction in falls and

increases in vitamin D prescribing.

There has been excellent progress in vitamin D prescribing. All residents admitted into residential care are

commenced on Vit D unless contraindicated. The CNS is working with general practice to identify patients at high

risk of falls so that they can be fully assessed for fragility and suitable treatment provided.

Aged care facilities have been supported in developing and implementing systems and programmes to assist

with falls prevention. Physical exercise programmes are being encouraged and referrals into the “Step to Move”

programme are being incorporated into discharge planning from secondary services.

Education and support for nursing staff in aged care continues to be a valued part of this service. Education

provided has included care of dementia patients and also blood withdrawal skills.




A recent routine Healthshare audit (24 March) highlighted 8 areas that were partially attained and low risk. A

corrective action plan was developed and approved by TDHB in June. Remedial work has commenced on

corrective actions as per plan.

53 people were seen by the service during the quarter. This is an increase on previous quarters. Referrals in were

from Hospice, GPs, TDHB, Waikato DHB and Hutt Valley DHB, with outward referrals made to Occupational

Therapy, GPs, Hospice, TDHB Ulcer Clinic.


Q1: 46 PATIENTS, 584 CONTACTS




Nurse Practitioner and Clinical Nurse Specialist Falls Prevention

Community Nursing Services - Inglewood


63

CONTRACTING DHB: WAIKATO TARANAKI LAKES TAIRAWHITI



The Palliative care visit allowance is intended to facilitate the care of terminally ill patients in their home

environment by increasing access to primary care through GP home visits.

It also ensures early access to palliative care/hospice services.

Within a set of criteria, the allowance covers:

• Home visits and mileage to support these.

• Visits to support the patient’s family and complete a certificate after the death.

The service is widely available across all MHN practices that provide palliative care.

Palliative Care

CONSULTATION TYPE WAIKATO

Death Certificate Visit 45

Family Visit 12

PC Visit < 30 Minutes 144

PC Visit > 30 Minutes 112

Practice Nurse Home Visit 1

Surgery Visit 42

Totals 356

CONSULTATION TYPE TAIRAWHITI


Family Visit 2




Surgery Visit 9

Totals 41

CONSULTATION TYPE TARANAKI


Family Visit 9




Surgery Visit 18

Totals 273

CONSULTATION TYPE LAKES


Family Visit 3




Surgery Visit 17

Totals 139


64




The total calls for this quarter were 3343. This was a decrease of 376 calls form last quarter. The service was provided

to 15 practises with a combined ESU of 62278. The average call duration was 3:46 minutes. 1986 calls were non

clinical.

454 calls were handed over to oncall GP, 188 were handed over to ED with 694 calls for next day GP contact. 21%

calls triaged by age bracket were aged 65+ ,18% were 0-4yr and 45-64 years and 16% 5-14 years.

The top three health issues triaged were 1. Trauma/Injury, 2. Gastrointestinal and 3. Pain musco-skeletal.

Telephone Nurse Triage



The total calls for this quarter were 481. This was a decrease of 71calls from last quarter. The service was provided to 4

practises with a combined ESU of 34110. The average call duration was 3:46 minutes. 282 calls were non clinical.

61 calls were handed over to oncall GP, 25 were handed over to ED.

41% calls triaged by age bracket were 0-4years, 18% were 5-14 and 15% 45-64

The top two health issues triaged were 1. Gastro-intestinal, 2. Respiratory with Fever being the third highest health

issue.

After hours Under 6s


65


CONTRACT NUMBER: WT-MORP-01.13 / WP-TEKHSMOC-02.13


Marae based services are outreach services provided by Te Kauwhata Health Centre. They aim to improve access to

GP and nursing services, particularly for those with high needs.

Meremere Outreach Pharmaceuticals Services are currently provided by Te Kauwhata Health Centre.

Q4:

• Acceptability remains the same.

• Number of patients seen for the three months 281

• Clinics: two one hour clinics per week although this usually goes to 2- 3 hours per clinic.

• Registered patients 96. Most are casual because of their short stays in the village. The number of registered

patients varies because of the movements.

• Smoking cessation prescriptions are given out and are encouraged with patients.

• Champix prescriptions given

• Child immunisations done. Recalls sent out and also referred to outreach service.

• Cervical smears encouraged at Doctors surgeries as facilities not really suitable for doing smears. Patients are

reminded about them. We have run a nurse only clinic at the rooms to try and encourage those with transport

difficulties to come for smears. It was a mixed result, times made and not kept.

• Diabetic annual checks are done on registered patients

• CVD screening done on registered patients

• Enrolling in the free mammogram programme has been encouraged.

• The population remains about the same. Many short stay residents and quite a few empty houses.

• Pharmacy delivery and drop off of medication at shop continues with no problems.

• Security cameras have been installed around the building with noticeable less graffiti and damage being done

in this area.

Meremere Outreach Pharmaceuticals / Meremere Outreach Clinic




Marae based services are outreach services provided by practices in Marae. They aim to improve access to GP and

nursing services, particularly for those with high needs.

Kai-a-te-mata Marae Outreach Clinic Services are currently provided by Morrinsville Medical Centre.

THE PROVIDER REPORTS THAT

• A total of 202 patients were seen in quarter 4

• The average number of patients seen per clinic is 15.5

• 48 flu vaccinations were given

• There is now a practice nurse present which helps completing screening and blood tests.

Kai-a-te-mata Marae Outreach Clinic


66


CONTRACT NUMBER: WAIHB-90.00


Marae based services are outreach services provided by practices in Marae. They aim to improve access to GP and

nursing services, particularly for those with high needs.

Otawhiwhi Marae Services are currently provided by Waihi Beach Medical centre.

TOTAL SEEN

113 New enrol-

ments

1

ETHNICITY Maori Pacific Island European Other

104 1 7 1

AGE 0-5 6-17 18-24 25-44 45-64 65+

MALE 2 2 2 6 10 18

FEMALE 1 10 23 20 19

TOTAL 3 12 2 29 23 37

Otawhiwhi Marae Outreach Clinic

Mild Mental Health Contract Reports


68

Primary Mental Health Initiatives Service




Adult PMH services continue to be well supported by referrals from general practice with referral numbers slightly

increased from the same period last year. As is expected in this quarter, the service saw an increased number of

missed appointments due to seasonal illness and reluctance to travel in bad weather.

Staffing for the youth PMH service was increased during this quarter. Initial priorities included meeting with

community referrers to the service and ensuring that they were aware of service options that are available to

support them in working with youth. Any perceived gaps in service and unmet needs were also discussed. Feedback

will be used to inform service development.

Referral numbers to the Youth PMH service have already shown an increase and we expect that this will continue

as referrers become more familiar with the service options and the stepped care approach to supporting youth

experiencing mild to moderate mental health or addiction issues.






MRHNCT is contracted to provide 727 packages of care to adults annually. This deliverable has been fully achieved.

This quarter 303 referrals have been received for those aged 20 years and over with total number of adults seen

during the quarter being 346. Maori make up 14% of referrals. 252 (73%) females were seen by the service compared

with 94 (27%) males.

The level of severity of the referrals has been an issue during this quarter. There has been a high number of complex

referrals that have been made, which just barely meet the moderate criteria for Taranaki Primary Connections (TPC).

As a result there has been several conversations and meetings with psychologists about treating these clients in a

brief intervention service and the availability of extensions when necessary.

PREVIOUS QUARTER ACHIEVEMENT: PACKAGES OF CARE DELIVERED FOR CLIENTS AGED 20+ YEARS

Q1: 227 Q2: 347 Q3: 353 Q4: 346

During this quarter the TPC co-ordinators have utilised their new placement within the MH clinical team office and have

begun attending the MH services MDT. This has ensured that TPC co-ordinators are able to oversee the transition from

TPC referral to MH referral when it has been decided that the MH services are more appropriate for a patient. It has also

introduced a new level of safe practice with co-ordinators being able to discuss complex referrals in the MDT forum

in order to receive input from the clinical team. The introduction of a new co-ordinator has also enabled the TPC wait

times to be reduced which appears to have had a correlational impact on the DNA rate.



69

Primary Mental Health Extended GP Consult

Sexual Abuse Assessment and Treatment



HAS MET: VOLUMES: N DEMOGRAPHIC TARGETS: NA

This quarter MHN Lakes delivered 202 extended GP consults. 101 of these were to youth aged 12-19 years.

The full year target was for 872 GP extended consults, we delivered 831 this year.





Contracted Services have been delivered. There were no new referrals for this quarter.

Reporting as per the service specification is provided for ACC. There is no other reporting requirement.


70





MRHNCT is contracted to provide 329 packages of care to adults annually. This deliverable has not been fully achieved.

This quarter 97 referrals have been received for those aged 12-19 years with total number of youth seen during

the quarter being 85. Maori make up 29% of referrals. 43 (51%) females were seen by the service compared with 42

(49%) males.

PREVIOUS QUARTER ACHIEVEMENT: PACKAGES OF CARE DELIVERED FOR CLIENTS AGED 12-19 YEARS

Q1: 66 Q2: 86 Q3: 58 Q4: 67

PREVIOUS QUARTER ACHIEVEMENT: GROUP SESSIONS DELIVERED FOR CLIENTS AGED 12-19 YEARS

Q1: 0 Q2: 0 Q3: 0 Q4: 18

EXPLANATION IF NOT ACHIEVED:

Further embedding of the youth PMH programme is required. Three issues have been highlighted:Staff changes in

schools have meant that orientation to the PMH programme has been missed in some cases in handover to new staff,

in particular school guidance counsellors (SGC). TPC have followed up to ensure information on the programme and

appropriate documentation has been distributed.

Some SGC have felt limited by the number of voucher they have been allocated and due to the underutilisation a new

method of distributing youth vouchers has been devised. This new approach will include a ‘pool’ of youth vouchers for

appropriate referrers to use, instead of individual allocations made per school.

Due to lack of access to counselling/psychology services in South Taranaki, referrals from SWEET service have been nil.

A review of contracted psychologists and counsellors is commencing in the next quarter and a new model of care for

TPC co-ordinators is planned for 2015-2016 contract year including providing brief intervention to assist with addressing

delivery of services in South Taranaki.


Primary Mental Health Service - Youth




There has been a continuation of youth service through our link with the school nursing service and referrals through

GPs. We have maintained service in only one high school this quarter. There has been an increase in the number of

youth referred into the service. Brief intervention provided to youth by our primary mental health co-coordinators is at

the same volumes as previously with an increased number being treated by psychologists and counsellors.



71

Primary Mental Health - Adult




There has been an increase in brief intervention delivered by primary mental health co-ordinators which reflects

the increased resource available with some recruitment to vacancy over this quarter. There are 142 patients who

are referred into the service and declined as they are ineligible for the service, the patient declines the service or

they chose to cease counselling. A number of these patients require secondary service and we have changed our

reporting to capture this going forward.


Smokefree Contract Reports


73

Better Help for Smokers to Quit Health Target – Primary Care

Tobacco Health Target and Stop Smoking


CONTRACT NUMBER:


General Practices throughout the Waikato were introduced to the ‘Better help for smokers to Quit’ national health

target for 2015 – 2016. Electronic tools, administrative resources and support have been contributing factors in

assisting their improvement towards the health target. MHN has provided practices with a short term telephone

campaign to deliver brief advice to those patients who have not been seen in practices in the last twelve months.

The final quarter of MHN’s 2014 – 2015 Quality Plan of ‘Smokers given brief advice’ in the Waikato has seen its most

successful result ever. Of the 52 practices, 48 achieved 90% plus of both quality goals, 40 of those had maintained

their achievement from the previous quarter. Of the remaining four practices, three utilise non-Medtech practice

management systems, therefore results of their achievements are not yet known, so the potential for a higher

achievement is possible. Overall, sustainability of practice processes and procedures are evident.


Q1: 85% Q2: 85% Q3: 88% Q4: NOT YET KNOWN


Should the national health target of 90% not be achieved this quarter a more robust phone campaign will be

anticipated as soon as possible. Practices are presently working on their own strategies to refresh dated patient

contact details



HAS MET: VOLUMES: NO DEMOGRAPHIC TARGETS: NO

To support achievement of the national health target, MHN has provided Pinnacle practices with a short term

telephone campaign to deliver brief advice to those patients who have not been seen in practices in the last 12

months.

Practices have been introduced to the new ‘Better Support for Smokers to Quit’ national health target for 2015-

2016, electronic tools and front desk resources to assist with improvement towards the health target.

Spotlight on smoking cessation in pregnancy series was published in Practice Matters (electronic newsletter) to

general practice during April to June 2015. The information also features on the Pinnacle provider website.

To support World Smokefree Day, promotional material was distributed to general practices and MHN has run a

competition to encourage general practices to send smoking cessation referrals to local AKP providers. General



74

practices in North, Central and South Taranaki with the most referrals to local AKP services will receive a morning

tea shout in July.


Tui Ora Ltd has been contracted to provide a dedicated smoking cessation service to a minimum of 55 patients

to support Pinnacle general practices. This service commenced on 15 June 2015 and given the service involves a

minimum of a 12 week programme for patients, volumes have not been achieved as yet.


Tobacco Control Services – Aukati Kai Paipa Service and Hapu Women Smoking Cessation Service

CONTRACTING DHB: TAIRAWHITI DHB


HAS MET: VOLUMES: YES DEMOGRAPHIC TARGETS: YES FOR AUKATI KAI PAIPA SERVICE

HAS MET: VOLUMES: YES DEMOGRAPHIC TARGETS: YES FOR HAPU WOMEN SMOKING CESSATION SERVICE

AUKATI KAI PAIPA SERVICE

General Practices: The service continued to provide on-site Smoking Cessation services at Three Rivers Medical

and Waikohu Health Centre.

Antenatal Classes: The service made presentations to five Turanga Health Antenatal classes during this period.

Tairawhiti Smokefree Coalition: The service attended hui for Taki Tahi Toa Mano during this period. The service

supported the coalition submissions to the Gisborne District Council to make the CBD smokefree.

Wero Challenge: The service provided smoking cessation support to groups participating in the regional Wero

challenge. One hapu mama and her partner participated in the Wero Challenge.

HAPU WOMEN SMOKING CESSATION SERVICE

GP Inductions: Turanga Health continued its Induction programme to new doctors employed by Three Rivers

Medical. During this nine new doctors were inducted. The doctors were introduced to the Smoking Cessation

service. There were advised on how our programme is delivered and how to refer patients to the service.

ABCs: The Turanga Health Smoking Cessation team continued to provide vital support in assisting Midland Health

GP practices to meet their ABC targets.

Tu Kaha: The service attended the Tu Kaha programme during this period, offering smoking cessation support to

whanau that attended.



75



AUKATI KAI PAIPA CLIENTS ENROLLED ON THE PROGRAMME

Q1: 25 Q2: 31 Q3: 37 Q4: DATA UNAVAILABLE AT TIME OF PUBLISHING

61 (66%) patients completed the programme during quarters 1-3 with 19 (31%) who had not a single puff at 3 months.

HAPU WOMEN SMOKING CESSATION SERVICE CLIENTS ENROLLED ON THE PROGRAMME

Q1: 6 Q2: 4 Q3: 4 Q4: DATA UNAVAILABLE AT TIME OF PUBLISHING

70% of those enrolled were pregnant women, 30% were partners/whanau supporting family to quit. 76% of those

referred to the programme were Maori, with no Pacific people referred to the programme.

3 (21%) patients completed the programme during quarters 1-3 with 1 (7%) who had not a single puff at 3 months.


The Hapu Women Smoking Cessation service was underutilised. This contract has been exited by Tairawhiti DHB.

ISSN-2463-2740

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QUARTERLY REPORT APR – JUN 2015 · HEALTH CARE HOMES 3728 B4 SCHOOL CHECKS COMPLETED All under 6s...

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