hutt valley district health board community public … · yvette grace thanked the presenter. the...

Hutt Valley District Health Board

HUTT VALLEY DISTRICT HEALTH BOARD

Community Public Health Advisory Committee17 AUGUST 2018

Ground Floor Board Room, Pilmuir House, Lower Hutt Hospital, High Street, Lower Hutt 9.00am.

ITEM ACTION PRESENTER MIN TIME PG

1 PROCEDURAL BUSINESS

1.1 Karakia 2 min 9.00am

1.2 Apologies Record Y Grace 3 min 9.02am

1.3 Continuous Disclosure

- Conflicts and Declarations of Interest Register

Confirm

Accept

Y Grace

Y Grace

2 min 9.05am 2

1.4 Confirmation of Draft Minutes 18 May 2018

Approve Y Grace 5 min 9.07am 3

1.5 Matters Arising Note Y Grace 3 min 9.12am 6

2 PRESENTATIONS

2.1 Health of Older Persons 2018 Update

Paper

Discussion

Kate Calvert 30 min 9.15am 8

2.2 Palliative Care Paper

Discussion

Jazz Heer &

Biddy Harford

30 min 09.45am 19

3 DISCUSSION

3.1 CPHAC Membership

(Public Health Expert)Discussion H Carbonatto 5 min 10.15am

3.2 Work Programme Paper 2 min 10.20am 7

4 FOR INFORMATION

4.1 Funding of Dental Treatments for Low Income Adults

Note Keith Fraser 30 min 10.22am

5 OTHER5.1 General Business Note Y Grace 8 min 10.52am

DATE OF NEXT MEETING 16 NOVEMBER 2018 – BOARDROOM, GROUND FLOOR, PILMUIR HOUSE, HUTT HOSPITAL

APPENDICES

2.1 Health of Older Persons 2018 Update2.1.1 Health of Older Persons Report 82.1.2 Hop Dashboard 20180731 182.2 Palliative Care2.2.3 Palliative Care Report 192.2.2 Advanced Care Planning Report 242.2.1 Living Well, Dying Well Strategy 274.1 Funding of Dental Treatments for Low Income Adults4.1.1 Possible Low Income Adult Dental Services 87

2018 08 17 Hutt Valley CPHAC - Public - AGENDA

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Wairarapa, Hutt Valley and Capital & Coast District Health Boards

Conflicts & Declarations of Interest Register

Hutt Valley District Health BoardCommunity & Public Health Advisory Committee

UPDATED AS AT 01 MARCH 2018

Name Interest

Yvette GraceChairperson

∑ Member, Hutt Valley District Health Board∑ Member, Hutt Valley District Health Board Hospital Advisory Committee∑ Deputy Chair, 3DHB combined Disability Support Advisory Committee∑ Chair, Hutt Valley District Health Board Community and Public Health Advisory Committee∑ Chair, Te Oranga O Te Iwi Kainga Maori Relationship Board to Wairarapa DHB∑ Trustee, Rangitane Tu Mai Ra Treaty Settlement Trust∑ Manager, Compass Health Wairarapa∑ Member, 3DHB Youth SLA (Service Level Alliance)∑ Member, Te Whiti Ki Te Uru Central Regions Maori Relationship Board∑ Husband, Family Violence Intervention Coordinator and Child Protection Officer Wairarapa

DHB∑ Husband, Community Council, Compass Health∑ Husband, Community member of Tihei Wairarapa Alliance Leadership Team∑ Sister in law, Nurse at Hutt Hospital∑ Sister in Law, Private Physiotherapist in Upper Hutt∑ Niece, Nurse at Hutt Hospital

Prue LamasonMember

∑ Member, Hutt Valley District Health Board∑ Member, Hutt Valley District Health Board Hospital Advisory Committee∑ Member, 3DHB combined Disability Support Advisory Committee∑ Deputy Chair, Hutt Mana Charitable Trust∑ Deputy Chair, Britannia House – residence for the Elderly∑ Councillor, Greater Wellington Regional Council∑ Deputy Chair, Greater Wellington Regional Council Holdings Company∑ Trustee, She Trust∑ Daughter is a Lead Maternity Carer in the Hutt

John TerrisMember

∑ Member, Hutt Valley District Health Board∑ Member, Hutt Valley District Health Board Hospital Advisory Committee∑ Member, Disability Support Advisory Committee

Lisa BridsonMember

∑ Member, Hutt Valley District Health Board∑ Member, Hutt Valley District Health Board Hospital Advisory Committee∑ Member, 3DHB combined Disability Support Advisory Committee∑ Hutt City Councillor∑ Chair, Kete Foodshare

Mr Andrew BlairMember

∑ Chair, Capital & Coast DHB∑ Chair, Hutt Valley District Health Board∑ Chair, Hutt Valley District Health Board Hospital Advisory Committee∑ Member, Hutt Valley District Health Board Finance, Risk and Audit Committee∑ Member, 3DHB combined Disability Support Advisory Committee∑ Owner and Director of Andrew Blair Consulting∑ Advisor to the Board, Forte Health Ltd Christchurch∑ Former member of the Hawke’s Bay DHB (2013-2016)∑ Former Chair, Cancer Control (2014-2015)∑ Former CEO, Acurity Health Group Limited

Tim Ngan keeMember

∑ Member, Hutt Valley District Health Board∑ Member, Hutt Valley District Health Board Finance, Risk and Audit Committee∑ Member, Hutt Valley District Health Board Hospital Advisory Committee∑ General Practitioner, Churton Park Medical Care∑ Partner, Churton Park Medical Care

2018 08 17 Hutt Valley CPHAC - Public - PROCEDURAL BUSINESS

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CPHAC Meeting Minutes

DATE: 18 May 2018 Time: 9.00am – 11.40am

VENUE: Board Room, Pilmuir House, Hutt Hospital, Lower Hutt

PRESENT: Yvette Grace (Chair), Prue Lamason, Tim Ngan Kee, John Terris, Lisa Bridson

APOLOGIES: Andrew Blair

IN ATTENDANCE Christine Rabone (Minutes), Dale Oliff, Helene Carbonatto, Kerry Dougal

PUBLIC No members of public present

PRESENTERS Clinical Services Plan (Scenarios/Integrative Workshop Report Back)David Moore, Managing Director, Sapere Research Group

Wellness PlanDr Peter Murray, Strategy, Planning & Outcomes, Hutt Valley District Health Board

Agenda Item Discussion Action Required and by Whom

1 PROCEDURAL BUSINESS1.1 KARAKIA Yvette Grace led the Karakia and welcomed attendees to the Hutt Valley DHB

CPHAC Meeting.1.2 APOLOGIES Received from Andrew Blair.


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1.3 INTEREST REGISTER John Terris noted a new conflict of interest.

Board Members would note any further conflicts.

John Terris will email Kristine McGregor with his interest register update.

1.4 CONFIRMATION OF PREVIOUS MINUTES

Minutes were accepted as true and correct.

Moved Prue Lamason seconded by Tim Ngan Kee.ACTION POINTS All action Points completed.

2 PRESENTATIONS2.1 Clinical Services Plan Presentation from Sapere Research Group Limited on the CSP was well

received. There was discussion on the importance of early communication and acceptance from the general public, the operating model, and the need to not overburden primary care.

HV DHB CSP CPHAC 18052018 v3.pptx

Yvette Grace thanked the presenter.

The Committee NOTED the presentation.3 DISCUSSION3.1 Wellness Plan The presentation was well received and the Committee passed on their

compliments. The need to keep the general public informed was noted and the committee will pass on any further suggestions.

Yvette Grace thanked the presenter.

The Committee NOTED the presentation.

CPHAC members will email Christine Rabone / Peter Murray if they have any further suggestions to the Wellness Plan content.

3.2 Work Programme The Committee NOTED the updated Work Programme.4 DECISION4.1 CPHAC MEMBERSHIP The Committee thanked Kerry Dougal for putting forward the names of two

high caliber Maori nominees.


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The Pacific nominee’s biography will be circulated to Committee members for approval to recommend the Board accepts their nomination onto the CPHAC.

The Committee RECOMMENDED that the Board appoints a further Board Member to the Committee - Ken Laben.

The Committee further RECOMMENDED the appointment of Teresa Olsen (Maori Representative) and once agreed via email, Taefu Heker Robertson (Pacific Representative) as co-opted members of CPHAC.

The Committee further RECOMMENDED that a third co-opted member with Public Health expertise will be sought following an Expression of Interest process.

Moved Lisa Bridson seconded by Prue Lamason.

Christine Rabone to circulate Pacific representative’s bio (via email) for approval once received.

4 FOR INFORMATION4.1 Response from Letter to

Minister (Sugar Tax)The Committee NOTED the response from the Ministers Office.

5 OTHER5.1 General Business No general business.


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CPHAC PUBLIC

Hutt Valley District Health Board May 2018

MATTERS ARISING FROM PREVIOUS MEETINGSOriginal Meeting Date

Ref Topic Action Resp How Dealt with Delivery date Completed Date

18 May 2018 Interest Register Advise of Interest Register update John Terris

Email Kristine McGregor so she can update the formal Interest Register

August 2018

18 May 2018

CPHAC Membership

Recommendation for Maori and PacificCPHAC representatives to be put forwardto the Board for approval

Christine Rabone

Circulate Taefu Heker Robertson’s Bio via email to CPHAC Members for agreement

Table recommendations for additional CPHAC Members at the next Board Meeting

18 May 2018

2 March 2018Update on Primary Care in the Hutt Valley

Develop a proposal considering the costsand benefits of funding dentaltreatments for low income adults to bedeveloped by 30 June 2018.

Helene Carbonatto

Paper drafted for the Board June 2018


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Meeting Date Topic Responsibility Meeting Date Topic Responsibility Meeting Date Topic Responsibility Meeting Date Topic Responsibility

2-Mar 18-May 17-Aug 16-Nov

Clinical Integration Stef Fridd Clinical Services David Moore (Sapere) Older Persons Kate Calvert Population Health Dr Peter Gush

Pacific Health Services Nanai Muaau Wellness Plan Dr Peter Murray Palliative Care Jazz Heer Inequality Reports TBA

Primary Care in the Hutt Bridget Allan Annual Planning TBA

Community Public Health Advisory CommitteeWork Plan for 2018

2018 08 17 Hutt Valley CPHAC - Public - FOR DISCUSSION

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PUBLIC

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CPHAC DISCUSSION PAPER

Date: 09 August 2018

Author Kate Calvert, Service Planning & Integration Manager

Endorsed by Helene Carbonatto, General Manager, Strategy Planning & Outcomes

Reviewed/approved by Helene Carbonatto, General Manager, Strategy Planning & Outcomes

Subject Health of Older people

RECOMMENDATION

It is recommended that the CPHAC:

b)a) NOTES the Health of Older People update and the overview of key activities outlined in this report that serve to improve health of older people across the Hutt Valley.

c)b) NOTES the Healthy Ageing Forum is an active participant in ensuring that the Principles of Decision Making support the Vision of the HVDHB.

d)c) NOTES that the Health of Older People Dashboard indicates 6.6% of the 65+ population receives Home and Community Support Services. A further 5% of people aged 65+ are in Aged Residential Care.

APPENDUMS:

A. Older Persons Performance Dashboard

1. PURPOSE

The purpose of this paper is to provide the CPHAC with an overview of the programmes that support healthy ageing in the Hutt Valley region. The paper also includes a Health of Older Persons Performance Dashboard which provides a snap shot of performance in this area.

2. BACKGROUND

Our planning confirms a significant growth rate in our older population with at least 1 in 4 people being aged over 65 by 2040 (refer Figure 1).

2018 08 17 Hutt Valley CPHAC - Public - APPENDICES

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Figure 1 Growth on 2017 by age group, Hutt Valley DHB

There will be resulting demand for community, primary care, hospital, and residential care services as the clinical needs of this ageing population become more complex. It is essential for the HVDHB to focus their efforts on supporting healthy ageing to enable ‘older people to live well, age well, and have a respectful end of life in age-friendly communities’1.

3. STRATEGIC ALIGNMENT

The New Zealand Healthy Ageing Strategy was released in 2016 and provides a useful framework with five key outcome areas we can focus our actions on. Implementing the Healthy Ageing Strategy in the Hutt region is underway, with Figure 1 localizing each of the five key areas under that Strategy withalignment to Our Vision for Change that works to transform our health system and shift from high cost, reactive and bed-based care to a focus on wellness and healthcare that is preventative, proactive and closer to home.

Figure 1: Hutt Valley DHB Healthy Ageing Strategy – Work Programmes

Under the five elements of the Healthy Ageing Strategy, we are advancing the following:

3.1 Ageing Well

A range of services are in place to enable older people to continue to live in their own homes in their communities. These include:

∑ Implementation of the Pay Equity Legislation which has led to a framework for Support Workers to progress in their Support Worker carer. Level 4 trained Support Workers can provide care to complex clients in the home environment under the supervision of a Registered Nurse.

∑ Supporting carers through increased use of respite and day care.

1 Healthy Ageing Strategy, 2016.


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∑ Supporting GPs through: health pathways, healthcare communities, and the newly established healthcare home model.

∑ Funding small NGOs to provide face to face support to those in greatest need.∑ Home and Community Support Services that encourage restoration and independence through

the use of allied health and a well-trained support worker workforce.∑ Specialists providing more support in the community and to GP practices.∑ A national Falls Prevention Programme, Living Stronger for Longer, that provides in-home (one to

one) as well as community based Strength & Balance classes.∑ Proactive and mature Needs Assessment and Service Coordination agencies.∑ Residential village populations have grown. These living arrangements are able to support people

to live longer in their villa by addressing the problems of loneliness and insecurity. Both of these are significant factors in tipping the balance for people choosing to remain at home.

Falls Prevention and Management

The Hutt Valley is part of the 3 DHB Falls Management Model. Components of the model include proactive identification of falls risk (including medication review and the home environment assessment), notification of fractures due to falls and access to Strength and Balance classes that may be community based or provided one to one. A part-time Physiotherapist and full-time Allied Health Assistant have been recruited to provide the In-Home Strength and Balance Service for Hutt Valley clients. These roles are part of the Community Allied Health Team. The community based Strength and Balance Service is provided by accredited community providers and coordinated by Sport Wellington. Ensuring the classes are reaching vulnerable population groups is the focus for 2018/19.

Dementia

A strong focus has been placed on supporting Dementia Wellington in providing timely and accessible information and support to people living with dementia in the community. A steering group, including a supporter of a person living with dementia, a community advocate, Dementia Wellington, Wesley Community Action and a DHB Pacific Health Facilitator, has looked at socialisation opportunities in the Hutt Valley. Evidence informs us that people living with dementia want to continue to do the things that they have always done. An aspect of the work plan is to inform and guide a range of organisations and business to become dementia friendly. Included in the conversation are the two Hutt City Councils. These conversations are in their early stages. A 2 DHB meeting that focuses on the needs of Māori and Pacific people living with dementia is also contributing to the conversations. Information, dementia friendly café opportunities, dementia friendly golf days, a volunteer buddy course and cognitive stimulation therapy are all outputs of the group.

Dementia Day Care Programmes Review

A review of Dementia Day Care Service is underway. The Hutt Valley has 6 Aged Residential Providerswho are able to support people living with dementia in day care programmes funded by the DHB. OneARC provider is able to provide care in a secure setting. There is one non-residential provider who also provides day care. There are challenges with the current model if we align current services with the guidance outlined in the NZ Dementia Framework. Through a series of community based workshops,with People Living With Dementia (PLWD), their whanau and with service providers; we identified important advantages and key challenges with the current service model. The costs of some activities will be a barrier (e.g. transport costs) and knowing who the key person to communicate with is, regarding the PLWD is difficult. The facility worker is not available or unable to come to the phone. Care planning is minimal at day care programs so there is no sense of any changes in the illness over time. There is a need for families to be engaged. Day care does not support the needs of full-time working family members who are the informal carers of many living with dementia. There is no coordination between activities nor the value to ensure they are meaningful, physical and provide socialisation.


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The current support for PLWD is uncoordinated. There are pockets of good practice that, if rolled out,can provide a sustainable model of care as the ageing population increases. Day care does not support families who are providing care for their family member living with dementia while they need to work. Supporting the carers needs strengthening with advice about using respite regularly and not saving it up for a crisis. Flexibility in allocation of funding to individuals will support carers to continue to be able to look after their family member at home for longer. Carers need to be reassured about the quality of care and impact on their family member. Home care support based costs are less than the costs of residential care. Therefore, enabling clients to remain at home for as long as it is possible is the best use of resources.

3.2 Acute and Restorative Care

Community Health Services Integration

Community health Services Integration (and in particular reconfiguring our district nursing and allied health services to better respond to the needs of patients referred from the primary care team, as well as supporting improved hospital avoidance and early supported discharge) will support the reduction in acute hospital bed days and lead to better health outcomes for older patients. The early identification of risk of falls in primary care as well as a planned common use of a frailty tool will support preventative intervention sooner and closer to home in the older person age group. A consultant liaison model supports primary care access to geriatrician advice over the phone and is available out of hours. A further program of work to include a multi-disciplinary review of clients in Aged Residential Care is under consideration.

Medicine Service Improvement Plan

The early recognition of frailty in the ageing population by primary care or ED can prevent admission to hospital. The Medicine Service Improvement Project has a number of work streams. The Red2Green work stream is looking at improving how in-patients are discharged. The key is that a discharge date is set at the time of admission. The deconditioning of the older person on admission to hospital is fast, and delays in discharge increase the risk. So through the use of electronic whiteboards, identifying what is delaying a discharge will be identified. This includes the work of the Needs Assessment and Service Coordination Team who provide assessments for entry into care or for home care support services. Frailty is also being considered at ‘the front door’ of ED to identify this group of patients sooner. Key is the role of primary care to reduce ED admission by also implementing a frailty identification plan.

Home and Community Support Services

In preparation for our Home and Community Support Services Tender, we are engaging with both community and consumer stakeholders to better understand their views of the components of good service that would allow older person to remain independent in their own homes for as long as possible.

3.3. Living Well with Long Term Conditions

Health Pathways

Clinical Pathways providing electronic best practice for primary care are continuing to be developed and localised across the sub region. Over 360 pathways2 are now live, 12 pathway reviews have been completed, and multiple pathways are under development. Over the recent quarter, the Health Pathways Team have localised the following pathways:

2 Over 50 pathways have gone live throughout 2017/18 and we have met our Q4 target of 360 pathways.


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∑ Dyspepsia and Heartburn / GORD, Goitre in Adults, Thyroid Nodule, Ultrasound Thyroid, Thyroid Advice, Endocrinology Requests, Chronic Throat Irritation, Oral Ulceration, Oral Lesions, Dental and Oral Surgery, assessment for Adults, and Video Learning

Following a review of the Cognitive Impairment and Dementia Pathway, the most viewed pathway of HVDHB, there has been an increase in referrals to Dementia Wellington. Help and advice is being sought sooner, enabling access to a range of opportunities to supporting people living with dementia.

Health Navigator

The Health Navigator patient information website is in place across our sub region. This is a web based resource that supports the population to keep well, through providing a source of accurate health information, self-management guides and person centric support tools.

Melon Health

Following a review of self-management work, the project team investigated innovative digital self-management support options for patients with diabetes and long term conditions to address the gaps and opportunities identified (especially service gaps and equity issues for Māori and Pacific).

BetaMe was identified through this process and is an online, web based programme that includes peer support, education, health coaching as well as other medication reminders, health and symptom tracking. HVDHB has contracted with Melon Health who has developed this 16 week disease management programme for people with obesity, CVD, pre-diabetes and Type 2 diabetes.

Melon Health is working closely with TeAHN and Ropata Medial Centre to offer this digital health programme to the Hutt Valley population (with a focus on Māori and Pacific) for the next 12 months. This will be evaluated after 6 months to inform decisions about future investment in digital health programmes to support self-management.

3.4 Support for People with High and Complex Needs

Health Care Home

Part of the work underway in Health Care Home is ensuring the implementation of the ‘year of care’ for those identified as at risk. Using a risk stratification indicator with the populations of the Health Care Home Practices, the group with the most complex needs with be provided with proactive care planning.This work is aligning with our Palliative Care Project, which is now also linking in Older persons expertise at Inter-disciplinary meetings when reviewing dying patients who also have age related issues like frailty, dementia and loss of function.

Clinical Support for residential care staff

There is an ongoing programme of training and support delivered to residential care staff (nurses and caregivers) to strengthen knowledge and expertise to enable the management of residents with high and complex needs. This includes Nurse Practitioners from the Older Persons team with expertise in physicaland mental health undertaking case reviews and education sessions monthly at residential facilities. Reviews often identify gaps in knowledge as well as quality improvement opportunities. They are now delivering this programme in 13 facilities. Nursing education and support is also available from Te Omanga Hospice to enable staff to care and support those residents at the end of life. These nurses are also available for any clinical advice and support that might be needed.


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Additional support and guidance from specialist doctors is also available from the gerontology team and Te Omanga Hospice via phone for any facility doctors or nurse managers to support the clinical management of residents presenting with complex needs.

3.5 Respectful end of life

Work is well underway to implement our Palliative Care Strategy, and in particular broadening the scope of reconfiguration of how Hospice supports primary care, residential care, and the hospital; to better support those with palliative needs earlier in their journey. This is the subject of a separate paper to the CPHAC in this same agenda.

4. THE HEALTHY AGEING FORUM

The Alliance Leadership Team (ALT also known as Hutt INC) governs the integration work programme and is committed to improving the care and health for older people in the Hutt Valley. In 2017, the ALT endorsed the establishment of a forum that was primarily focused on the needs of our older population to support healthy ageing. This would complement other networks and better align projects within the integration work programme. Given the number of change programmes already underway, it is essential that we focus our efforts on enhancing and embedding the current work programme, alongside communicating, sharing learnings and strengthening input and linkages across agencies/services within our health system.

The Hutt Valley Healthy Ageing Forum aims to bring together clinicians, managers and community members from across health and social services. The purpose is to share information, collaborate and seek input to successfully implement work currently underway in the older person’s health area. This Forum will be held twice annually and enables the Healthy Ageing Strategy implementation in the Hutt Valley.

The first forum was held on June 19th 2018 and was attended by approximately thirty people. The attendees included local GPs, PHOs, Home Care & Support Service providers, Aged Residential Care Managers, City Council representation, NGO’s and Hutt Hospital based clinicians. The presentations include the 3 DHB Falls Prevention Model and its local implementation as well as an example of how hospital based clinicians are incorporating Advanced Care Planning as part of their regular work. The example focused on cardiac patients for whom their diagnosis can lead to a sudden deterioration in health.

The event provided stimulating questions. The awareness for a whole population approach to ensure the prevention of disease and deconditioning as the population travels through the life span is required to keep people well and in their communities. The need to understand what older people want to enable them to stay engaged was asked. A further issue was the need to continue to strengthen how hospital and community services link to support older people to stay safely in their homes. The next Forum will be held in November.

5. OLDER PERSONS SERVICES PERFORMANCE DASHBOARD

In order to better understand our investment and outcomes to support older people, a performancedashboard has been developed and is attached as appendix one.

It tells the story of the Hutt Valley older population, its current utilisation of acute services and visits to primary care. The dashboard illustrates that despite living with long term conditions, home based support services are enabling a large group to continue to live at home. Day programmes and respite care support informal carers to continue ‘to care’. Five per cent of the over 65 age group are currently in Aged Residential Care, though the number of people in aged care has reduced as more people stay supported in their own homes for longer.


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The first section of the chart provides further information on the rate of growth of the older age group and the ethnic breakdown.

∑ Health of Older People in Hutt Valley, the population aged over 65∑ A breakdown of the over 55+ age group by ethnicity.∑ Two charts indicating the numbers and growth in the over 65 age group between 2018 -2030

Key points to note are:∑ ED utilisation by older persons remains static, with about 55% of ED visits by people aged 75

years and over.∑ Acute beds days for older people has reduced over the last few years, showing the value of

supports we have in the community for this group to allow them to return home faster and the concerted efforts by the system to move people through the system quicker

∑ At 85 years there are more people in ARC than who are receiving home care and support services. The number of new people entering ARC is slowly reducing.

∑ 5% of the total Hutt population of those aged over 65 years are in Aged Residential Care.∑ The number of subsidised beds has decreased as there is no current high demand despite

increased numbers of people over 75 entering ARC.∑ In the Home and Community Support section of the Dashboard, there is an increase in the

number of clients staying at home with supports – with nearly 50% of clients receiving an hour of supports a week, with a further 28% receiving between 2-4 hours per week.

∑ Day care, carer support and respite care is increasing to support more individuals.∑ As more individuals choose to stay in their own homes for longer, it is expected that this group

of carer supporting activities will increase.∑ There is an increase in the number of visits to the GP and Practice Nurse in the 65+ years age

group, visits still remain higher for Māori clients

6. OPERATIONAL FOCUS

6.1 Aged Residential Services

Part of our management of the older person’s portfolio is the significant oversight of our aged care facilities. We currently have 15 facilities in our district, with a further two facilities looking to establish themselves in the next two years. We spend $37,297,000 per annum on aged care services, including $253,500 for respite services and $361,000 on day care services.

There are contractual and legislative controls regarding the cost of care in a residential facility. Quality of care is expected to be the same regardless of the person’s financial status. Contractually, residents must have the choice of whether they wish to pay additional charges relating to their accommodation.

Aged residential care services are provided at different levels of care:∑ Rest Home - people can do some daily tasks themselves but cannot manage safely at home. (e.g.

need help during the night)∑ Continuing Care – as above and requires a higher level of resource (e.g. immobile and requires

specialist equipment and registered nurse oversight, and clinical input)∑ Dementia – requires a secure environment (e.g. person wanders and becomes lost)∑ Specialised Hospital Services (Psychogeriatric) – requires a high level of staffing resources for

people with a very high level of dementia or challenging behaviour within a secure environment.

Entry into long term residential care is based on peoples’ long term support needs. For a person to receive DHB subsidised care, they must meet income and asset limits as assessed by Work and Income. People may be assessed as eligible to be admitted into aged residential care but choose to remain at home.


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The average age of admission to residential care has increased from 82 to 84 years since 2011. This reflects good availability of home-based support services that allow people to remain in their own homes longer. Most of the time services work very well for the people being cared for but sometimes people don’t get the care they need, in terms of both timing and intensity.

Aged care facilities are monitored in numerous ways including the following:

Certification

∑ All facilities are audited by a Designated Auditing Authority (DAA) for certification. ∑ Certification can be between one and four years.∑ Facilities have a surveillance audit half way between their certification periods. This is an

unannounced audit. Therefore, if a facility has a three year certification they are audited every 18 months.

The audit is based on the Health and Disability Sector Standards and the Aged Residential Services Agreement. The standards include: Consumer rights, Organisational Management, Continuum of Service delivery, Safe and Appropriate Environment, Restraint Minimisation and Infection Protection and Control. Without certification a facility is not be able to hold a contract with the DHB.

Provisional Audits

Prospective providers undergo a provisional audit to establish the level of preparedness to provide a health and disability service and conformity prior to a facility being purchased or developed. Partial provisional audits are undertaken to establish the level of preparedness of a certified provider to provide a new health and disability service. Both provisional and partial provisional audits are for a maximum of one year. All of the above audits are publically available on the MoH website.

Claims Audit

Claims audits are undertaken randomly unless specifically requested by the DHB to assess a provider financial compliance.

Certification Periods

As at August 2018, HVDHB has 100% of the ARC facilities with three or more year’s accreditation. The maximum 4 year certification period requires the facility to have no or very few low risk corrective actions and to have been commended for quality and care initiatives. We have 3 facilities with the highest certification period of 4 years (March 2018).

Monitoring Corrective Actions Arising from an Audit

DHBs work with the facilities once an audit has been undertaken, agreeing a plan to address all corrective actions and monitor compliance with the plan. This approach works well.

It enables the DHBs to:• Identify those facilities that could gain the most benefit from additional quality improvement inputs

such as Nurse Practitioner (or other) led education sessions. Other learning and development opportunities have been developed in each DHB to support ARC facilities. CCDHB employs a PDRP and District Nurses for their input to support up-skilling within ARC teams. The Older People Nurse Practitioners and the Director of Nursing Community have significant input into ARC facilities.

• Monitor the progress against the corrective actions and share examples of good practice.• Maintain and strengthen relationship between the facility and the DHB.

6.2 Non-Government Organisations (NGOs)


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Services provided by the smaller NGOs are invaluable to improving the quality of life for those elderly who require support to live at home. They are acknowledged within the Healthy Ageing Strategy (2016) as instrumental in enabling people to stay independent, connected and respected. Some are funded directly by the DHBs, and others are national organisations funded via the Ministry of Health.

Most of the NGOs meet regularly with the Needs Assessment and Service Coordination Agency and the DHBs.NGOs are funded by the Hutt Valley DHB to support older people in the community.

∑ Wesley Community Action Supported Independent Living (SIL) ContractThis assists those who are very vulnerable living at home due to isolation, lack of natural supports and social issues. The range of support is wide and includes managing hoarding, budgeting, isolation, and addictions. The service providers accept referrals from the Needs Assessment and Service Coordination (NASC) Agency and provide reports to the DHB.

∑ Dementia Wellington (previously known as Alzheimer’s Wellington)Dementia Wellington has a schedule of advice sessions to raise awareness of the issues of living with dementia. For people living with dementia and their supporters they provide a two day courses aimed at newly diagnosed people living with dementia. Dementia Educators (Registered Nurses or Social Workers) visit people with dementia and their supporters at home. This ensures that they are well aware of what support is available. They also provide social interaction through community based, dementia friendly activities. Cognitive Stimulation Therapy can be provided when funding allows and includes music therapy.

They are fully engaged in educating health professionals on the dementia pathway and advocating forits use and full implementation. They accept self-referrals and provide reports to the DHB’s Health of the Older Person Portfolio Manager. The DHB contributes approximately 25% of the costs of the service with grants, private donations, and fundraising which contribute to service delivery

∑ Accredited Visiting ServiceThis is a national service provided by Age Concern with funding provided by DHBs. In the Hutt Valley there has been a change in manager and the number of people being visited at home by volunteers has increased. This is a well-respected service that matches volunteers to older people who are isolated and/or lonely.

∑ Kokiri Marae Kaumatua Support ServicesThe role of the Kaumatua service is to assist in improving the welling of Māori Kaumatua enhancing their health status. Information and contacts are provided to gain confidence to access health services that contribute to a healthier lifestyle. Examples of support include improving access to health services through access to transport, supporting visits to hearing services, GP and specialist appointments as well as group opportunities to support physical activities such as swimming.

∑ Parkinson’s, Arthritis and Stroke Support ServicesWhilst not specific to the elderly, these NGOs offer field worker support to those with the illness and their carers. They provide education, navigation of services and individualised support. This is funded through regional and national contracts.

6.3 Carer Support

The role of informal carers in enabling older people to stay at home in their communities is critical. However, through InterRAI assessments the pressure on carers has been measured. Carers who are not supported or unaware of services that can be provided may choose to transfer their care to that of an aged residential care facility, earlier than was necessary. Providing respite day services or volunteer buddy services, carer support groups can support this group of informal workers. The DHB funds 3 dedicated


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respite beds that can be booked in advance through the Needs Assessment and Care Coordination Service. Carers need support to use respite regularly to prevent a negative impact on their own wellbeing needs.

6.4 Home & Community Support (HCSS)

The Home and Community Support Service sector for people over 65 years of age is a bulk funded, single provider (Access) , restorative services approach that has been in place in both HVDHB and CCDHB since 2016. This service has quality targets to meet and incentives to enable people to do as much of their daily living activities as they can. Weekly and quarterly monitoring and Key Performance Indicator attainment have enabled reassurance to both DHBs that a satisfactory service has been provided.

In July 2018, the Boards of Hutt Valley and Capital Coast Health DHBs posted their intention to issue a tender for home and community support services for people over 65 years of age on the Government Electronic Tender Site (GETS). A Request for Tender will occur early September 2018, with services in place from 1 April 2019. This is a planned, mutual and amicable decision with Access Community Health Services to go back to the market.

The DHBs are generally pleased with the quality of service provided by Access Community Health, which has worked hard to meet the needs of our clients and grow a professional and skilled workforce and service. While circumstances such as the impact of pay equity have played a role in this mutual decision, all parties concluded that offering some choice of provider better suits the needs of clients who want to live independently in their homes for as long as possible. For the time being, nothing will change and clients will continue to receive services from Access Community Health until 1 April 2019. Stakeholder meetings are being held in August 2018.

6.5 NASC Services

The Needs Assessment & Care Coordination Service is mandated to work with people in need of care, and their families, to identify support needs and determine eligibility for ministry funded support services. As well as supporting those with chronic health conditions and age related health issues, there are separate NASC services supporting people with disabilities and diagnosed mental health conditions who also require additional support.

The Hutt Valley NASC (also known as Care Coordination) is provided by Nurse Maude. The service has strong relationships with primary care, the hospital teams and community organisations in the Hutt Valley.


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Health of Older

People

22,420

Upper Hutt 32% 7,097

Lower Hutt 68% 15,323

15% of HVDHB are age 65+

-

5,000

10,000

15,000

20,000

55-64 65-74 75-84 85+

People aged 55+ in HVDHB 2018/19

Other Asian Pacific Maori

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

20

18

/19

20

19

/20

20

20

/21

20

21

/22

20

22

/23

20

23

/24

20

24

/25

20

25

/26

20

26

/27

20

27

/28

20

28

/29

20

29

/30

20

30

/31

Number of people in older population

65+ 75+ 85+

0%

1%

2%

3%

4%

5%

6%

7%

8%

20

18

/19

20

19

/20

20

20

/21

20

21

/22

20

22

/23

20

23

/24

20

24

/25

20

25

/26

20

26

/27

20

27

/28

20

28

/29

20

29

/30

20

30

/31

% Growth in older population each year

65+ 75+ 85+

Maori aged 55+ 3,520 13% of Maori people

Pacific aged 55+ 1,780 15% of Pacific people

Asian aged 55+ 3,980 22% of Asian people

Acute Service Utilisation

0%

5%

10%

15%

YE Mar 16 YE Mar 17 YE Mar 18

Standardised 28 day Readmit rate - Age 75+

Hutt National

55% 57% 58% 56%

0%

20%

40%

60%

80%

0

2000

4000

6000

2014/15 2015/16 2016/17 2017/18

% a

dm

itte

d

nu

mb

er

of

visi

ts

Total ED visits aged 75+

Total visits Total admitted % admitted

384 357 402 386 413 389

0

10

20

30

40

50

60

0

100

200

300

400

500

2012/13 2014/15 2016/17

pe

r 1

00

0 a

ge

d 7

5+

pe

op

le

New people entering ARC

(subsidised and unsubsidised)

people rate per 1000 people aged 75+

0

1000

2000

3000

4000

65 to 69 70 to 74 75 to 79 80 to 84 85+

Acute beddays per 1000 people

YE Mar 16 YE Mar 17 YE Mar 18

Primary Care Home & Community Support Age Residential Care

145

8.2

0

25

50

75

100

125

150

5

6

7

8

9

2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Vis

its

-Th

ou

san

ds

vis

its

pe

r p

ers

on

GP & Nurse visits per enrolled person aged 65+

provided by Te AHN practices

number of visits to GP/Nurse 65 and over

10

88

5

6

7

8

9

10

20

11

/12

20

12

/13

20

13

/14

20

14

/15

20

15

/16

20

16

/17

20

17

/18

GP&Nurse visits per person aged 65+

at TeAHN practices by ethnicity

Maori Pacific Other

0%

10%

20%

30%

<65 65-69 70-74 75-79 80-84 85-89 90+

HVDHB ARC & HCSS clients by age

Jun 2016

ARC HCSS

Older people living well will need less of these services

People aged 65+ 21,140

Maori aged 55+ 3,209

Pacific aged 55+ 1,843

May include non Hutt Residents

Enrolled with a Hutt GP

(TeAHN & Ropata) Jul 18

2017/18 - $000 Actual Budget Variance

Home Based SS (incl travel) 16,005$ 15,643$ -$362

Carer Support 163$ 164$ $2

Day Programmes 437$ 361$ -$76

Respite Care 1,072$ 895$ -$177

2017/18 - $000 Actual Budget Variance

Continuing Care & Psychogeri 17,715$ 19,250$ $1,535

Rest Home & Dementia 11,360$ 12,310$ $950

IDF Outflow 4,599$ 4,317$ -$282

0.5-1

48%

2 - 4

29%

5 - 6

10%

7 - 11

11%

12 +

2%

HCSS Clients by Avg Weekly

Hours received 2017/18

343 396 418 420 468

0

5000

10000

15000

20000

0

500

nu

mb

er

of

da

ys

nu

mb

er

of

pe

op

le

Supporting Carers

with Day Care, Carer Support & Respite

unique clients using any service

CS DC Respite days

25

3

1931 1878 1906 1917 1987 2035 2056 1979 1922

0

100

200

300

400

500

-

500

1,000

1,500

2,000

2,500

20

09

/10

20

10

/11

20

11

/12

20

12

/13

20

13

/14

20

14

/15

20

15

/16

20

16

/17

20

17

/18

nu

mb

er

of

ho

urs

-T

ho

usa

nd

s

nu

mb

er

of

clie

nts

Clients receiving HCSS & Hours

Total hours Total clients YTD

People aged 65+ in ARC (June 2018) 5%

Ave no. years receiving DHB ARC

subsidy (Jun16)2.2

number of ARC facilities in HVDHB 15

Rest Home beds 333

Dementia beds 153

Psychogeriatric beds 46

Continuing Care beds 95

RH/Continuing Care swing beds 532

Total beds 1159

0

5,000

10,000

0

250

500

750

1000

20

09

/10

20

10

/11

20

11

/12

20

12

/13

20

13

/14

20

14

/15

20

15

/16

20

16

/17

20

17

/18

tota

l n

um

be

r o

f p

eo

ple

ag

ed

75

+

be

ds

sub

isid

ise

d i

n A

RC

Avg Subsidised beds vs population aged 75+

Total subsidised beds number of people aged 75+

575

396

53

201

0

200

400

600

800

20

09

/10

20

10

/11

20

11

/12

20

12

/13

20

13

/14

20

14

/15

20

15

/16

20

16

/17

20

17

/18

Nu

mb

er

of

clie

nts

Subsidised Clients by level of ARC

Continuing

Care

Rest home

Psychogeriatric

Dementia

-

10,000

20,000

30,000

2015/2016 2016/2017 2017/2018

Community Nursing Age 65+

DOM101 Professional Services

DOM107 Personal Care (Hours)

-

2,000

4,000

6,000

8,000

10,000

2014/15 2015/16 2016/17 2017/18

Older Persons Rehab Bed days

ATR Psychogeriatric


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Date: 6 August 2018

Author Jazz Heer, Service Development Manager, Strategy Planning & Outcomes


Reviewed Alliance Leadership Team (Hutt INC)

Subject Hutt Valley Palliative Care Project

RECOMMENDATION

It is recommended that CPHAC:

a) NOTES the Palliative Care Project update and the overview of key developments to date outlined in this report that work to improve palliative care provision across the Hutt Valley.

b) PROVIDE feedback on the current approach.

APPENDUM

LIVING WELL, DYING WELL

1. PURPOSE

The purpose of this paper is to update CPHAC on the progress of the Hutt Valley Palliative Care Project to implement the 3DHB Palliative Care strategy Living Well, Dying Well (refer Appendix 1). Hutt Valley DHB staff were integral to developing this Strategy in 2016.

2. BACKGROUND TO HUTT VALLEY PALLIATIVE CARE PROJECT

The 3DHB Palliative Care Strategy Living Well, Dying Well is currently being implemented locally in the Hutt Valley through the Alliance Leadership Team. This commenced in September 2017 and works to achieve the following key objectives:

∑ Understand the current palliative care patient journey - identify any gaps/duplications and what is working well.

∑ Develop a consistent palliative care pathway - implement strategies to improve the coordination and integration of services and to enhance best practice.

∑ Consolidate one comprehensive assessment/care planning tool and process.∑ Define and develop a ‘single point’ of service facilitation and access for palliative care patients,

re-aligning resources to match this new service specification.

This work focussed on working with a number of vanguard sites to test and pilot new models of care across the system to support the palliative care patient journey. Learning is being incorporated to roll out to embed new models of care and best practice across the palliative care system through further service development at other practices/facilities in the future.


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3. STRATEGIC ALIGNMENT

Improving palliative care services also aligns with the strategic objectives of Our Vision for Change which include supporting palliative patients to live well and die well, shifting care so that it can be delivered closer to home and ensuring our patients/whanau/families experience shorter, safer and smoother care. Integrating the components of care across services is a cornerstone of Living Well, Dying Well.

This project also focuses on ensuring the development of a skilled and competent workforce and takes advantage of the growing technological developments that can help build an infrastructure that enables more effective communication to support individualised care planning. There is an equity focus to the Strategy, linking hospice staff with community providers better and ensuring Maori and Pacific patients receive culturally appropriate services.

This work is also well aligned to government priorities, through implementing the core palliative care components of the Healthy Ageing Strategy as well as the Ministry of Health’s Palliative Care Action Plan.

4. IMPROVING PALLIATIVE CARE IN 7 VANGUARD SITES

This project has involved Te Omanga working with the following General Practice vanguard sites:• Ropata Medical Centre• Whai Oranga• Muritai Health Centre• Upper Hutt Health Centre

Further rollout of this work has also included Hutt City Health Centre, Queen Street Medical Centre and Gain Health.

The following Residential Care Facilities have also been involved in this project:• Home of Compassion/ St Josephs, Upper Hutt• Enliven, Woburn• Fergusson, BUPA, Upper Hutt

4.1 General Practice Vanguard Sites

The work to date across the 4 GP vanguard sites has involved:

Supporting the identification of palliative care patients∑ Embedding the palliative care planning claims process, encouraging use of an agreed template, as well

as simplifying and promoting claiming for general practice (Hospice Innovations funded).∑ Promoting SPICT (Supportive and Palliative Care Indicators tool) to identify appropriate patients to put

on the palliative care pathway.∑ Linking general practice teams with the collaborative care clinics between Cardiology and the Hospital

Palliative Care Team, where the team is undertaking monthly clinics to review and plan palliative/end of life care with patients with end stage heart failure.

Supporting the review and planning of palliative care patients∑ Developing a register of palliative care patients at each of the general practice vanguard sites.∑ Applying Gold Standards Framework coding to determine need/demand and plan care and support.∑ Embedding model of specialist support to primary care (Hospice Primary Care Liaison Team – Hospice

Innovations funded).


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∑ Undertaking Inter-Disciplinary Team (IDT) meetings to plan and coordinate care. IDT membership includes general practice team, Needs Assessment and Service Coordination (NASC) team, Community Health (district nursing) team, hospice community nurse, oncology nurse, primary care liaison team which includes Hospice OT and Hospice social worker as well as Nurse Practitioner/CNS. A recentaddition to these meetings is a nurse practitioner with older persons (physical and mental) health expertise.

∑ Nurse Practitioner clinics at general practice to assess and review patients, often in partnership with GPs, practice nurses, as well as their carers/whanau.

∑ Ambulance management plans for palliative care patients including refining the management plan template and putting in place a Memorandum of Understanding between ambulance and the practice.

∑ Supporting more immediate provision of Occupational Therapy assessment from Hospice, including access to adaptations/equipment if needed.

Supporting the integration of specialist palliative care services ∑ Relationships and collaborations have been strengthened through IDTs and related pieces of work

with District Nursing, NASC, and hospital complex discharge teams.

Improving quality by building capability in general practice∑ Wider roll out of link nurse training programme (Hospice Innovations funded) across primary palliative

care providers (district nurses, practice nurses and residential care facility nurses) – priority has been given to staff from our vanguard sites but this is also available for any nurse in the Hutt Valley. Organisations receive funding for staff backfill to release staff to undertake this free week long training programme.

∑ Provision of one on one training from Hospices Primary Care Liaison team.∑ Specialist Hospice doctor/NP training sessions with general practice teams.

Shared Learnings of GP Vanguard Sites – Key themesA recent GP Peer Forum including representatives from the vanguard sites was held. This identified significant benefits from the project especially strengthened relationships and communications between Hospice, primary care and other external providers (e.g. NASC, Wellington Blood and Cancer centre and HVDHB District Nursing team). Challenges were also identified including: issues with the claiming system, the wide variation across general practice expectations, knowledge, training and experience in palliative care as well as the complexity of patients’ needs. Many opportunities to improve these issues were explored which included a review of funding arrangements, additional training opportunities and clarity about admission criteria and roles and responsibilities across services.

4.2 Residential Care Facility Vanguard Sites

Work across the 3 Residential Care Facility vanguard sites has included:

Improving the respite/short term care pathway∑ Reviewing terminology to refer patients discharged from hospital to residential care – changing from

“respite” to “short term care to assess long term support needs”.∑ Improving processes/documentation to support the transition of palliative care patients to Residential

Care Facilities on short term packages (whether this is from hospital or direct from the patient’s home).

Supporting access to concerto∑ A trial to support Residential Care Facilities clinical nurse managers to access the hospital management

system to review residents’ history. Currently on hold awaiting for one click solution to be developed through the 3 DHB Information Management Alliance work programme.


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Improving quality and building capability in Residential Care Facilities∑ Raising awareness and encouraging access to primary care clinical Health Pathways for clinical nurse

managers at residential care facilities∑ Strengthening support from Hospice and gerontology – including case review and mentorship

programme.∑ Embedding the link nurse training programme (Hospice Innovations funded) – as with GP vanguard

sites above.∑ Promoting uptake of advance care planning.∑ Developing a process to identify and plan for residents with increasing palliative needs.

5. WIDER WORK ACROSS THE PALLIATIVE CARE SYSTEM

5.1 Links with Advanced Care Planning

The Palliative care Project has also included supporting the wider implementation of advanced care planning at each of the 7 vanguard sites, including: Promoting advanced care planning uptake through:

1. Growing awareness.2. Encouraging training – there has been an increased uptake of e-learning for advanced care planning

training across the vanguard sites. Education sessions delivered to clinical teams at a few of the vanguard sites have also proved successful in increasing understanding and awareness.

3. Improving processes/pathways for identifying appropriate patients to have advanced care planning conversations with, recording different levels of advanced care planning conversations, and developing processes to share these on patient management systems and with other key professionals/services.

5.2 Supporting a review of current model of care for Hospice

Work at the vanguard sites, especially at the general practice sites, is informing a review of the specialist care/hospice service provision. There is an increased understanding of the model of care that is needed to support primary care palliative care providers. This includes considering the service needed to support the after-hours management of patients in the community. Hospice is working closely with the DHB, in consultation with our primary care partners to identify solutions and reconfigure services. Funding has also been set aside to support this development and any change management that might be needed for hospice personnel.

5.3 IT infrastructure to support the identification, review and management of palliative care patients in primary care

General practice have also identified the need for additional support to enable them to compile and manage an accurate register of their palliative care patients. There is an opportunity to invest in IT support to develop the infrastructure to enable the identification, review and management of enrolled patients, as well as to improve the process for accessing claims by primary care providers. TeAHN had engaged with Datacraft to potentially drive a project to test a proposed solution at the vanguard sites. This could enable the development of a palliative care dashboard for the Hutt Valley which would identify the details of all enrolled patients with a palliative care need.

5.4 Linking Hospice Innovations Funding and LTC Practice Planning Funding

There is an opportunity for a wider review of the financial arrangements for both the Hospice Innovations Funding (funding up to $400 per patient that GPs can claim to plan/support/care for their palliative patients) and Long Term Conditions Practice Plan Funding. General Practice have indicated that it is their Long Term Conditions population of patients and their frail elderly population that are in need of a palliative care approach, especially as their condition and function deteriorates. TeAHN (in conjunction with the Hospice Innovations Steering Group) are undertaking a review of the financial arrangements to clarify and consider how the provisions can be developed to offer more flexibility for practices.


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5.5 Project to implement Te Ara Whakapiri (End of Life Care) guidelines at Hutt Hospital

A project has begun to support the implementation of Te Ara Whakapiri in the Medical Ward at Hutt Hospital. Te Ara Whakapiri are principles and guidance for the last days of life outlining the essential components and considerations required to promote quality care at the end of life for all adults in New Zealand. These guidelines involves dedicated resource from a Hospice Clinical Nurse Specialist to educate and support staff over 3 months to align documentation and processes with these recommended guidelines. Work to support the implementation of these guidelines for other primary palliative care providers (i.e. general practice and Residential care) is also underway through the work at the vanguard sites.

5.6 3 DHB Health Pathways work

This 3 DHB project is also informing work to develop a localised palliative care patient pathway which will clearly document the pathway for patients identified as having a palliative care need to support primary care palliative care providers.


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Date: 06 August 2018

Author Jazz Heer, Service Development Manager, Strategy Planning & Outcomes


Reviewed/approved by Alliance Leadership Team (Hutt INC)

Subject Advance Care Planning priorities 2018/2019

RECOMMENDATION


a) NOTES this update on the Advance Care Planning priorities for the Hutt Valley in 2018/2019.

b) PROVIDE feedback on the current approach.

1. PURPOSE

The purpose of this paper is to update CPHAC on the priorities for 2018/2019 to support the wider implementation and uptake of advance care planning across the Hutt Valley.

2. BACKGROUND

Implementation of Advance Care Planning (ACP) across the 3DHBs is overseen by the ACP Steering Group who are progressing a programme of work that is related to activities to develop the following components of this project:

∑ Raising awareness and wider communication and training; and ∑ Baseline current practice, training and intensive implementation of ACP in Hutt Valley vanguard

sites

3. STRATEGIC DIRECTION

This project aligns with the strategic objectives of Our Vision for Change which include supporting all patients to live well and ensuring patients/whanau/families experience shorter, safer and smoother care. By ensuring that as many people across the Hutt Valley can start thinking about their end-of-life stage before they get there, and think about having an ACP signalling their wishes so that families/carers/health professionals can make complex medical decisions on their behalf and help ensure that an individual’s wishes are honoured and respected at times of medical crisis.

There is a strong learning and workforce development component to ACP and therefore this project also addresses our strategic workforce enabler – an adaptable workforce – by focusing on developing a skilled and competent workforce to have early conversations.

Advanced Care Planning is also identified as a government priority through the Healthy Ageing Strategy.


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4. LOCAL ADVANCED CARE PLANNING PRIORITIES FOR 2018/19

1. Strengthen ACP training programmes to build local workforce capability and capacity

Training has previously been offered by the national ACP group. However there have been challenges getting adequate uptake of the training programmes across the sub region to date due to the length of the training programme. As a result, a programme to identify a pool of locally trained facilitators to deliver ACP training is currently being progressed to allow greater flexibility and access to training across the subregion.

Recruitment is underway to train 6 facilitators across the sub-region from a range of organisations including general practice, residential care, and hospital and community service providers. It is anticipated that these facilitators will deliver up to 9 workshops per annum across the sub-region, with 2-3 of these held in the Hutt Valley.

Priority for 18/19:∑ Support the improved training approach for the subregion, which will include local Hutt Valley

facilitators delivering training in the Hutt Valley. ∑ Consider options for improving uptake of virtual and electronic training modules.

2. Supporting General Practices to proactively identify and support people to discuss and complete Advance Care Plans.

General practice teams are pivotal in supporting people to discuss and develop ACPs. It has been highlighted that a nurse led model with GP support would be a more sustainable model for general practice going forward. This will be investigated and progressed in the Hutt Valley alongside the roll out of Health Care Home (through the risk stratification/year of care elements) and the existing Te AHN Long Term Conditions programme.

Priority for 18/19:∑ Strengthen the implementation of ACP in primary care initially focusing on the palliative care

vanguard sites (ARC and general practices).∑ Consider utilising HCH and LTC programme mechanisms for developing and implementing an ACP

model of care in General Practice.∑ Expand the roll out beyond the vanguard sites and establish ACP champions in each General Practice

team across the Hutt Valley over next 1-3 years.

3. Coding and reporting ACP activity in General Practice

Compass Health PHO now have data demonstrating the increase of ACP activity over time in general practices, though there is currently limited read coding and data available in the Hutt Valley.

Priority for 18/19:∑ Work with TeAHN and Cosine PHOs and general practices to establish ACP coding in primary care in

the Hutt Valley and develop regular reporting on ACP activity and the completion of Advanced Care Plans1.

1 Note the transition to Indici and the use of Snowmed coding will also need to be considered across the subregion in the longer term.


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4. Engaging Māori and Pacific with advance care planning

The ACP programme needs to be implemented with a focus on equity. There is an opportunity to work with Māori and Pacific health practitioners and leaders in Hutt Valley to engage with whanau/fanau to strengthen the focus on advance care planning in the Maori and Pacific community.

Priority for 18/19:∑ Work with Hutt Valley Maori and Pacific Health leads to develop an approach and plan for

strengthening the awareness and use of Advanced Care Plans with the local Maori and Pacific Community in the Hutt Valley.

5. Investigate the development of a dynamic electronic Advanced Care Plan

Waikato have developed an IT solution for documenting ACPs that meets requirements of a ‘live’ document being available to the person themselves (via Manage My Health) and their healthcare providers the primary and secondary health care records. Developing a similar solution in the 3DHBs is the highest priority for providing the infrastructure required to enable ‘safe’ communication of advance care plans. This needs to beinvestigated alongside the Information Management Alliance work programme and the Indici (a primary care patient management system) shared care planning tool.

Priority for 18/19:∑ Investigate options for a dynamic electronic ACP across the subregion through the 3DHB Information

Management Alliance work programme (including linkages to the Indici shared care planning tool).


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LIVING WELL, DYING WELL

A Strategy for a Palliative Care Approach

2017 – 2020

In partnership with


27

In partnership with


28

Living Well, Dying Well

1

A Strategy for a Palliative Care Approach (Wellington, Hutt Valley and Wairarapa DHBs)

Many people have been involved in the development of this strategy document, which represents the passion of the people, whānau, consumers and community leaders who have given it the highest level of importance for the future provision of palliative care services. It is a result of the collaborative effort of the Lower North Island Palliative Care Managed Clinical Network engaging with many stakeholders, including consumers, across Wellington, Hutt Valley and Wairarapa districts. There is no single author – we are all contributors and accountable to advancing a common vision through our individual and collective actions.

It sets the direction of palliative care in the sub-region to improve the experience for people, whānau and their communities. The document focuses on a palliative care approach and how to better understand and respond to people’s needs.

This strategic plan is specifically aimed at meeting the needs of all people who would benefit from a palliative approach. Over the next couple of decades New Zealand will see a dramatic change in the patterns of life, disease, dying and death. There will be more people dying each year; people will be dying at older ages and with a range of more chronic conditions and frailty. This increasing and changing demand has wide reaching implications for our wider society and health system, but especially our palliative care system.

Services do an excellent job of providing specialist palliative care – and this plan supports sustaining specialist palliative care – but we need to do a much better job of providing coordinated and individualised care for the large and growing number of patients for whom a palliative approach would be beneficial. This groups of patients, which is projected to increase by 60% in 2036, have not been in the forefront of our minds in planning palliative care services – and it is this group of patients whose needs this plan is principally intended to address.

The themes of the refreshed NZ Health Strategy (April 2016) were used to inform this strategy and are embedded in this document. People powered, care closer to home, value and high performance, one team and smart systems are all key drivers.

The ultimate goal of this palliative care strategy is for greater system integration that puts the patient and their whānau at the core of every decision that is made.

It represents a common consensus on a vision for palliative care across the sub-region and outlines the steps we need to take together to make that vision a reality. Members of the network will all use this document as a framework to engage more broadly with our colleagues and stakeholders to inform and implement change.

Foreword

Adri Isbister Project Sponsor, Chief Executive, Wairarapa DHB


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2



30


3


Foreword 1

Section1: Background and Context 4

Introduction 4

Methodology 5

What is Palliative Care? 5

Supporting an Integrated Model of Palliative Care 6

Future Demand for Palliative Care 9

Ageing population and increased need 11

Palliative Care for Māori 12

Palliative Care for Diverse Cultural Groups 13

Our Current Palliative Care Services 13

Advance Care Planning 15

A Future Model of Palliative Care – a new way of working 15

Seamless and holistic patient care 16

Service provision is based on need 16

One integrated care team 16

Led by primary care 17

Supported by specialists in palliative care 17

Clearly defined roles and responsibilities 17

Section 2: Vision, principles and goals 18

Our Vision – Te Aho 18

Principles 18

Goals 18

Goal 1: Patients and their whānau have timely identification that end of life is approaching, and early discussions to ensure they make informed choices about what, where and how they receive care and support (Self Management) 19

Goal 2: Patients and their whānau receive coordinated assessment, care planning and review throughout their palliative care journey (Planning) 22

Goal 3: Patients and their whānau experience equitable and seamless care through coordinated service provision (Integration) 24

Goal 4: High quality sustainable services are delivered (Quality) 26

Goal 5: Care in the last days of life is comprehensive, with good symptom control, is in the most appropriate setting in the company of family and friends (Last Days of Life) 30

Goal 6: Whānau experience high quality care after death (After Death Support) 32

Section 3: Next Steps - Implementing the strategy 33

Appendices 34

Appendix 1: Glossary of Definitions and Concepts (Ministry of Health, 2015) 34

Appendix 2: Engagement with Stakeholders 40

Appendix 3: Summary of feedback 42

Appendix 4: Population Information 43

General overview 43

Population and Projections 44

Deaths in the sub-region 47

Appendix 5: Bibliography 48

Appendix 6: Example of patient experience in future palliative care system 50

Appendix 7: Role functions and definitions 51

Appendix 8: Data sources 54


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INTRODUCTION There are a number of challenges facing our health care system, and in particular palliative care services across our sub-region. Evidence indicates there will be more people dying each year and more people dying in older age. Therefore the needs of the dying population will change as this older population becomes increasingly frail and with the presence of multiple comorbidities including dementia. As more patients identify their preferences for palliative care (with developments in Advanced Care Planning) it is likely that palliative patients will increasingly indicate a preference to die at home (currently this figure is two thirds of the palliative patient population). This will mean that future demand will increasingly be driven into community settings, primary care and aged residential care.

Our current health care system is primarily focused upon keeping people alive; however, more focus is needed on the quality of patients’ living and dying. Although people are becoming more aware of hospice and palliative care services, health professionals do not always see dying as an integral part of the health system. In order to ensure that all people have access to a palliative approach in our sub-region, we must work to change attitudes towards death and dying. Recent Kings Fund research found health professionals must be able to talk about death and dying if we are to improve end of life care throughout our regions (Rachael Addicott, 2010).

There is overwhelming evidence indicating the need for a considerable shift in the way palliative care is organised and delivered at a sub-regional level. Carers, whānau and health care staff report that there is currently large variability in the range of services and supports for those nearing the end of life and those services are not always responsive to the needs of patients and their whānau. For some, particularly those that enter a hospice pathway, the experience for the most part is a positive one. However, for others, patients and their whānau are left to navigate the myriad of options available on their own, with often sub optimal outcomes. Our inability to support the needs of all those requiring such care must be addressed into the future.

We must also address the extent to which separate services are currently set up to work towards their own organisational priorities, and shift the dominance of vertical silos. Our funding and commissioning models are outdated, and support an insular approach to service delivery. It is essential to develop effective working partnerships between primary and specialist palliative care, whereby a sufficient specialist workforce can provide the support, advice and education to those providing primary palliative care so that a palliative approach to end of life care becomes ‘everyone’s business’.

Consequently, work is needed at both the sub-regional and district levels to ensure that all people in the Lower North Island “face death surrounded by those (they) love, feeling safe, comfortable and cared for” (Canadian Hospice Palliative Care Association, 2009). This strategy details a comprehensive integrated model of palliative care to align treatment with a patient/whānau’s goals and preferences for care as they near the end of their lives. It seeks to improve the quality of palliative care services for adults in our sub-region, irrespective of their ethnicity, age, gender, locality or socio-economic status, and ensure that they have every opportunity to access services to meet their needs. This includes but is not limited to: Māori, members of the Pacific and Asian community, prisoners, immigrants, refugees, mental health patients as well as those with physical or intellectual disabilities.

The Lower North Island Palliative Care Managed Clinical Network (Network) was established in 2014 following a successful submission for funding from Health Workforce New Zealand (HWNZ) to address the probable gaps in palliative care service delivery across the sub-region. The network’s vision is of palliative care services working in a seamless, integrated, cost effective way across all levels of primary, secondary and tertiary care to improve equitable access and care for patients and their whānau. In February 2016, the Network agreed its work programme to develop a Palliative Care Strategy for the sub-region, and include a future way of working.

Section1: Background and Context


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METHODOLOGYThis strategy was developed using a participatory process of engagement with key stakeholders (Appendix 2) and builds on earlier work carried out by the Network, as well as the programme of work to develop service proposals as part of the new initiatives funding to hospices for community focused palliative care services.

The results (summarized in Appendix 3) from focus groups with service providers across district areas; focus groups with carers/consumers; and interviews with the many stakeholders across the sub-region who interact with patients with palliative care needs and their whānau, were used to inform the strategic direction and the goals for this plan. Data was also derived from a variety of other sources including a comprehensive review and analysis of national and international literature, as well as a stock take analysis.

WHAT IS PALLIATIVE CARE?Palliative care is the care of people of all ages who have a life-limiting or life-threatening condition and aims to:

• Optimise an individual’s quality of life until death by addressing the person’s physical, psychosocial, spiritual and cultural needs.

• Support the individual’s family, whānau, and other caregivers where needed, through the illness and after death.

Palliative care is provided according to an individual’s need, and may be suitable whether death is days, weeks, months or occasionally even years away. It may be suitable sometimes when treatments are being given aimed at improving quantity of life and should be available wherever the person may be located. It should be provided by all heath care professionals, supported, where necessary, by specialist palliative care services. Palliative care should be provided in such a way as to meet the unique needs of individuals from particular communities or groups. These include Māori, children and young people, immigrants, refugees, prisoners, homeless and those in isolated communities. (Ministry of Health, 2015)

Palliative care can be provided to patients at any point on their journey irrespective of whether the goal of treatment is cure or palliation of symptoms. They can be provided by primary palliative care providers or specialist palliative care providers. Many individuals and health professionals do not differentiate between a palliative approach and the palliative care provided by specialist palliative care. Indeed, palliative care can occur at the same time as curative or life-prolonging treatment. Palliative care programs include psychosocial and spiritual care for patient and family; management of symptoms such as pain, fatigue, shortness of breath, depression, constipation, and nausea; support for complex decisions, such as discussions of goals, do not resuscitate (DNR) orders, and requests for treatment; and coordination of care across various health care settings (Kate Rowland, Dec 2010).

Throughout this document, we use the words palliative care and palliative approach to describe the above.

The diagram below (Figure 1) illustrates the different journeys that palliative care patients may take as they transition between primary and specialist palliative care, according to their needs or service expertise/experience.


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Figure 1: The relationships between primary palliative care and specialist palliative careSource: Ministry of Health (2015a)

Four examples of patient journeys are illustrated:

1) All care is provided by the primary palliative care providers with no input required from specialist palliative care services.

2) Care is provided by specialist palliative care for the duration of the illness with little or no input from primary palliative care providers.

3) Initial involvement from specialist palliative care to guide a plan of care with ‘re-referral’ during the deteriorating phase or during the last days of life.

4) Multiple episodes of specialist palliative care involvement during times of increased need/complexity, not necessarily during the last days of life.

SUPPORTING AN INTEGRATED MODEL OF PALLIATIVE CAREIn 2014, the first ever global resolution on palliative care, World Health Assembly resolution WHA67.19, called upon WHO and Member States to improve access to palliative care as a core component of health systems, with an emphasis on primary health care and community/home-based care.

The Resource and Capability Framework for Integrated Adult Palliative Care Services in New Zealand (Ministry of Health, 2012) provides a good framework for the composition and requirements of palliative care services that are appropriate for the New Zealand context. The Framework (see Figure 2) places the family and their whānau at the centre with primary care (the main providers of palliative care) providing the first level of care. Primary care providers work in an integrated (hub and spoke) way with secondary care providers, specialist palliative care providers and other providers. The family/whānau is critical in coordinating care and supporting the person requiring palliative care. This means that for many people, the need for palliative care can be met by their existing primary care provider (e.g. their general practitioner). The need for specialist palliative care services may be episodic or shared rather than required on an intensive basis.

Time with a life-limiting condition

Primary Palliative Care

Specialist Palliative Care

1

2

3

4


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Figure 2: Framework for Integrated Adult Palliative Care Services

The underlying intent of the Framework is equity of access and quality care at the appropriate level of care. Patients and their whānau are not necessarily concerned if the care they receive is delivered by primary or specialist providers, but more that the right services are delivered by the right people, at the right time, in the place that is right for the patient and their whānau. The Framework emphasises the importance of partnership and integration where primary palliative care providers work in collaboration with specialist palliative care providers and other providers to provide the palliative care services that are required for the DHB population in a seamless way.

Primary carer

Primary care

Specialist palliative

care

Secondary care

Other providers (eg. NGOs)

Community

Patient Family/whānauEnablers > < Enablers

Figure 3: Levels of Need for Palliative Care (Ministry of Health, 2012)

Group Need

Increasin

g inten

sity of need

C Complex

Episodic

Non-complex

B

A

= Patient movement between levels


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Figure 3 represents the differing needs of the palliative care population. The majority of people requiring palliative or end of life care have non–complex needs and are managed successfully by their existing primary palliative care providers (Group A) and do not need to access specialist palliative care. Patients in Group B require episodic access to specialist services, although continued to be managed by their primary palliative care provider in a shared care model. As complexity and need increases, standard palliative care clinical practice guidelines may not meet the needs of Group C and this small group of patients are likely to require on-going care by specialist palliative services. This strategy addresses the needs of all those within these levels (Figure 3).

Palliative care services have traditionally been offered once all the options for active treatment have been exhausted and patients have come to the end stage of their disease (usually cancer). There are a number of patients who would benefit from a palliative approach much sooner than they currently experience, with early conversations providing guidance and support on the range of services available as the patient moves through various stages of dying.

The traditional model of palliative care is shown in the first diagram in Figure 4. The second diagram illustrates how an integrated curative and palliative approach differs. New evidence for the effectiveness of palliative care together with the emerging needs of people living with serious chronic illness, have shown a palliative care conversation and options should start earlier than previously thought. Many patients can benefit from receiving life prolonging or disease modifying treatments while simultaneously having their palliative care needs addressed.

Figure 4: Palliative Care Models

Historically palliative care has been linked to cancer services, however, it is now recognised that, as New Zealanders live with chronic disease, patients dying from other conditions (e.g. renal failure, motor neurone disease, respiratory conditions) will all benefit from high quality palliative care services.

Old concept

Palliative approach concept

Identification Death

Trea

tmen

tTr

eatm

ent

Life prolonging treatment

Life prolonging treatment

End of life care

End of life carePalliative care

Bereavement care

Palliative approach

Time


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Figure 5 outlines the various trajectories of chronic illness with the first showing the typical profile for cancer patients with rapid progress from diagnosis to treatment to dying. The second trajectory shapes the profile for organ failure with a more erratic decline. This might occur with renal disease, heart disease, chronic obstructive pulmonary disease (COPD), liver disease, or general neurological diseases such as motor neurone disease, Parkinson’s disease or multiple sclerosis. Palliative care services may become involved after a ‘serious episode’ and then remain involved for the remainder of the illness.

The final trajectory shows gradual decline with ‘prolonged dwindling’ over time; these include frailty, dementia or cerebral vascular accident (CVA/stroke). It is vital that discussions with individuals living with dementia are started as early as possible to ensure that whilst they still have mental capacity they can discuss how they would like the later stages managed. This would ensure that these patients receive the right information about their disease necessary to make advance decisions about prioritising their resources, including time, psychological energy and financial resources. This can cause issues for those funding and delivering palliative care services, as for many patients it is very difficult to define when a patient becomes ‘palliative’.

Finally, it is important to note that palliative symptoms in patients with chronic terminal illness can often go unrecognised or under treated i.e. patients with dementia who experience pain are often not recognised. This strategy extends a palliative approach to include all those that would benefit. That is, a palliative approach should be available to everyone over the course of their terminal illness regardless of who is the principal provider of their health care.

FUTURE DEMAND FOR PALLIATIVE CAREIt is estimated that across the 3DHB sub-region there will be approximately 3,050 deaths in 2016, this number is projected to increase to 4,190 deaths in 2036 (see Figure 6). It is projected that although there will be minimal growth in those deaths where specialist palliative care services will be involved, the biggest increase will be amongst those patients involved with primary palliative care services (1337 to 2146).

Figure 5: Disease Profile of Chronic Terminal Disease in Older PeopleSource: Lynn et al, Edited Higginson, 2004

Frailty/ Dementia

Organ Failure

Cancer

Sudden Death

Illness Trajectories GP’s workload - 20 deaths/GP/yr

1

2

3


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Patients who do not receive specialist palliative care (denoted as primary palliative care in Figure 6) are already in a healthcare environment where many of their needs are being proactively managed by the primary healthcare team (check-ups, tests, reminders etc). In a wider context than palliative care, patients who are at risk of deterioration might already have a plan of care developed with their primary palliative care provider to meet this need. Figures 7 (a, b and c) below illustrate this growth for each district.

Figure 6: Projected deaths in the 3 DHB region – 2016 to 2036

Deaths (not palliative) – 24% increase Primary palliative care involved deaths – 60% increase

Specialist palliative care involved deaths – 17% increase

2016 2020 2024 2028 2032 20360

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

30503220

33903610

3870

4190

Figure 7a: Projected deaths in Capital & Coast DHB



2016 2020 2024 2028 2032 20360

2,500

2,000

1,500

1,000

500

16701770

18702000

2150

2340


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Ageing population and increased need

As our population ages so demand for palliative care increases, as does the nature of that demand (See Appendix 4).

By 2038 there will be approximately 3624 people per annum needing a palliative approach in this sub-region, with approximately one third likely to be receiving support from specialist palliative care services. It is projected that the number of older people 75+ years needing palliative care will almost double by 2038 – from an estimated 1,632 in 2016 to 3,069 in 2038. The number of people under 74 years needing palliative care is expected to decrease, from an estimated 836 in 2016 to 555 in 2038 (McLeod, June 2016).

Figure 7b: Projected deaths in Hutt DHB



2016 2020 2024 2028 2032 20360

1,400

1,200

1,000

800

600

400

200

9601010

10601120

12001290

Figure 7c: Projected deaths in Wairarapa DHB

Deaths (not palliative) – 24% increase Primary palliative care involved deaths – 57% increase Specialist palliative care involved deaths – 9% increase

2016 2020 2024 2028 2032 20360

600

500

400

300

200

100

420 440460

490520

560


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Wairarapa DHB has the oldest population of the three DHBs, with 9,000 people (20% of the population) aged over 65 years. This distribution is roughly the same across all three of Wairarapa’s territorial authorities. The proportion of Wairarapa DHB’s population who are 65+ years is projected to increase from 19% in 2013 to 32% in 2038. The largest increases in people aged 65+ years are expected to be in the Asian and Other ethnic groups.

In Hutt Valley DHB, 21,000 people (14%) are aged over 65 years. This distribution is roughly the same across Lower and Upper Hutt. The proportion of Hutt Valley DHB’s population who are 65+ years is projected to increase from 13% in 2013 to 25% in 2038. The largest increases in people aged 65+ years are expected to be in the Other and Asian ethnic groups.

In Capital and Coast DHB, 39,400 people (12%) are aged over 65 years. The Kapiti Coast has the highest proportion of older people of the territorial authorities in the CCDHB region, with one in four people (11,100) aged over 65 years. In Wellington and Porirua, approximately one in ten people (5,800 and 19,700, respectively) are aged over 65 years. The proportion of CCDHB’s population who are 65+ years is projected to increase from 12% in 2013 to 22% in 2038. The largest increases in people aged 65+ years are expected to be in the Other and Asian ethnic groups.

Palliative Care for Māori

There is anecdotal evidence that Māori do not receive the benefits of a palliative approach early enough, and do not equitably access palliative care services that are available. The reasons for this are complex, and likely to be in part due to the fact that current palliative care models of care do not specifically address Māori needs, or the differing views on death and dying by Māori.

Maori (and Pacific people) experience a higher incidence of chronic and degenerative disease and die at an earlier age than those of other ethnicities. This higher incidence combined with “palliative care treatments that prolong life mean whānau are increasingly being called upon to provide end of life care for months or years. Caring requires families to balance their paid work, their caring responsibilities and other aspects of their lives. When carers have their own health issues, or face financial or housing challenges, caring for whānau at the end of life requires resilience. Whakapapa, shared cultural and familial values, and a commitment to the process of caring for a loved person and their whānau as a whole both strengthen and encourage a way forward.” (Tess Moeke- Maxwell, 2014)

The Ministry of Health publication Palliative Care and Māori from a Health Literacy Perspective (2014) identified approaches to enhance Māori health literacy and access to palliative care. This publication identified health system, organisational, and patient and whānau level factors that have the potential to influence the achievement of health literacy and access to palliative care for Māori patients and their whānau. Key measures to improve Māori health literacy in palliative care and service delivery relate to strengthening a Māori focus and presence, and a whānau orientation within the palliative care system. This should be reflected in:

• the constitution of the workforce (i.e., Māori representation)

• increased coordination between providers, including Māori community organisations

• the availability of quality palliative care information that is tailored to Māori

• quality ethnicity data that is routinely analysed and reported to inform palliative care planning and decision-making

• health professionals who engage in health literacy and cultural competence training that enables them to communicate effectively with Māori and support the integration of Māori culture into palliative care

• specific Māori navigator roles

• palliative care services that reflect the values and preferences of Māori

• high health literacy among Māori in palliative care.


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Health literacy for Māori in the palliative care context is a complex topic. This plan contributes to achieving health literacy within palliative care systems, organisations and health professionals in order to realise the potential of palliative care for Māori. That is, palliative care that supports whānau, optimises quality of life for patients including the maintenance of their mana, and enables preferred death experiences that give free expression to cultural values and practices relating to death and dying.

Te Ara Whakapiri (MoH, 2015) provides principles and guidance specifically related to the care of the person in their last days of life. It defines what all New Zealanders can expect as they come to the end of their life and is based upon the Te Whare Tapa Whā model of care.

Palliative Care for Diverse Cultural Groups

The experiences outlined for Māori are also relevant to other diverse cultural groups in the Lower North Island sub-region, including the many different Pacific and Asian communities. It is well documented that the health outcomes of Pacific and Asian peoples are worse when compared with the general population in New Zealand and are often the result of poor utilisation and access to palliative care.

While each Pacific and Asian culture within New Zealand has its own experiences of death and dying, there are some similarities between cultures. These experiences are similar to those outlined for Māori above and approaches to enhance health literacy and improve access to palliative care will have benefits for the wider population.

OUR CURRENT PALLIATIVE CARE SERVICESThe 3 DHBs within our sub-region currently spend just under $13 million per annum on a range of specific palliative care services. In Capital and Coast DHB, the level of funding is $7.2m, for Hutt DHB it is $4.4m and for Wairarapa DHB it is $1.4m. However, there are other services which are provided to palliative care patients that are not included in these figures such as Home Based Support Services, who provide personal cares and household management to palliative patients. It also excludes the majority of services provided to such patients in public hospitals, ARC facilities and general practice teams (except in Wairarapa) as palliative care patients are not as distinctly identified as such. The range of services currently provided across the sub-region are summarised in Table 1 on the next page.


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Table 1: Summary of palliative care services in the 3DHB region

Level of Care Provider Type of care

Primary Palliative Care Providers

General practice teams – General practitioners (GP) and practice nurses

Primary care in the community

Aged residential care facilities Continuing care and rest home care

District nursing services Community (home based) nursing care

General ward staff at public hospital, as well as disease specific teams for instance respiratory, renal, cardiology, oncology teams)

Inpatient and outpatient palliative care (non-specialist)

DHB allied health staff (e.g. occupational therapists, physiotherapists, social workers, dietician etc.)

Assessment for equipment, therapy, access to support services

NGOs and volunteer organisations, carer support agencies

Support care

Specialist Palliative Care Providers

Kahukura & Te Omanga Hospice1

Te Omanga Hospice – HVDHB

Mary Potter Hospice – CCDHB

CCDHB

HVDHB

Each region has available:

Community care

Day care

Inpatient care2

Hospital teams3

Hospice Wairarapa Bereavement support, counselling, massage, podiatry, wellness therapies, biographies, art table, day respite programme, caregiver programme.

Specialist community nursing care for specialist palliative care patients in CCDHB is provided by the district nursing teams with support from specialist palliative care nurses. Wairarapa DHB has a dedicated palliative care team. Te Omanga Hospice provides 24/7 nursing support to patients under the care of the hospice in the HVDHB district.

Inpatient care for palliative patients is provided by both Mary Potter Hospice and Te Omanga Hospice for hospice patients. These inpatient units also provide respite care. Wairarapa district does not have a dedicated inpatient unit but patients that have complex symptom management that need to be addressed in a specialist inpatient unit, can be admitted to the Te Omanga Hospice inpatient unit.

Specialist hospital palliative care teams are based in both Hutt Hospital and Wellington Regional Hospital and support primary palliative care colleagues to address palliative care need within the hospital setting. Wairarapa Palliative care team provide a daily in reach service to the hospital wards and a visiting consultant from Te Omanga will do weekly inpatient domiciliary visits. Kenepuru Hospital, CCDHB does not have access to a specialist palliative care team.

General practice team involvement varies across the sub-region. For patients living in Wairarapa and Capital and Coast DHBs, the General Practitioner (GP) remains the lead physician throughout the journey. In Wairarapa, the GP provides all medical care for all but a few patients who need specialist medical support on an ad hoc basis.

1 Specialist palliative care assessment, advice and education only in Wairarapa DHB district

2 Wairarapa does not have an inpatient unit.

3 Hutt and Wellington Regional Hospital only.


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For CCDHB patients, the hospice physicians work closely with the primary care team, and only take over medical care where the GP requests this. In the Hutt Valley district, patients remain under the care of their GP until they reach the final stages of life, at which stage some are transferred to specialist palliative care. More recently, GPs in the Hutt Valley have been supported to remain the lead carer for patients with non-complex palliative care needs although this development is still in the early stages.

ARC facilities across the sub-region manage the majority of patients with palliative care needs, either in a residential care or a respite care capacity.

Home based support for palliative patients to assist with personal cares is provided by various home based support providers. Eligibility for access to these and aged residential care (for either residential or respite care) is through an assessment by Needs Assessment and Service Coordination (NASC) services within each respective DHB.

Recent funding for new initiatives (Service Development Proposal, Palliative Care Innovative Funding, 2016) will see the implementation of a number of initiatives to support closer linkages between specialist and primary palliative care providers. One initiative that is being introduced across CCDHB and HVDHB is free visits for palliative care patients and their whānau to meet with their GP to develop an individualised palliative care plan. This initiative is currently being trialed and will be modified as opportunities for improvements arise.

Advance Care Planning

Advance Care Planning (ACP) is a key focus nationally and regionally. ACP is a process of discussion and shared planning for future health care. The planning process assists the individual to identify their personal beliefs and values and incorporate them into plans for their future health care. ACP provides individuals with the opportunity to develop and express their preferences for care informed not only by their personal beliefs and values, but also by an understanding of their current and anticipated future health status and the treatment and care options available. The ACP process may result in the person choosing to write an advance care plan and/or an advance directive and/or to appoint an enduring power of attorney (EPA).

The 3DHB sub-regional Advance Care Planning (ACP) Steering Group has approved a plan to forward the ACP project with two tiers of activity. Tier one builds on the work in the sub-region over the last few years to increase awareness through educating and engaging both public and health professionals about what ACP is and what the benefits are. Tier two will focus on more intensive ACP work with specific services and practices in the sub-region. The goal with these providers will be to embed ACP into models of practice by developing workforce competence and confidence as well as the systems, processes and measures that are needed for discussing and recording ACP conversations.

A FUTURE MODEL OF PALLIATIVE CARE – A NEW WAY OF WORKINGBased on the inequity of access across the sub-region as well as increasing future demand with limited resources, we need to move towards a consistent, coordinated and integrated model of palliative care in the Lower North Island. The future way of working will facilitate a coherent and seamless patient journey through the palliative care system. There will be improved collaboration and sharing of knowledge, expertise and resources across the system to create opportunities for operational efficiency and collective wisdom.

A future model of care will ensure that a palliative approach is made available to palliative care patients and their whānau from the time it is first identified end of life is approaching. There will be earlier identification and recognition by health professionals about curative treatment moving to palliative care and earlier conversations to enable patients and their whānau to make informed life choices. These honest conversations will enable earlier planning, with multiple disciplines if necessary, to ensure patients’ palliative care needs are met 24 hours, seven days a week.


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This new way of working will be characterized by seamless patient care delivered efficiently and effectively by one integrated team; service provision will be based upon needs and; a palliative care approach will be firmly embedded in and led by primary care with support from specialists; as well as clearly defined roles and responsibilities for those involved along the patients journey.4

Seamless and holistic patient care

There is overwhelming evidence that good palliative care has the same elements as goodchronic disease management and care. A future palliative care system should be integrated with care and support right from the time when it is first identified that end of life is approaching, through the last days of life and into bereavement. Partnerships and integration between all service providers, volunteers, patients and whānau will create a seamless journey for patients. Communication, collaboration and sharing of resources are fundamental to addressing patient need and achieving efficiency.

Palliative care provided in a holistic way embraces the elements of wairua (spiritual), hinengaro (thoughts and feelings), tinana (physical) and whānau (family) (Durie, 1985) and ensures that these work together in harmony. Holistic care will include a range of allied health and psychosocial supports such as counselling, social work, spiritual care and bereavement support.

Service provision is based on need

The majority of patients in need of palliative care are non-complex to moderately complex and their needs can, and will be adequately managed by their primary palliative care provider. This may include indirect or direct (generally episodic) involvement of specialist providers. The relatively small proportion of patients with highly complex needs might receive direct specialist involvement, similar to what occurs in most other health care specialties and subspecialties.

One integrated care team

To enable shared care, each patient will have one virtual integrated inter-disciplinary care team who will ensure that the needs of the patient and their whānau are identified and met. The patient, whanau and any informal carers are crucial elements of this team. Each patient will have an individualised palliative care plan which will encompass all settings in which the patient receives care. This care plan will clearly identify all the key members that are directly involved in caring for the patient, as well as a designated lead palliative carer (LPC) and a palliative care facilitator (PCF). The LPC is responsible for clinical/medical oversight and the PCF is responsible for facilitating services to meet need.

Additional membership of this team will vary depending on other services that might be required to identify and address the expectations and needs of the patient, whanau or informal carers. The team may typically include one or more doctors, nurses, social workers, spiritual advisers, pharmacists, and personal care workers with other disciplines from voluntary and NGO sector becoming part of the team as resources permit (Ministry of Health, 2015). Team members may transition in and out of the caring team as they are needed i.e. locality palliative care specialists (see below) may be called upon to undertake assessment and/or provide episodic support/care during an acute phase.

4 Example of patient experience along future palliative care continuum is outlined in Appendix 6.


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Led by primary care

The general practice team will drive a palliative approach, and be well supported by the specialists within the Locality Palliative Care team, as well as responsive nursing, home based support and allied health services. A member of the general practice team will usually be the designated ‘lead palliative carer’ if the patient lives at home, and will be the first point of contact for patients and their whānau throughout their journey. They will ensure, in partnership with the palliative care facilitator, that the individualised palliative care plan details the arrangements for medical care and support 24 hours/ 7 days a week. After hours care may be provided by a coordinated suite of professionals whose core role includes a 24 hours /7 days a week service.

The Lead Palliative Carer (LPC) may change as the patients’ needs change, and when this change occurs there will be clear transfer of care, i.e. initially the GP may be the LPC but as needs increase this may change episodically to a community nurse or specialist palliative care nurse, although the GP should always remain involved through the journey. If the patient lives in an ARC facility, the LPC may still be a member from the general practice team or alternatively can be the registered nurse from the facility.

Supported by specialists in palliative care

Primary care providers will have access to expert consultation and advice from Palliative Care Specialists. These specialists will work together to support a cluster of GP practices, ARC facilities, and other health care providers like District Nursing, depending on the population within the locality. These teams will potentially include a gerontologist, a practice nurse with a special interest in palliative care, a gerontology nurse, social worker /allied health representative, nurse practitioner and nurse prescriber, specialist pharmacist, a palliative medicine specialist and nurse from the hospice community team. Their main role will be to make sure specialist knowledge is available for frontline workers. They will build and strengthen relationships and over time develop trust and confidence. This will improve the coordination between services and enhance the seamless experience of care for patients. These specialists will indirectly, and at times directly, support primary providers in their locality with facilitating interdisciplinary review of palliative care patients, case reviews and educational support. Certain specialists within this locality support team i.e. palliative medicine specialist will be contactable 24 hours/7 days a week.

Assessments and planning for patients with complex needs and multiple comorbidities may be undertaken in collaboration with this group of specialists and facilitated by the palliative care facilitator. They will be well equipped to offer advice and support in improving the patients experience across all settings, and especially where the patient has unresolved complex needs that cannot be met by the caring team – these needs may be physical, psychological, social and /or spiritual (Association for Palliative Medicine , December 2012).

Clearly defined roles and responsibilities

The new model of care will clearly define and agree the roles and responsibilities of the various providers including the roles of the lead carer and lead facilitator. In our current models, assessment, coordination and service delivery are often carried out by different people or different organisations. Under the new model, these functions will be pulled together into one agreed assessment and planning process which will be synchronized by the same person to maximize the connectivity between services for patients. This will help facilitate improved communication, collaboration and sharing of resources to address need and achieve efficiency.


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PRINCIPLESThe following principles will guide the implementation of the strategy:

• Patient and their families/whānau are at the centre of all care

• Patients and family/whānau can expect and receive high quality care wherever they may be

• Patients and family/whānau will be supported so they can die well

GOALSThe following outlines each step, and respective goal, of the pathway for the patient nearing the end of their life from the identification of their palliative care needs through to care after death (Rachael Addicott, 2010)

1 Self

management

2 Planning

3 Integration

4 Quality

5 Last days of life

6 After death

support

1. Patients and their whānau have timely identification that end of life is approaching, and early discussions to ensure they make informed choices about what, where and how they receive care and support (Self Management)

2. Patients and their whānau receive coordinated assessment, care planning and review throughout their illness (Planning)

3. Patients and their whānau experience equitable and seamless care through coordinated service provision (Integration)

4. Patients and their whānau experience high quality services in different settings (Quality)

5. Care in the last days of life is comprehensive, with good symptom control, is in the most appropriate setting in the company of whānau and/or friends (Last days of life)

6. Whanau experience high quality care after death (After death support)

Section 2: Vision, principles and goals

OUR VISION – TE AHO

‘All people who require a palliative approach live well and die well irrespective of their condition or care setting’.


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“I realise now that hospice is more than just dying and that they could have supported us earlier. It is not just the end of the road.”

“It’s the transition that is the issue – pre planning is important. No one has had the discussion with the patient and family.”

“What we experienced with our father was not palliative care as it could and should have been. Our family was robbed of what might have been a very different experience of our father’s last days. We appreciate that human grief is a different experience for every person and we knew he was at the end of his life. This should have been a moment of grace and of family experiencing love and support at his end. Instead we felt exhausted, empty and alone.”

For each of these goals, there are a number of desired outcomes, actions to achieve these goals as well as measures to determine if the goals have been achieved. Where relevant, statements attained from whanau and stakeholders through the consultation process are included to support each goal.

Goal 1: Patients and their whānau have timely identification that end of life is approaching, and early discussions to ensure they make informed choices about what, where and how they receive care and support (Self Management)

To enable self management patients and their whānau need early discussions and information to enable early involvement of a palliative approach.

Timely identification

Many health professionals struggle with the dilemma of when to inform patients that their condition is life limiting and recognising that a palliative approach might be beneficial alongside their treatment. For many people this discussion is left until they are in the final months or weeks of life. There is new evidence that early involvement of a palliative approach improves quality of life and allows patients and whānau to better adjust. The traditional care model is to aggressively treat to both prolong patients’ lives and ameliorate their symptom burden. Three recent studies in Boston showed early integration of a palliative approach for oncology patients with a poor prognosis showed improvements in outcomes, ranging from quality of life, mood, patient satisfaction, prognostic understanding, health service use, and possible length of survival. “Despite the barriers to the involvement of palliative care in the care of patients with advanced cancer, strong evidence now supports integrated palliative and oncology care.” (Temel, 2014)

An open conversation about palliative approaches to support patients and whānau from the time when it is first identified that end of life is approaching is crucial.

These early, timely conversations not only allow patients and whānau to adjust, but they allow patients to make informed life choices, as well as helping to identify any psychosocial needs that may need addressing.


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Early discussions as end of life approaches

There is ambivalence amongst some healthcare professionals to discuss dying, end of life care and death. Clinicians are often ill equipped and possibly reluctant to undertake these difficult conversations. All clinicians should be confident and competent in raising the issues as they arise and responding to questions from patients and whanau about prognosis, care preferences and options for the future. Training to improve the definition of diagnosis and to undertake conversations about planning as end of life approaches need to occur.

Information

Families experience frustration through lack of knowledge about what is available and often feel disempowered until they are referred to specialist palliative care services. The aim is not to stop curative treatment upon diagnosis of a terminal disease, but to have early conversations about what patients and their whānau might experience over the course of the illness.

“We now believe palliative care not to be what it could be. This should have been a moment of grace at the end… 1 ½ years on our family is still fractured, and we are not sure when treatment became palliative care.”

“Early information about what to expect would have been more helpful.”

“You can do the whole thing yourself… My wife and I were in control – we just need you to support us.”

The public and health professional understanding about palliative care has to change to allow the palliative care journey to begin much earlier (Kate Rowland, Dec 2010). By providing information and education to the public and promoting community resilience and self-management of care, we raise the profile of palliative and end-of-life care.

Patients and whānau need early information about their condition; what they can expect to occur over the coming weeks and months; the services and supports available to them; as well as information about how they can access them. This aligns with the future direction for the NZ Health Strategy to develop a ‘smart system – He atamai te whakaraupapa’ whereby services can make use of technologies such as shared care plans, e-referrals, and telehealth to ensure people have access to the information they need to enhance empowerment. The Health Navigator website5 provides patient information and self care resources on hundreds of health conditions, and palliative care resources for patients should be placed here, with health professionals directing people to this website.

5 http://www.healthnavigator.org.nz/


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“We were surprised to hear the term palliative care being used by a doctor as if the family were all aware that this was the stage things were at.”

“No one knew what was going on – and if they did, they didn’t communicate this to us – not being clear when the treatment became palliative care and not receiving guidance on how best to manage this.”

“We were waiting for tests and spaces to become available in rehab, then we were later told these were ‘pointless’ as it would not change anything in his care, and it was unlikely he would return home.”

As a patients condition changes, whānau may be told their whānau member cannot remain in their current environment i.e. in hospital, and that they need to urgently find an alternative i.e. seek a residential care facility or increase level of support. Frequently they are not given the context of why and what level of care they need to find.

Desired Outcomes

• Health professionals involved in palliative care are skilled in identifying people entering the end stage of their life and are well prepared at having early discussions with patients and their whānau about the choices they have.

• Health professionals, patients and whanau are aware of all palliative care services and supports for people and their families.

• Patients and their whānau are better prepared for their palliative care journey and have increased control and self-management over aspects of this journey.

Actions

1. Develop a method/pathway to support identification of people as their end of life approaches and implementation of lead palliative care model.

2. Implement individualised palliative care planning in primary care as a mechanism to identify and access services

3. Promote the Health Navigator website as the basis for information to support patients, whanau throughout the journey including after death support.

Measuring success

• Increase in competence, capability and comfort of health professionals having early conversations with people and their whānau requiring palliative care

• Palliative patients and their whānau will have recorded early conversations about a palliative care approach to enable adjustment and planning of their lives, advanced care plan and goals of care.

• Patients and their whānau will have accessed information and support in relation to palliative care and satisfaction with journey start and choices.


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Goal 2: Patients and their whānau receive coordinated assessment, care planning and review throughout their palliative care journey (Planning)

People nearing their end of life should have their needs assessed by an appropriate individual. Those needs should be recorded in the form of a care plan and reviewed as their condition changes. The care plan should identify patient’s preferences about care delivery and place of death. These records should be accessible by multiple health professionals from across the palliative care system, so the plan can be followed irrespective of where the patient is. An identified lead palliative carer (LPC) should be identified as part of the care plan. Patients and their whānau should be involved in this process as well as in all decisions that involve planning and provision of care.

Advance care planning can also be a component of this process, so that patients can express their preference for end of life care. It should be noted that advance care plans should be updated continually as the needs of patients change.

Assessment & Care Planning

Providing for initial and ongoing assessment of needs is an important part of care planning. Currently there are multiple assessment processes that patients are required to undergo and work is required to refine the assessment and care planning processes to reduce duplication. This will require shared information technology to ensure access to shared records.

Individualised palliative care planning is being introduced in primary care for patients that would benefit from a palliative approach. Patients and their whānau receive a free consultation(s) with their primary care team to consider all aspects of care over the next 12 months, including medical, nursing, physical, spiritual, psychosocial care. This is an opportunity to begin the early conversation for patients and their whānau. This process will identify the lead palliative carer (LPC) and trigger the engagement of a palliative care facilitator (PCF).

As the patient experiences diminishing health, the palliative care facilitator will initiate a palliative care assessment. This will be undertaken by an appropriately skilled health professional and include those already involved in the care of the patient (for example, oncology and respiratory specialists, Māori health provider, social worker, dietician, OT). This comprehensive assessment will evaluate the needs, strengths and preferences of the palliative patient and their whanau and build upon the individualised care plan.

Planning tools such as the Gold Standards Framework, (National Gold Standards Framework Centre 2011) the Supportive and Palliative Care Indicators Tool (SPICT™) or the interRAI Palliative Care assessment (interRAI 2014) can assist the PCF to identify those people who need a transition of care whether this is the place of care, the levels of care and/or the goals of care.

The nominated LPC will always be involved in the assessment and care planning. This LPC is most likely to be a member of the general practice team (GP or practice nurse), but might be a specialty nurse (eg oncology, respiratory, cardiac), Māori health provider nurse or health worker, or aged residential care provider, if this is more appropriate, but the GP will remain lead medical carer. The LPC identified to undertake this coordination role, will not necessarily provide the care themselves, but will be responsible for developing and coordinating the care plan and for facilitating (where appropriate through the palliative care facilitator) the services and resources identified in the plan.

Specifically the LPC will be responsible for ensuring that medical, social and spiritual needs are met, this might include domiciliary nursing, GP visits, social work input, hospice or other specialist assessment and advice and support services as required. They might also link patients/whānau to income/financial support, respite care and community and voluntary services.


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Discharge planning and service transitions

The shift to providing more end of life care in the community and home requires health professionals to work in a different way. Ward staff for instance, require support to ensure patients are appropriately discharged to their preferred place of care, and that the necessary supports are in place in a timely manner to allow for this. Enhanced discharge planning for complex cases will support ward staff to conduct assessments in more instances and allow planning for end of life care to be delivered in the individual’s preferred location.

Transition between health services such as public hospital and aged residential care facilities present challenges for patients. Hospital-based care teams, aged residential care teams and primary care teams have different health care systems that are geographically separated and use isolated health information systems. Generally patients and whanau experience excellent patient care within the services they access. However, if and when patients do transfer, the transition between services is interspersed with inconsistent information. Information that is provided is often provided by those who do not have good enough knowledge and end up providing inaccurate information. A fundamental change is required for transitioning between services. Discharge from hospital is a particular concern for family and almost all stakeholders we interviewed would like to see improvement. Examples included:

“Unfortunately no care plan or notes were transferred from the hospital to the rest home. We were asked several times by staff if we knew what medications Dad had been on, which we did not. The rest home doctor did not visit until the following day so it was 24 hours before any pain relief or sedation could be provided for Dad who seemed to have worsened with the move.”

“Mum was sent home alone after 3 days instead of the planned week after 8 hour surgery - I’m home alone with her and I’ve got no medication.”

“It’s the transition that is the issue – pre planning is important. No one has had the discussion with the patient and family.”

While the information systems are improving and shared care platforms edge closer, this separation creates significant obstacles to communication, resulting in poor handover of the care plan. Additionally there can be a lack of understanding of the capacity and capability of the service that the patient is being discharged to, resulting in essential medication not being available, or inadequate supports such as equipment being available. Consequently, patient care suffers, and often, patients recently discharged return to the hospital for further care.

It is important that patients at discharge have access and availability of their medications in a timely manner.


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Desired Outcomes

• An individualised palliative care plan is developed in conjunction with the person and their whānau and is available to them and their health and care teams with an Identified lead palliative carer and linked to a palliative care facilitator to support the co-ordination of the person’s care

• Suitably experienced health professionals carry out comprehensive assessment of the palliative care needs of a person. The integrated care team can further contribute and develop this as needed.

• Review of a patient’s health and care needs occur in a timely manner whenever the patient’s condition changes, and the care plan is then updated

• Duplication of assessment and service provision is avoided and transition between services is safe and easy for the patient and whanau

Actions

4. Consolidate current assessment tools and processes across multiple providers into one agreed assessment tool that allows access to a full complement of services.

5. Implement a consistent palliative care pathway across all services within a district that supports service transitions and transfer of patients between services.

Measuring success

• Patients identified as palliative will have one comprehensive palliative care assessment/care plan/goals of care with an identified lead palliative carer and palliative care facilitator for their palliative care

• The patients care team of interdisciplinary health professionals will have access to and be able to contribute to the assessment/care plan/goals of care and subsequent reviews

• Patients do not have assessment duplicated by different services but different services contribute to one assessment and transitions between services feels seamless to the patient and their whānau

Goal 3: Patients and their whānau experience equitable and seamless care through coordinated service provision (Integration)

Once a care plan has been developed and communicated, the provision of care under the care plan requires strong collaboration and coordination across the range of local providers. Poor coordination of care is the largest obstacle to achieving the care preferences of patients and their whānau.

Coordination needs to occur at various levels – within teams, across teams, within organisations and across organisations. This strategy proposes a single point of facilitation through which services can be coordinated that has a dedicated helpline for people nearing the end of their lives.

Seamless care for patients requires those involved in planning, funding and the provision of services to have a shared vision, employ a combination of processes and mechanisms and ensure that the patient’s perspective remains a central principle throughout. Our palliative care services will feature:

• the patient enfolded by a seamless system of service delivery, achieved by productive relationships between and among the various providers of palliative care

• a Whānau Ora approach to build on the strengths and resilience of families/whānau and ensure there is respect for their beliefs and values

• active support for vulnerable population groups.


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Single point of entry

For patients to experience seamless care, once it has been identified that a patient would benefit from a palliative care approach, a single point of entry for service facilitation and access is required. This will need to be well documented and understood by all health professionals and the wider community. This single point of service facilitation will enable access to all domiciliary nursing, support services, family/care support, and primary and specialist palliative care services. Referral to this single point can be made by referrers and patients/whānau at any stage of the patient’s journey. In the early stages of the patient’s journey, this may be as simple as sharing the individualised palliative care plan as a means of communicating the patient’s status and preparing for support to move quickly as and when need arises. Where referral is not made by the GP, the PCF will contact the primary care team to include them in the process. This approach is working successfully in Wairarapa for most patients, and should be expanded to both HVDHB and CCDHB districts. This could be locality based and be part of the local delivery alliance arrangements.

This strategic plan seeks to embed a palliative approach throughout health services, so that primary care clinicians can provide continuity of care throughout a person’s illness, with the support of specialist palliative care services. It is possible that services and funding streams for palliative care could be accessed through the same channels as other health and disability services.

The palliative care facilitator (PCF) will facilitate access to a range of services including equipment, end of life packages of care, nursing services, allied health, home and community support services, ARC facilities, respite, 24/7 support, prescribing services, specialist doctors and nurses, informal carers/Kaiawhina and volunteers.

To support the various providers in providing end of life care and support, it is proposed that this function is responsible for:

• Receiving referrals

• Notifying and communicating with the GP

• Identifying who is already involved

• Facilitating assessment and ongoing case review

• Identifying and closely liaising with the lead palliative carer (LPC)

• Providing administrative support to the LPC in the delivery of the care plan

• Arranging a range of packages of care and support services as required by agreed care plan

• Holding and administering equipment

Most importantly, the PCF function will support the coordination of care by providing a link between lead palliative carer and the necessary support services.

After hours care and support

After hours care and support is problematic. The needs of palliative care patients and their whānau continue 24 hours, 7 days a week, through weekends and statutory holidays. Individualised palliative care plans will detail the arrangements for medical care and support 24 hours/ 7 days a week. After hours care could be provided by a coordinated suite of professionals whose core role includes a 24 hours /7 days a week service. This planning and coordination of care is particularly vital to avoid unnecessary hospitalisation at the end of life as these services play a critical role in managing the care of patients in the community outside of normal working hours. These services can provide emergency and planned visits to patients homes (including a prescriber), as well as emotional support and guidance to patients and carers over the telephone during after hour periods.

Care planning will formalise a coordination and case management role that is at present frequently undertaken by community based health professionals. However, there is likely to be some impact on workloads, with


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consequent resource considerations. Additional resources may also be required to provide culturally appropriate coordination of services for Māori. Detailed service specifications and an implementation plan will be developed as part of the configuration of services. Clinical pathways, including after hours care, will be available on the 3DHB Health Pathways website to support care planning for those involved in the patients care.

The different technology platforms across the sub-region are of concern and awareness about the importance and value of shared care platforms is increasing, and Manage my Health is now becoming available to some health professionals. Shared care planning utilising Manage my Health needs to be available to all those involved in the patient’s care, both to view and to contribute. Patients, whānau and providers want to be able to check who is visiting the home and work together to minimise visits and maximise care.

Desired Outcomes

• Palliative care provision that is equitable across the whole of the population that the health systems serve

• Palliative care professionals and services that are aware of and address service access disparities for their local population

• Palliative care services that collaborate between primary, secondary and specialist services with a named lead palliative care professional co-ordinating service provision

• Palliative care that is well co-ordinated and seamless for the patient and their whānau

• Māori and Pacific services that are integrated with other services

Actions

6. Implement a local single point of service facilitation to access a wide range of comprehensive wrap-around palliative care services

7. Establish and implement locality palliative care specialists and case collaboration models to create a clear and formalised way of working across the palliative care system

8. Implement shared care planning across the 3 districts and enable access to all relevant health providers

Measuring success

• Single point of service facilitation in each district is implemented

• Patients have equal access to palliative care services across all parts of the community, whatever their ethnicities and socio economic situations

• Palliative care system is responsive to different cultural need across the population

• Palliative care services and provision is coordinated and seamless for patients and their whānau

• Providers of palliative care have integrated systems and processes with robust communication

Goal 4: High quality sustainable services are delivered (Quality)

People nearing the end of their lives might need to access a complex combination of different services from a range of different providers. These services need to be provided across a range of different care settings (hospital, aged care, hospices, and community) but also prisons, hostels for the homeless and homes for those with disabilities.

Providing high quality care in these various settings requires the implementation of quality tools (e.g. Hospice NZ Standards for Palliative Care (Hospice New Zealand, 2012) and the Gold Standards Framework (The Gold Standards Framework National Central Team , v25)), coordinated 24/7 responsive community services, and robust


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and consistent workforce training and education including identification of patient’s needs, communication skills, and the physical management of patients nearing the end of their lives.

Enabling care at home

“I’m dying and I want to go home.”

Many people want to die at home but this will always be dependant on the person’s and whānau circumstances, capacity and capability. For most this is not possible without supports that are currently difficult to organise. To enable dying at home, we need to provide responsive coordination and palliative care planning, access to respite care, home based support and whānau support. Service delivery requires a lead carer that can respond quickly to rapidly changing end of life needs by coordinating patient requirements such as equipment, carers, and domiciliary health providers – district nursing, hospice nursing and home support carers. Enabling this change may require a reallocation of current resources.

Developing and implementing system wide training for whānau and informal carers is necessary to empower care and self care. Those caring for patients can be trained to give injections and administer medication. The processes and support to enable this will need to be improved so that, when issues arise they can be managed safely. Concerted efforts to supporting carers to minimise carer fatigue will need to be made.

Medication protocols are also required to support patients and carers managing these in the home and for surplus medications to be safely managed. All health professionals involved in their care have responsibility to ask questions about and manage surplus medications.

Hospitals

Although it is acknowledged that, given the choice, most people would choose to die in their own homes, it may be appropriate for some patients approaching end of life to be treated and to die in acute settings. Data projections indicate that 28% of deaths, in 2016 of people needing palliative care will die in a public hospital and it is likely that this figure will remain the same in 2038 (MacLeod, 2016). It is crucial to ensure that care delivered in these settings is both compassionate and patient centred. Hospital palliative care teams already play a key role to develop and support the primary palliative care skills of hospital teams. In the future model, this will continue and they will provide essential advice and support to the LPC and PCF roles.

Aged Residential Care Facilities

Many aged residential care facilities are committed to enabling their residents to remain in this setting as they near the end of their lives, if that was their expressed preference. This could include sourcing additional specialist equipment, liaising with health and social care professionals, ensuring that there was sufficient staff capacity to provide particular attention to those residents very close to death.

Hospice

Patients and whānau experience of using hospice services is very good across the sub region. The role of hospice in the inpatient support and management of people with complex palliative care needs will continue to remain an essential component of palliative care in the future.


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Specialist palliative care services already play an important role in supporting the primary palliative care service, (including assessment and development of care plans) providing advice and education, episodic specialist consults, respite, management of patients with complex palliative care needs and end-of-life care. With the growing trajectory of people who will require palliative care support as people age, the role of hospice will also likely change to increase their support of the primary care and aged residential care teams to better manage patients in the home through changes in their model of care.

“Instead of a Park Royal for some, we need a Holiday Inn for all”

Workforce approach

Patients with similar needs currently experience varying service levels depending on which service they are accessing. This plan puts emphasis on the provision of high quality primary palliative care, provided through an integrated network of carers, volunteers, and health professionals from primary care, community services, aged residential care, secondary health services and specialist palliative care services. This network of palliative care providers will work in partnership and be underpinned by palliative care training for all providers, commitment to common palliative care standards, common assessment methodology, and a single shared plan of care for each dying person.

The palliative care workforce (medical specialists, nurses, allied health practitioners, and home and personal care workers) is a vulnerable sector as this is a maturing and ageing group. Although this is a concern for the whole of health, it is particularly relevant to palliative care. There is also a shortage of palliative medicine specialists and a forecast shortage of specialist nurses, GPs and Māori health workers.

There is considerable potential to better utilise the skills of the allied health and pharmacy workforce in palliative care. The carer and support workforce, including volunteers and those working in ‘compassionate communities’, are a fundamental component of current specialist palliative care services, and a workforce development approach needs to recognise the role of volunteers and ensure they are adequately prepared and supported.

A renewed workforce approach is needed to ensure the provision of a consistent high standard of care. We will develop a palliative care approach across all health services through workforce development and training, and through the adoption of a recognised care pathway for the dying. On-going education in palliative care will be required for all health professionals who are closely involved in the care of patients with end of life needs.

We need to build capability and capacity in primary palliative care services to enable all those who would benefit from a palliative approach to receive high quality services appropriate to their needs. Simultaneously a concerted effort to maintain sufficient capacity in the specialist workforce is needed in order to provide the necessary support, advice and education. A sub-regional stocktake to ascertain workforce capacity would inform a workforce development programme that will:

• actively advance expertise amongst providers of primary palliative care services (European Association for Pallative Care, 2016);

• explore rotating of nurses through specialist palliative care services, district nursing service and primary care;

• mentoring or secondment programmes for nursing and medical graduates;

• ensure a culturally competent workforce to accommodate diverse personal, cultural and spiritual customs and values;

• build and grow the non-regulated workforce with a particular focus on Māori;


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• develop, train and support the informal carer and volunteer workforces;

• support sub-regional approaches to workforce development including e-learning, face to face mentoring and support, resource development, training of medical and nursing staff in primary and specialist services;

• enable supportive work practices such as mentoring, case collaboration, specialist partnership staff working alongside primary providers; and

• enhance the utilisation of the skills of allied health professionals, pharmacists and specialist palliative care nurses.

Specialist palliative care nurses offer a range of skills, from assessment and care planning and may initially participate in individualised palliative care planning conversations in primary care. Over time this support may reduce as primary care providers gain palliative care expertise, skills and confidence.

While approximately 43% of people suitable for a palliative approach die in aged residential care facilities, many facilities struggle with the provision of after hour’s medical care for their residents, particularly for unexpected changes in conditions and prescribing needs. These services will be supported by the locality palliative care specialists.

Clinical governance

Clinical governance is a framework through which organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish (Scally G, 1998). Clinical governance in conjunction with an agreed quality framework ensures the highest possible safety and quality of care (O’Rouke I, 2003). It provides a set of mechanisms to encourage people to work in teams to improve their workplace processes and performance. It represents an opportunity to emphasise systematically the importance of a range of ideas drawn from disciplines such as clinical practice improvement, organisational behaviour, management and quality and safety and use these in enhancing clinical and managerial processes (Scally G, 1998).

Effective system clinical wide governance will be required for the successful implementation of this plan. On-going service design and implementation will be led with effective clinical leadership and governance structure. A commitment to maintain the Lower North Island Managed Clinical Network for Palliative Care could be explored.

Quality Framework

Services will be supported by a culture of continuous innovation, quality improvement and learning that is embedded in the service design. To support equitable access to quality care, we will implement a quality framework that spans across the range of services. A quality framework sets out reasonable expectations of quality care for people that would benefit from a palliative approach, and their whānau. The recent draft palliative care services review highlights the need for an agreed national set of core outcome, quality and activity data. It proposes the development of an agreed outcomes framework.

Desired Outcomes

• A workforce with capability and capacity to deliver standardised high quality palliative care across the whole of the health and care system

• Palliative care education and resources that are available to all professionals, carers and community across the sub-region

• System wide clinical governance, quality framework and monitoring processes utilised in palliative care

• Sustainable and skilled workforce across the whole of health


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Actions

9. Complete a sub-regional workforce plan that considers the current gaps and future workforce requirements of specialists, nurses, and the allied health workforce. Such a Plan would identify ways in which the workforce across the sub region could best leverage off each other’s skills and expertise, and work together to strengthen the workforce capacity and capability.

10. Develop and implement a sub-regional workforce training and professional development programme based upon evidence based practice and quality measures to include:

• Clinical skills and prescribing management

• Cultural perspectives for end of life

• End of life recognition, planning and conversations for health professionals across the system

• Specialist partnership staff working in primary care settings

• Informal carers, volunteers and kaiawhina

11. Establish a system wide network/service level alliance in each district to oversee local implementation of the strategy

12. Implement the nationally agreed quality standards and increase the visibility of palliative care quality indicators in accountability arrangements, as proposed in the draft service review (Ministry of Health, June 2016). These would include:

• A regional platform for the exchange, comparison and benchmarking of patient focussed best practice between providers and linked to clinical governance.

• Linkages to education and research in palliative care.

13. Implement a patient/whānau satisfaction survey following initial referral/planning and the VOICES (Views of Informal carers – Evaluation of Services) survey to establish a baseline of consumer experience and measure improvement over time.

Measuring success

• Curriculum and development programme for health professionals within primary and specialist palliative care providers across the palliative care system is in place and utilised

• Specialist services/primary provider partnership agreements in place and utilised

• Active palliative care clinical governance, quality framework and standards monitoring are in place

• Patients and whānau report a ‘good death’ in satisfaction surveys

Goal 5: Care in the last days of life is comprehensive, with good symptom control, is in the most appropriate setting in the company of family and friends (Last Days of Life)

The identification and management of care needs in the last days of a patients life requires particular attention. This phase can be identified by various signs and it is vital for the professionals involved with the patient to recognise and to communicate this to the patients and their whānau. It is also imperative that this recognition is then followed up by the making of any changes necessary in how care is provided. The care given to patients during their very last days of life is very much dependant upon health and social care professionals having previously taken steps to identify, discuss and assess palliative care needs and also planning and reviewing care.

Te Ara Whakapiri (MoH, 2015) provides a statement of guiding principles and components for the care of adults in their last days of life across all settings, including the home, residential care facilities, hospitals and hospices. It will be used as a foundation document to inform end of life care and education.


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Preparation for the dying phase

Early preparation is important to meet the support and care needs of patients that are nearing the end of their life as well as their whānau/carers. Care professionals that have built up a relationship with a patient over time are familiar with patients, and are able to observe signs of deterioration or other changes in physical and cognitive capacity. Being aware of significant changes in strength, appetite or cognitive function prompts care professionals to take the actions necessary to prepare for end of life care. For example, ARC facility staff will inform the GP and organise anticipatory medication to avoid inappropriate admissions to hospital at the end of life.

Once a patient has been identified as nearing the end of life, it is necessary to review the advance care plan continually to check that all the resources are in place to provide the preferred end of life care services. Information sharing and communication amongst various teams is critical at this stage, and the palliative care facilitator will need to be closely involved to ensure the right resources and services are available.

Compassionate and person-centred care

A core aim of this strategy is that patients experience a ‘good death’. To achieve this patients are treated as individuals with dignity and respect, without pain and other symptoms, in familiar surroundings (where possible), and in the company of close family and /or friends. Preparation underpinned by communication between various providers is key to compassionate and person centred care.

Desired Outcomes

• Health professionals across the health systems recognise the transition of the patient towards the last days of life and are able to communicate this to the patient, whānau, carers and the wider health team occurs in a skilled manner

• Care provision is comprehensive and supportive for the end of life phase in the most appropriate and preferred place for the patient and their whanau

• Patients and their whānau are treated as individuals, with dignity and respect and given emotional support throughout the end of life phase

• Whanau and carers are well informed, have their needs supported, included in decisions and supported to provide physical care if they wish.

Actions

14. Ensure a wide range of responsive and comprehensive service options exist, including 24 hours/ 7 days a week carer, specialist, nursing and medical support, and psycho-social support for those patients and their whanau in the last days of life.

Measuring Success

• End of life transition moments are recognised, documented and well communicated.

• Health professionals feel well prepared and supported for patient’s end of life care

• End of life care is resourced appropriately

• Support for a patient’s whānau through the end of life phase is appropriate for them


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Goal 6: Whānau experience high quality care after death (After Death Support)

Care of the person after death

It is clear that when a person dies, high quality end of life care also means providing due care and attention to the patient and their whānau after death, especially if there are any cultural or religious procedures that must be carried out after death. This would be outlined in the care plan of the deceased (as well as the wishes of the whānau). The whānau will also be supported with practical information that they may need such as obtaining a death certificate and registering the death. Efforts should be made to ensure a dignified and respectful farewell. Although this will vary across different settings, the common principle is showing respect for the individual who has died.

Bereavement Support

The period after a person has died is obviously a sensitive time for any whānau as well as those involved in providing palliative care, including staff and volunteers. Currently support for bereavement care is limited, and for palliative care patients this is further limited and variable depending upon whether the patient is receiving services from a hospice or their GP. There is often comprehensive support for hospice patients but little for others. Having early discussions and enabling planning about what to do are crucial for all those involved. It is important to note that in reality, bereavement support begins earlier along the trajectory for both the palliative care patient themselves and their whānau in order to prepare and adjust to the impending loss.

Providing end of life care has tremendous emotional impact upon a whānau and anyone involved in a patients care needs to be sufficiently trained in communication skills and be able to signpost whānau to a source of support, such as carers group or bereavement support services.

The emotional impact of providing palliative care can also be felt by paid and unpaid staff working closely with someone who is dying. Recognising the emotions of staff is important to ensure that their motivation levels are sustained and that they have the emotional and physical capacity to continue to look after other patients.

Desired Outcomes

• Due care and attention is provided to the patient and their whānau after death

• Bereaved whanau, formal and informal carers will have access to good quality information about the practical steps they need to consider and where to access emotional support if required.

Actions

15. Implement culturally appropriate bereavement support services and enable equitable access for those in need of support after death

Measuring Success

• Bereaved whānau have appropriate and accurate information about the post death requirements.

• Formal, and informal carers and whānau are aware of and able to access bereavement support.


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Achieving the future vision for palliative care across the sub-region will clearly involve a period of evolutionary change over the next five years. Despite the gaps and barriers of the current palliative care system there are some pockets of effective integration and partnership working in each district. The implementation plan will build on this and expand it across services to achieve further integration and enhance the coordination of palliative care services.

Implementation will be achieved through local, or sub-regional alliancing arrangements which will be responsible for driving agreed actions to improve the patient and whanau journey. These will ensure clinically-led service development and implementation is within a “best for patient, best for system” framework. The alliances are also expected to build on the work currently underway to implement the primary care component of the new initiatives funding for primary care announced in Budget 2015.

The alliancing arrangements will give consideration of the issues relevant to each district, i.e. the rural needs for some Wairarapa DHB patients, in order to:

• provide system-level advice, oversight, monitoring and evaluation of the implementation of the Strategy, ensuring connectedness and a whole of system approach to alliance activities;

• provide whole of system clinical governance with resourcing, which is in touch with region wide sector activities;

• support a distributed model of care (more emphasis on non-specialist /primary services);

• maximise opportunities to implement the 3DHB Palliative Care Strategy;

• create shared leadership for all palliative care initiatives across the region;

• agree the work, activity and services that need to be provided to meet the alliance objectives.

In order to ensure a stable and enduring transition to the future model, it will be important to protect the gains and relationships that have already been made in developing this strategy. The sector is motivated and committed to the coordinated change that is needed as we, locally, regionally and nationally, face the challenge of the increasing and changing nature of future demand.

Section 3: Next Steps – Implementing the strategy


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APPENDIX 1: Glossary of Definitions and Concepts (Ministry of Health, 2015)Advance Care Planning (ACP): Advance Care Planning (ACP) is a process of discussion and shared planning for future health care. It is focused on the individual and involves both the person and the health care professionals responsible for their care. It may also involve the person’s family/whānau and/or carers if that is the person’s wish. ACP provides individuals with the opportunity to develop and express their preferences for care informed not only by their personal beliefs and values but also by an understanding of their current and anticipated future health status and the treatment and care options available.

Individualised Palliative Care Planning: Individualised palliative care planning is being introduced in primary care for patients that would benefit from a palliative approach. Patients and their whānau receive a free consultation(s) with their primary care team to consider all aspects of care over the next 12 months, including medical, nursing, physical, spiritual, psychosocial care. This is an opportunity to begin the early conversation for patients and their whanau, identify a lead palliative carer and will trigger the engagement of a palliative care facilitator. This information will also be used to inform the initial palliative care assessment.

Bereavement: The period after a loss during which grief is experienced and mourning occurs. Although there are similarities in people’s responses, there are also marked differences. Each person will grieve and recover in however they need to, and in their own time.

Care Pathway: A care pathway is a complex intervention for the mutual decision making and organisation of care processes for a well-defined group of patients during a well-defined period. Defining characteristics of care pathways include:

• An explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics;

• the facilitation of the communication among the team members and with patients and families;

• the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives;

• the documentation, monitoring, and evaluation of variances and outcomes; and

• the identification of the appropriate resources. The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimising the use of resources.

Chronic Condition: A biological or physical condition where the natural evolution of the condition can significantly impact on a person’s overall quality of life, including an irreversible inability to perform basic physical and social functions. Serious and persistent chronic conditions are multidimensional, interdependent, complex and ongoing. Chronic conditions are characterised by persistent and recurring health consequences lasting for three months or more.

[Note: this document proposes to not use the term ‘illness’, as it implies a more narrow scope of health issues that impact on a person’s quality of life.]

Compassionate Communities: A compassionate community is where a community provides support to someone who is dying has been introduced overseas . The community could be family, neighbours, local organisations, churches, local businesses or people living in a particular area. People in a compassionate community help care for a dying person through small acts of compassion, supporting the dying person and their family during their end of life, often enabling them to die well and, if possible, at home.

Appendices


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Death: The cessation of all vital functions of the body, including the heartbeat, breathing and brain activity (including the brain stem).

Dying: A person is considered to be dying when they are in the process of passing from life to death. It is characterised by a gradual failing of vital functions including the cardiac, respiratory and central nervous systems, followed by an absence of criteria that define life (spontaneous heartbeat, breathing and brain function). The dying phase is generally considered to be minutes to hours in duration, but can occasionally be just seconds.

End of Life: is that period of time prior to death but the duration can never be precisely defined in advance ((European Association for Pallative Care, 2016)).4

Recognising and identifying those people who are at risk of dying at some point in the year ahead enables the health and social systems to respond to the deteriorating person and their families/whānau/carers in a holistic and comprehensive way.

Although prognostication is inherently difficult, being better able to predict when people are reaching the end of life phase, whatever their diagnosis, makes it more likely that they receive well-coordinated, high quality care. This is more about the health care system meeting needs than giving defined timescales. The focus is on anticipating the needs of the person and families/whānau/carers so that the right care can be provided at the right time. This is more important than working out the exact time remaining and leads to better proactive care in alignment with preferences.

The end of life period is triggered by a transition in the place of care, levels of care and/or goals of care. The major transition to the end of life period is in changing the focus on the person from curative and restorative care, which aims to extend the quantity of life, to palliative care which aims to improve the quality of life.

End of Life Care: is the care guided by the person’s needs and goals, and is the responsibility of all who work within the health sector.

Planning for coordinated end of life care across all levels of the health system is essential for District Health Boards. Tools such as the Gold Standards Framework, (National Gold Standards Framework Centre 2011) the Supportive and Palliative Care Indicators Tool (SPICT™) (Boyd and Murray 2014) or the interRAI Palliative Care assessment (interRAI 2014) can assist to identify those people who need a transition of care. This may include a transition in the place of care, levels of care and/or goals of care.

End of Life Care covers the full range of clinical services provided. It incorporates treatments, programmes, policies, initiatives, benefits and entitlements that are provided for the person and their family/whānau/carers from the point when a life-threatening condition or illness is diagnosed until after the death, to include the care of the deceased person’s body and care of their family/whānau/carers.

Family: A family is defined as those who are closest to the patient in knowledge, care and affection. The family may include the biological family, the family of acquisition (related by marriage/ contract), and the family of choice and friends (including pets). See also Whānau.

Generalist Palliative Care: Refer to ‘Primary Palliative Care’. [Note: this document proposes not to use the term ‘Generalist Palliative Care’, as it does not adequately describe the nature of palliative care provided by health services that are not specialist palliative care services)

Gold Standards Framework (GSF) (from UK GSF website): The Gold Standards Framework (GSF) is a systematic evidence based approach to optimising the care for patients nearing the end of life delivered by generalist providers. It is concerned with helping people to live well until the end of life and includes care in the final years of life for people with any end stage illness in any setting. Several DHBs in New Zealand are now looking at implementing the programme in primary and aged residential care settings.

The National GSF Centre in the UK is the national training and coordinating centre for all programmes in the UK, enabling generalist frontline staff to provide quality care for people nearing the end of life, whatever their illness,


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wherever the setting. It aims to support best implementation of GSF in all settings, using a common framework and toolkit of resources.

GSF improves the quality, coordination and organisation of care in primary care, care homes and acute hospitals. This enables more patients to receive the type of care they want, in their preferred place, with greater cost efficiency through reduced hospitalisation.

Holistic: A system of comprehensive or total patient care that considers the physical, emotional, social, economic, and spiritual needs of the person; their response to illness or life-limiting/life-threatening condition; and the effect of the illness or condition on the ability to meet self-care needs. The principles of palliative care are framed around holistic care and the interdependent physical, social, emotional, cultural and spiritual aspects.

Hospice: Hospice is not only a building; it is a philosophy of care. The goal of hospice care is to help people with life-limiting and life-threatening conditions make the most of their lives by providing high quality palliative and supportive care.

Hospices provide care for the whole person, not just their physical needs but also their emotional, spiritual, and social needs. They also care for families and friends, both before and after a death. Irrespective of where a hospice service is, this philosophy of care does not change. In New Zealand all aspects of hospice care are provided free of charge.

Integrated Care Team: each patient will have one virtual integrated, inter-disciplinary care team who will ensure that the needs of the patient and their whānau are identified and met. The patient, whanau and any informal carers are crucial elements of this team. Each patient will have an individualised palliative care plan which will encompass all settings in which the patient receives care. This plan will clearly identify all the key members that are directly involved in caring for the patient, as well as a designated lead palliative carer (LPC) and a palliative care facilitator (PCF). The LPC is responsible for clinical/medical oversight and the PCF is responsible for coordinating services to meet need.

Additional membership of this team will vary depending on other services that might be required to identify and address the expectations and needs of the patient, whanau or informal carers. The team could typically include one or more doctors, nurses, social workers, spiritual advisers, pharmacists, and personal care workers with other disciplines becoming part of the team as resources permit (Ministry of Health, 2015). Team members may transition in and out of the caring team as they are needed i.e. locality palliative care specialists (see below) may be called upon to undertake assessment and/or provide episodic support/care during an acute phase.

interRAI (Palliative Care) Assessment Tools (interRAI stands for International Resident Assessment Instrument) provide a standardised, comprehensive clinical assessment of a palliative patient’s medical and support needs and can provide information to help write tailor-made care plans. From July 2015 the interRAI became the mandatory clinical assessment tool for nurses to use in residential aged care facilities in NZ. A pilot project is currently underway to test the use of the interRAI Palliative Care assessment and care planning tools in three District Health Boards (Hawkes Bay, Mid Central and Canterbury) in the home based community setting. The findings will be used to inform requirements for a wider implementation of this tool across New Zealand.

Lead Palliative Carer (LPC): This is the lead carer in the community for palliative care patients and is the first point of contact for patients and their whānau. They will ensure, in partnership with the palliative care facilitator, that the individualised Palliative Care Plan details the arrangements for medical care and support 24 hours/ 7 days a week. This person takes the responsibility for the lead medical care for the patient and likely to be aGP, practice nurse or registered nurse (if the patient resides in an Aged Residential Care facility).

Life-Limiting Condition: A life-limiting condition is one for which there is no reasonable hope of cure and from which the person will die. Some of these conditions cause progressive deterioration rendering the person increasingly dependent on family and carers. Also refer to ‘Life-threatening condition’ and ‘Terminal condition’. [Note: this Glossary proposes to not use the term ‘illness’, as it implies a more narrow scope of health issues that impact on a person’s quality of life.]


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Locality Palliative Care Specialists: Locality based palliative care specialists will support primary palliative care providers with expert consultation and advice. These specialists will work together to support a cluster of GP practices and ARC facilities, depending on the population within the locality. These virtual teams could include a gerontologist, a practice nurse with a special interest in palliative care, a gerontology nurse, allied health worker, clinical pharmacist, a palliative medicine specialist and nurse from the hospice community team. Their main role will be to make sure specialist knowledge is available for frontline workers. They will build and strengthen relationships and over time develop trust and confidence. This will improve the coordination between services and enhance the seamless experience of care for patients. These experts will indirectly, and at times directly, support primary providers in their locality with facilitating interdisciplinary review of palliative care patients, case reviews and educational support. Certain specialist’s within this locality support team i.e. palliative medicine specialist will be contactable 24 hours/7 days a week.

Palliative Approach: A palliative approach embraces the World Health Organization definition of palliative care. It incorporates a positive and open attitude toward death and dying by all service providers working with patients and their families, and respects the wishes of patients in relation to their treatment and care. A palliative approach aims to improve the quality of life for individuals with a life-limiting illness and their families, by reducing their suffering through early identification, assessment and treatment of pain, physical, cultural, psychological, social, and spiritual needs.

Underlying the philosophy of a palliative approach is a positive and open attitude towards death and dying. The promotion of a more open approach to discussions of death and dying between health care professionals, patients and their whanau facilitates identification of their wishes regarding end-of-life care.

A palliative approach is not confined to the end stages of an illness. Instead, a palliative approach provides a focus on active comfort care and a positive approach to reducing an individual’s symptoms and distress, which facilitates patients’ and their families’ understanding that they are being actively supported through this process.

Palliative Care: The World Health Organization defines palliative care as: an approach that improves the quality of life of patients and their families facing the problems associated with life-limiting or life-threatening conditions, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:

• provides relief from pain and other distressing symptoms;

• affirms life and regards dying as a normal process;

• intends neither to hasten nor postpone death;

• integrates the psychological and spiritual aspects of patient care;

• offers a support system to help patients live as actively as possible until death;

• offers a support system to help the family cope during the patient’s illness and in their own bereavement;

• uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;

• will enhance quality of life, and may also positively influence the course of illness;

• is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life,

• clinical complications.

A New Zealand specific definition of palliative care is: Care for people of all ages with a life-limiting or life-threatening condition which aims to:

• Optimise an individual’s quality of life until death by addressing the person’s physical, psychosocial, spiritual and cultural needs.

• Support the individual’s family, whānau, and other caregivers where needed, through the illness and after death.


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Palliative care is provided according to an individual’s need, and may be suitable whether death is days, weeks, months or occasionally even years away. It may be suitable sometimes when treatments are being given aimed at improving quantity of life. It should be available wherever the person may be. It should be provided by all heath care professionals, supported, where necessary, by specialist palliative care services. Palliative care should be provided in such a way as to meet the unique needs of individuals from particular communities or groups. These include Māori, children and young people, immigrants, refugees, and those in isolated communities.

Palliative Care Facilitator (PCF): The palliative care facilitator refers to the clinician assigned the responsibility for facilitating and coordinating access to services. They will belong to the Palliative Care Facilitation Service and work in close partnership with the Lead Palliative Carer. They will fundamentally be the first point of call for the lead palliative carer seeking support for their palliative care patients and will maintain close linkages with locality specialists.

Palliative Care System: This refers to palliative care services, primary palliative care providers and the other factors that enable them to deliver palliative care, such as communication and coordination between providers. Without these ‘other factors’ palliative care providers cannot function as part of a ‘system’. It is not simply the existence of primary palliative care providers and specialist palliative care services (i.e hospice and hospital palliative care specialists) that comprises the palliative care system; it is the links that exist between them that tie together ‘a system’.

Patient: A patient is the primary recipient of care. In the practice of palliative care, the patient together with their family/whanau and carers are the focus of care.

Informal Carer: The informal carer (or carers) are generally from within the close kin network/family or whanau of the patient and usually self identified. They can be the patient’s spouse, child, another relative, family member or friend. He/she may be supported by others, and will take a key role in the co-ordination and delivery of care and support to the patient. They provide for the practical needs of the patient and can take on additional tasks that may be of a technical nature, to provide ongoing care for the patient, e.g. the administration of medications.

Primary Palliative Care: Primary palliative care is provided by all individuals and organisations that deliver palliative care as a component of their service, but their substantive work is not in the care of people who are dying. It is palliative care provided for those affected by a life-limiting or life-threatening condition as an integral part of standard clinical practice by any healthcare professional that is not part of a specialist palliative care team.

In the context of end of life care, a primary palliative care provider is the principal medical, nursing or allied health professional who undertakes an ongoing role in the care of patients with a life-limiting or life-threatening condition. A primary palliative care provider may have a broad health focus or be specialised in a particular field of medicine. It is provided in the community by general practice teams, Māori health providers, allied health teams, district nurses, and residential care staff etc. It is provided in hospitals by general ward staff, as well as disease specific teams – for instance oncology, respiratory, renal and cardiac teams.

Specialist Palliative Care: Specialist palliative care is palliative care provided by those who have undergone specific training and/or accreditation in palliative care/medicine, working in the context of an expert interdisciplinary team of palliative care health professionals. Specialist palliative care may be provided by hospice or hospital based palliative care services where patients have access to at least medical and nursing palliative care specialists.

Specialist palliative care is delivered in two key ways in accordance with New Zealand Definition of Palliative Care.

Directly – to provide direct management and support of patients and families/ whānau where more complex palliative care need exceeds the resources of the generalist provider. Specialist palliative care involvement with any patient and the family/ whānau can be continuous or episodic depending on the changing need. Complex need in this context is defined as a level of need that exceeds the resources of the generalist team – this may be in any of the domains of care – physical, psychological, spiritual, etc.

Indirectly – to provide advice, support, education and training of other health professionals and volunteers to support the generalist provision of palliative care provision.


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Standards: A standard is something established as a measure or model to which other similar things should conform. There are three types of standards in health care: structure, process, and outcome standards. Structure refers to evaluation of the setting in which care is rendered and the resources that are available. Process refers to evaluation of the actual activities carried out by the care giver. Outcome refers to evaluation of the results of activities in which the nurse has been involved (what the result is for the patient). For example: the Hospice New Zealand Standards set out best practice in relation to the provision of end of life care in hospices. They identify the essential elements that need to be in place to ensure consistent quality end of life care across the hospice sector.

Supportive Care: Supportive care helps the patient and their family / whānau to cope with their condition and treatment of it – from pre-diagnosis, through the process of diagnosis and treatment, to cure, continuing illness or death and into bereavement. It helps the patient to maximise the benefits of treatment and to live as well as possible with the effects of the disease.

When the underlying disease has been identified as incurable, ‘Supportive Care’ would be best substituted with ‘Palliative Care’.

Terminal Condition: A progressive condition that has no cure and that can be reasonably expected to cause the death of a person within a foreseeable future. The definition is inclusive of both malignant and non-malignant conditions and ageing. Also refer to ‘Life-limiting condition’ and ‘Life-threatening condition’.

Virtual Integrated inter-disciplinary teams: A virtual team that enables shared care. Palliative care will be delivered by having a virtual integrated inter-disciplinary team (IDT) with each patient having a coordinated and continually updated palliative care plan. Each patient will always have a designated lead palliative carer (LPC) and a palliative care facilitator (PCF). These health practitioners will be responsible collectively for ensuring that the needs of the patient and their whānau are met.

VOICES (Views of Informal Carers – Evaluation of Services) Survey: collects bereaved peoples’ views about eh quality of care provided in the last three months of life. An adaptation of this survey is being piloted in New Zealand (South Island Alliance and Auckland DHB) at the time of developing this plan.

Whānau: Whānau means the extended family, family group, a familiar term of address to a number of people - in the modern context the term is sometimes used to include friends who may not have any kinship ties to other members. This close kin network of the patient may encompass informal carer/ who provide for the practical needs of the patient and can take on additional tasks that may be of a technical nature, to provide ongoing care for the patient, e.g. the administration of medications. They provide the primary support role for the patient at all levels of need.


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APPENDIX 2: Engagement with Stakeholders

The following groups of stakeholders/partners have been consulted (either in meetings or by phone/email communications) and provided input to this Strategic plan:

Consumer/Carer Group

A total of 29 groups of consumer/carers provided feedback from across the sub-region.

Hospice staff

Ria Earp (CE, Mary Potter Hospice) Biddy Harford, Diane Greenwood-Havea, Eleanor Barrett and Mary Death (Te Omanga Hospice) Suzie Adamson (Hospice Wairarapa)

Other DHB staff

Adri Isbister (CE, Wairarapa DHB) Anne Savage (Palliative Care Nurse Educator, Wairarapa DHB) Lisa Burch Joanne Edwards, Ondine Claridge and Jan Marment (SIDU, Hutt, CCDHB and Wairarapa DHBs) Simon Allan (Director of Palliative Care, Arohanui Hospice)

PHOs

Martin Hefford, Chris Kerr and Justine Thorpe (Compass Health) Teiringa Davies (Ora Toa PHO) Sharon Cavanagh (Well health Trust PHO) Lyn Allen (Cosine PHO) Dr Tony Becker (Masterton Medical Centre) Bridget Allan and Paul Abernethy (Te Awaikarangi Health Network) Dr Chris Masters (Ropata Medical Centre)

Hospital & Hospice Palliative Care specialists

Dr Jonathan Adler (CCDHB, Hospital Palliative Care Service) Dr Brian Ensore and Dr Annabel Dunn (Mary Potter Hospice) Dr Thomas Middlemiss, Dr Salina Iupati and Dr Ian Gwynne-Robson (Te Omanga Hospice)

Community & Hospital Nursing

Gabrielle Driscoll, Alison Rowe and Louise Forsyth (CCDHB) Karen Blair (HVDHB) Rosanne King (Mary Potter Hospice) Mary Death, Jude Pickthorne and Sarah Shellard (Te Omanga Hospice) Fred Wheeler and Carol Hinton (Kahukura)


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NASC Organisations

Lynn Jones (Capital and Coast Care Coordination Centre) Michelle Main (Life Unlimited) Myree Ahpene (FOCUS Wairarapa) Susan Bowden (Hutt Valley Service Care Coordination Paul Moles (Capital Support) Kym Park (Mental Health Service Coordination Team) Helene Dore (Wairarapa DHB and NASCA)

Aged Residential Care and Rest Homes

Capital and Coast/ Kenepuru

Keren Lusty (Retire Kapiti) Maria Ramsbottom (Parkwood Lodge, Waikanae) Roxanne Rosquita and Ailene Ragotero (Dementia Care NZ, Waikanae) Karen Gear (Ultimate Care, Mt Vic, Wellington)

Hutt

Anneke Barkwith (Woburn Home, Enliven) Eileen Thomson (Riverleigh Residential Care, Lower Hutt)

Wairarapa

Irene Bull (Wairarapa Masonic Village) Robyn Brady (Arbor House) Adelita Ganotan and Christine Burton (Lansdowne Court) Lynn Olds (Wairarapa Metlife) Rebecca Waldron (Glenwood Masonic Hospital) Mike Keyworth (Kandahar) Jacqui Witbooi (Ultimate Care, Greytown)

Māori and Pacific Health

Kuini Puketapu (Māori Health HVDHB) Cheryl Goodyer (Māori Health CCDHB) Taima Fagaloa (Pacific Health, CCDHB) Tofa Suafole Gush (Pacific Health, Wairarapa & Hutt Valley DHBs)

Ambulance Services (Wellington Free Ambulance)

Andrew Bos, Executive Manager Service Delivery Paul Fake Clinical Quality Improvement Manager, Clinical services


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APPENDIX 3: Summary of feedback

The following summarises what we heard from consumers/carers:

• Palliative care means different things to different people and it should be much more than just caring during the dying phase

• Hospice provide fantastic care and support

• We all want to die in our own beds, in our own homes

• We want to have early conversations

• We want information about what is available and what to expect

• We want to have access to medication when we need it

• We want to know who to call when we don’t know what to do

• We want palliative care at an earlier stage for more of us

• We want to be involved in decision making

• We want to be supported to care and have easier access to respite

Feedback from other stakeholders included:

• Dying at home is the preferred option but is the exception rather than the norm

• Overall, patients experience good quality services from within each service

• There is a large discrepancy of care between those receiving hospice services and those receiving other services

• Transition between services/discharge processes need attention - systems to share information (i.e. assessments, plans, notes in a timely fashion) are not well connected “unfortunately no plan or notes were transferred...it was 24 hours before any pain relief or sedation could be provided”

• Bereavement support is only available for those under hospice care

• Peoples needs change so services need to be responsive, coordinated and flexible in meeting changing needs

• There are mixed views about a number of issues including duplicate/multiple assessments and the need for an inpatient unit in Wairarapa

• We are a death denying society where patients, families and some health professionals feel discomfort and denial about death and dying which can act as a barrier to accessing services to improved quality of life

• Generally ARC facilities deliver palliative care well, however both Hutt and Wellington ARCS want to do better in delivering end of life care

• Services are mostly available during normal working hours but patients needs are 24hours/7days a week.

• There is inequity of service dependent on patients choice of where to die/who the lead carer is “hospice took care of everything – we could focus on being with her rather than worrying about her care”

• There is variation in night support arrangements

• There is a need to strengthen partnerships with supports in the community

• A clear pathway for palliative care patients is needed (for W’ton & Hutt)


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APPENDIX 4: Population Information

General overview

The sub-regional DHBs – Wairarapa, Hutt Valley, and Capital & Coast – represent three of the twenty DHBs in New Zealand in 2016. They are located in the lower North Island and comprise urban, rural and coastal settings. CCDHB is the largest DHB (by population) of the sub-region, followed by Hutt Valley and Wairarapa. The population of the sub-region was 463,194 at the last Census in 2013, which represented ten percent of New Zealand’s total population of approximately 4.2 million.

The Wairarapa DHB includes three territorial authorities (council areas) – Masterton District, Carterton District and South Wairarapa District – and covers a total land area of 5,936 square kilometres. Like CCDHB and Hutt Valley, the area is served by the Greater Wellington Regional Council. The Wairarapa is a diverse rural area, separated from the rest of the Wellington region by the Rimutaka ranges. Masterton, Wairarapa’s one large urban town, had a 2013 Census population of just over 23,000.

The land area of the Hutt Valley DHB is 916 square kilometres. The area is predominantly flat in the Hutt River valley, bordered by mountainous ranges in the east (Rimutakas) and north (Akatarawas and Tararuas) and a coastal southern edge. Lower Hutt City and Upper Hutt City are the Hutt Valley’s two territorial authorities.

The Capital & Coast DHB has a land area of 739 square kilometres. It is made up of three Territorial Authorities: Wellington City, Porirua City and Kapiti Coast District. The Kapiti Coast District includes some territory which is part of the MidCentral DHB (Otaki and near surrounds). The CCDHB area has relatively high density residential living (by New Zealand standards), with on-going expansion of urban areas.


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Population and Projections

Capital & Coast DHB – Population 65+ years in 2013 & Projected Population for 2038

The proportion of Capital & Coast DHB’s population who are 65+ years is projected to increase from 12% in 2013 to 22% in 2038. The largest increases in people aged 65+ years are expected to be in the Other and Asian ethnic groups. The proportion of Other who are 65+ years in CCDHB is expected to increase by 12% from 15% in 2013 to 26% in 2038. The proportion of Asian residents who are 65+ years in CCDHB is expected to increase from 7% in 2013 to 17% in 2038. It is also projected that the proportion of Māori who are 65+ years will increase by 7% from 4% in 2013 to 11% in 2038. Between 2013 and 2038, there is projected to be no increase in the total proportion of Pacific people 65+ years of age as a proportion of their population.

Projected population 65+ years (2038), Capital & Coast DHB

65-69 70-74 75-79 80-84 85-89 90+

Other Māori

Prop

ortio

n of

Eth

nic

Gro

up

Pacific Asian0

10%

8%

6%

4%

2%

Population 65+ years (2013), Capital & Coast DHB

65-69 70-74 75-79 80-84 85-89 90+

Other Māori Pacific Asian0

10%

8%

6%

4%

2%Prop

ortio

n of

Eth

nic

Gro

up


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Hutt Valley DHB – Population 65+ years in 2013 & Projected Population for 2038

The proportion of Hutt Valley DHB’s population who are 65+ years is projected to increase from 13% in 2013 to 25% in 2038. The largest increases in people aged 65+ years are expected to be in the Other and Asian ethnic groups. The proportion of Other who are 65+ years in HVDHB is expected to increase by 18% from 17% in 2013 to 35% in 2038. The proportion of Asian residents who are 65+ years in HVDHB is expected to increase by 14% from 8% in 2013 to 21% in 2038. It is also projected that the proportion of Māori who are 65+ years will increase by 8% from 4% in 2013 to 12% in 2038. Between 2013 and 2038, the proportion of Pacific people aged 65+ years in HVDHB as a proportion of their population is projected to increase by 2% from 6%.

Population 65+ years (2013), Hutt Valley DHB

65-69 70-74 75-79 80-84 85-89 90+


10%

8%

6%

4%

2%Prop

ortio

n of

Eth

nic

Gro

up

Projected population 65+ years (2038), Hutt Valley DHB

65-69 70-74 75-79 80-84 85-89 90+

Other Māori

Prop

ortio

n of

Eth

nic

Gro

up

Pacific Asian0

10%

8%

6%

4%

2%


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Wairarapa DHB – Population 65+ years in 2013 & Projected Population for 2038

The proportion of Wairarapa DHB’s population who are 65+ years is projected to increase from 19% in 2013 to 32% in 2038. The largest increases in people aged 65+ years are expected to be in the Asian and Other ethnic groups. The proportion of Other who are 65+ years in WRDHB is expected to increase by 18% from 23% in 2013 to 41% in 2038. The proportion of Asian residents who are 65+ years in WRDHB is expected to increase by 17% from 6% in 2013 to 23% in 2038. It is also projected that the proportion of Māori who are 65+ years will increase by 7% from 6% in 2013 to 13% in 2038. Between 2013 and 2038, there is projected to be a 2% increase from 4% in the total proportion of Pacific people 65+ years of age as a proportion of their population.

Population 65+ years (2013), Wairarapa DHB

65-69 70-74 75-79 80-84 85-89 90+


10%

8%

6%

4%

2%Prop

ortio

n of

Eth

nic

Gro

up

Projected population 65+ years (2038), Wairarapa DHB

65-69 70-74 75-79 80-84 85-89 90+

Other Māori

Prop

ortio

n of

Eth

nic

Gro

up

Pacific Asian0

10%

8%

6%

4%

2%


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Deaths in the sub-region

Across the sub-region, the top causes of death were disorders of the circulatory system (36% of all deaths between 2006 and 2010, inclusive), cancer (29%), disorders of the respiratory system (9%), and external causes (6%).

In the sub-region, it is projected that the number of older people 75+ needing palliative care will almost double by 2038 – from an estimated 1,630 in 2016 to 3,065 in 2038. The number of people under 74 needing palliative care is expected to decrease by a third, from an estimated 745 in 2016 to 560 in 2038.

Of these people needing palliative care in 2016, it is estimated that 43% (1,068 people) will die in residential care, 28% (680 people) will die in a public hospital, 12% (288) will die in a hospice inpatient unit, and the remaining 18% (435 people) will die in the community in 2016. Projections show the place of death is likely to be similar in 2038.

Projected number of people in the 3 DHB region who will need a palliative approach by age group

Under Age 40 Age 40-65 Age 65-74 Age 75-84 Age 85-94 Age 95+

0

1,800

1,600

1,400

1,200

1,000

800

600

400

200

Num

ber o

f pal

liativ

e pe

ople

2016 2018 2022 2026 2030 20342020 2024 2028 2032 2036


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APPENDIX 5: Bibliography

Ashton, E. b. (2010). Delivering better care at end of life. London: The Kings Fund.

Association for Palliative Medicine . (December 2012). Commissioning Guidance for Specialist Palliative Care: Helping to deliver commissioning outcomes. London,UK: Association for Palliative Medicine of Great Britain and Ireland, Consultant Nurse in Palliative Care Reference Group, Marie Curie Cancer Care, National Council for Palliative Care, and Palliative Care Section of the Royal Society of Medicine.

Canadian Hospice Palliative Care Association. (2009). Caring for Canadians at End of Life. A Strategic Plan for Hospice, Palliative and End-of-Life Care. Canadian Hospice Palliative Care Association.

Durie, M. H. (1985). A Māori perspective of health. Social Science Medicine, 20(5),, pp. 483–486.

European Association for Pallative Care. (2016, July 19). Toolkit for the Development of Palliative Care in the Community. Retrieved from European Association for Pallative Care: http://www.eapcnet.eu/LinkClick.aspx?fileticket=QDeFwspXKhA%3d

Hospice New Zealand. (2012). Standards for palliative care - Quality review programme and guide 2012. Wellington: Hospice New Zealand.

Jennifer S. Temel, M. J. (n.d.). Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. The New England Journal of Medicine.

Kate Rowland, M. a.-A. (Dec 2010). Palliative care: Earlier is better. Journal of Family Practice, 59(12): 695–698.

Lynn et al, Edited Higginson. (2004). The Solid Facts Pallaitve Care. Denmark: WHO, World Health Organisation.

Managed Clinical Network Lower North Island. (2016). Palliative Care Services in Wairarapa. Hutt Valley and Capital & Coast DHBs Description and Analysis. Lower Hutt: Hutt Valley DHB. (May 2016).

McLeod, H. (June 2016). National Model of Need for Palliative Care. Hanmer Springs, New Zealand .

Ministry of Health. (2012). Resource and Capability Framework for Integrated Adult Palliative Care Services in New Zealand. Wellington: Ministry of Health.

Ministry of Health. (2014). Specialist Palliative Care Service Specification. Wellington: Ministry of Health .

Ministry of Health. (2015). New Zealand Palliative Care Glossary. Wellington: Ministry of Health.

Ministry of Health. (2015). Te Ara Whakpiri. Principles and guidance for the last days of life. Wellington: Ministry of Health.

Ministry of Health. (April 2016). New Zealand Health Strategy Future Direction. Wellington: Ministry of Health.

Ministry of Health. (August 2014). Palliative Care and Māori from a Health Literacy Perspective. Wellington: MInistry of Health.

Ministry of Health. (June 2016). Draft Adult Palliative Care Services Review version 9. Wellington.

Palliative Care Council of New Zealand. (2011). National Health Needs Assessment for Palliative Care Phase 1 Report: Assessment of Palliative Care Need. Wellington: Cancer Control New Zealand.

Palliative Care Council of New Zealand. (2013). National Health Needs Assessment for Palliative Care Phase 2 Report: Palliative Care Capacity and Capability in New Zealand. Wellington: Cancer Control New Zealand.

Palliative Care Council of New Zealand. (2016, May 6). Referral Criteria for Adult Palliative Care Services in New Zealand. Retrieved from Ministry of Health: https://www.health.govt.nz/system/files/documents/publications/referral-criteria-for-adult-palliative-care-services-in-new-zealand.pdf


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Palliative Care Council of New Zealand. (February 2012). Measuring What Matters: Palliative Care. Wellington: Cancer Control New Zealand.

Palliative Care Subcommittee, NZ Cancer Treatment Working Party . (2016, July 13). New Zealand Palliative Care: A Working Definition. Retrieved from Ministry of Health: https://www.health.govt.nz/system/files/documents/publications/nz-palliative-care-definition-oct07.pdf

Rachael Addicott, S. R. (2010). Implementing the end of life care strategy. Lessons for good pracitce. London: The King's Fund.

Service Integration and Development Unit, Wairarapa DHB, Hutt Valley DHB, Capital & Coast DHB. (May 2016). Palliative Care Services in Wairarapa, Hutt Valley and Capital & Coast DHBs, Description and Analysis Report. Wellington.

Supportive and Palliative Care Indicators Tool www.spict.org.uk

Temel, J. R. (2014). The Integration of Early Palliative Care with ONcology Care: The Time has come for a new tradition. JNCCN - The Journal of the National Comprehensive Cancer Network, 1763-1771.

Te Omanga Hospice, Mary Potter Hospice and Wairarapa District Health Board (February 2016) Service Development Proposal: Palliative care Innovative Funding

Tess Moeke- Maxwell, L. W. (2014). End of life care and Maori whanau resilience. MAI JOURNAL, VOLUME 3, ISSUE 2, .

The Gold Standards Framework National Central Team (v25). Full guidance on the uisng QGF to improve palliatve/end of life care in pirmary care. NHS.

Wairarapa, Hutt Valley and Capital & Coast DHBs. (May 2016). Palliative Care Services in Wairarapa, Hutt Valley and Capital & Coast DHBs, Description and Analysis Report. Wellington: Service Integration and Development Unit.


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APPENDIX 6: Example of patient experience in future palliative care system

An example of the patient experience along the future palliative care continuum is outlined below.D

iagn

osis

/ear

ly s

tag

e of

illn

ess

Dim

inis

hin

g h

ealt

h &

wel

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ng

End

of l

ifeA

fter

dea

th

Palliative Care Continuum

Patient Outputs Coordination

GP

rem

ains

lead

med

ical

car

er -

may

or m

ay n

ot b

e LP

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are

pla

n vi

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are.

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id

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Car

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eliv

ered

as

per

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pec

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put

as

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d

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om m

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ple

m

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d v

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us

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eath

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s id

enti

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Tria

ge

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Serv

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chan

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m

ade

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om

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ed

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se

PCF

PCF

PCF

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Patie

nt &

/or

whā

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Patie

nt &

/or

whā

nau

Patie

nt &

/or

whā

nau

Patie

nt &

/or

whā

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IDT

IDT

IDT

PCF

PCF

LPC

LPC

Patie

nt &

/or

whā

nau

IDT

LPC

Patie

nt &

/or

whā

nau


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APPENDIX 7: Role functions and definitions

An example of the patient experience along the future palliative care continuum is outlined below.

Once a palliative patient has been identified then there is consultation with patient and/or family/whanau to begin an individualised Palliative Care Plan (PCP)

This early assessment and planning could be facilitated by GP team or ARC nurse (depending upon where patient resides)

Referral to Palliative Care Facilitation Service

This service will assign a locality Palliative Care Facilitator (PCF) within the service

Bereavement support

This individualised Palliative Care Plan (can be part of Advanced Care Plan) will outline:

• Patient’s goals, basic symptom management and psychosocial needs are…

• What is required to meet these needs…

• Who will help meet these needs…

• Lead Palliative Carer is…

• After Hours support is…

• Permission to share manage my health clinical record

The PCF will facilitate an assessment, when necessary, to build upon and expand the individualised Palliative Care Plan in order to access the services that the patient will require to meet increasing need. This might mean adding components of the InterRAI to the assessment and subsequent planning.

Thus creating and binding together one virtual integrated inter-disciplinary team (IDT) that follows the patients individualised Palliative Care Plan

Lead palliative Carer and Palliative Care Facilitator will ensure that following death, an assessment of additional support following bereavement is undertaken and put in place.

Identification and Early Planning

Service Coordination and delivery 24/7

After death support


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Functions Roles – Who? Notes Output

Identification & referral

Primary care team

Secondary care

Community nursing

Self or carer referral

People who will benefit from a palliative care approach

Referral sent to single point of service coordination (ideally electronic)

Early planning

Primary care team Free consults with GP and primary care team:

Early conversation

Identification of needs

Development of early plan including advance care plan and determining goal of care, curative to palliative with treatment as needed

Individualised palliative care plan

Preliminary triage

Single point of service facilitation (Palliative Care Facilitation Service)

Palliative care coordinator/facilitator (PCF)

Facilitator does preliminary triage and will coordinate access to services and equipment when needed, depending on where patient is along their palliative care journey.

Point of contact for lead palliative carer and makes things happen behind the scene. They will facilitate specialist assessment if needed, but endeavour to build upon information and not undertake duplicate/multiple assessment

Specialist Assessment & Planning

Specialist palliative care nurse (based either in spec PC or NASC)

Interdisciplinary approach/ virtual assessment coordinated by the PC nurse if needed

Identify and assign lead palliative carer (LPC) if not already identified

Care plan for 24/7 care

Afterhours contacts both medical and nursing must be specified, noting that in most instances the lead palliative carer/initial point of contact for patients /whanau, and nursing in the later stages of the PC journey. In rare cases, ambulance may be the most appropriate first point of contact.

Clinical management

Lead palliative carer (LPC)

Responsible for clinical management, arrangements for after hours medical contact and first point of contact for patients and whanau. LPC can change throughout journey as needs change (initial part of journey is likely to be GP, but as need increases may change to community nurse or spec pc nurse (in ARC likely to nurse /nurse manager of facility). GP will still remain involved to provide medical oversight.


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Functions Roles – Who? Notes Output

Service & resource coordination

Palliative care facilitator (PCF)

After the LPC identifies need for service /resources, they contact PCF who will organise appropriate services as needed

Planned service delivery

Palliative care facilitator (PCF)

Primary, hospital, spec PC

Community nursing and other community services

Whānau, volunteers

Range of roles as specified in care plan

Support in the home

Whānau

HCSS

Volunteers/NGOs

Depends on need identified by LPC

Nursing Practice nurse

Community nursing

ARC nurse

Specialist pc nurse

Majority of nursing care is provided by practice and community nurses. When a patient moves into an ARC facility, nursing care is provided by facility nurses. Specialist nursing support is available to these nurses as and when required. As the final days of life approach, increasing support from specialist PC nurses may be appropriate.

Medical GP, Specialist doctors including palliative care, GPSIs and other medical specialities such as cardio

The GP remains the patient’s primary /main medical carer.

Specialist support is sought from PC and other specialities as and when required. Spec services available for consult liaison to support the GP to be the lead palliative (medical) carer.

After hours Lead palliative carer Initial point of contact for patients

Allied health Social worker; Occ therapist,Counsellor

Physio,Dietician

Support provided as outlined in care plan to address identified needs

Other supports

Cultural support including Māori and Pacific liaison, chaplain services churches, community groups

Support provided as outlined in care plan to address identified needs


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APPENDIX 8: Data sources Statistical information about the need for palliative care in this document is based on the work by Heather McLeod completed in June 2016 - National Model of Need for Palliative Care.

The excerpts below are from “The Need for Palliative Care in New Zealand Technical Report – June 2016”

“The first estimate of the need for palliative care in New Zealand was produced by the Palliative Care Council in 2011. Three estimates were produced, a minimal estimate based on a list of conditions recorded on the death certificate, a mid-range estimate that included hospital admission data, and a maximal estimate based on a longer list of conditions. The report established, for the first time, the number of people who might benefit from palliative care in New Zealand. Overall, combining adults and children, the mid-range estimate in 2006 was that 56.3% of all deaths were amenable to palliative care.”

“The historic patterns of deaths in New Zealand were examined using data from the Ministry of Health Mortality Collection (MORT). The data for this analysis was extracted in December 2015 and covers all deaths registered in the calendar years 2000 to 2013.”

“The need for palliative care is an estimate of need at a population level for the whole palliative care system. Conceptually, the aim is to include all deaths that typically benefit from a palliative care approach.”


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In partnership with


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Date: 8 August 2018

Author Keith Fraser, Service Planning & Integration Manager


Reviewed/approved by Helene Carbonatto, General Manager, Strategy Planning & Outcomes

Subject Dental Treatment For Low-Income Adults

RECOMMENDATION


a) NOTE that inequalities in dental service utilisation are both considerable and globally consistentand the financial barrier is significant for low-income adults

b) NOTE that DHBs are required to provide: emergency dental treatment that is immediately necessary for the relief of pain or treatment of infection for low-income adults and basic dental services for low-income people unable to access private care, where capacity and funding of the DHB’s hospital dental service allow

c) NOTE that trials undertaken in Counties Manakau and Waitemata, and in hypothetical scenarios constructed by the Ministry of Health, suggest average costs of at least $2000 per person for a one-off package of care to address treatment needs for low-income vulnerable adults

d) NOTE that the cost of such services based on various eligibility criteria, range upwards from $2.6m

e) NOTE that the cost of providing oral health services to pregnant women in the Hutt Valley would be upwards of $2.6 million per annum and over $10 million for low income adults. ongoing costs for eligible people are likely to be less than initial one-off treatment but there would be costs from more people becoming eligible

f) NOTE the Ministry of Health is concerned about the variation in access to DHBs hospital dental service for low-income people and has commissioned work (due this year) to improve consistency in clinical criteria

g) NOTE that there has been recent public discussion about funding dental services for adults and it is a whole of health sector issue but not a current strategic priority for DHBs.

1. PURPOSE

This briefing responds to the 2 March meeting recommendation by the Community and Public Health Committee “that management develop a proposal considering the costs and benefits of funding dental treatments for low income adults to be developed by 30 June 2018”.

2. BACKGROUND


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The publically funded provision of oral health services occurs for a portion of the population. Oral health services are funded for under 18s, some oral health care is provided prior to surgery, and there is treatment provided for the relief of pain and to avoid further treatment in the future for low income adults. Assistance is also available to low-income adults through Work and Income.

Publicly Funded Oral Health Services

2.1 Service Coverage Requirements

The oral health services that DHBs are required to fund include:∑ Preventive, educative and treatment oral health services for all preschool and primary school-aged

children up to school year 8 (12-13 years of age). These services are mainly delivered through the Community Oral Health Service (in the Hutt Valley – Bee Healthy)

∑ Basic oral health services for adolescents up to their 18th birthday. These services are mainly delivered by contracted dentists under the nationally standardised Combined Dental Agreement and consist of: examinations, x-rays, diagnosis and advice, extractions, restorations and prosthetics.

∑ Hospital and community dental services that is necessary prior to surgery or other treatment (such as radiation therapy) or in conjunction with a medical condition, dental condition or disability that requires special management facilities.

∑ Emergency dental services for some Community Services Card holders. These services provide emergency dental treatment that is immediately necessary for the relief of pain or treatment of infection for low-income adults. In the Hutt Valley, this is provided by hospital dental services.

∑ Basic dental services for low-income people unable to access private care, where capacity and funding of the DHB’s hospital dental service allow.

In practice, Hutt Valley DHB uses its house surgeons to provide emergency dental services, relief of pain type services and any other treatments that they can provide in the time they have available. Ten to fourteen people per day are seen through this service, some of whom might need more than 1 appointment to treat to a level that avoids another presentation to the emergency department.

Some 5 years ago HVDHB provided annual checks for people with a Community Services Card by opening up for bookings on the first day of each month. In practice, the available capacity was quickly committed each month and there continued to be unmet need. There was a feeling by staff that this service wasn’t well targeted as some people with a Community Services Card had demonstrably low incomes but there appeared to be many other people living in greater deprivation so the service was discontinued.

2.2 Work and Income Assistance and ACC

For people on a low income or benefit, assistance may be available towards the cost of dental treatment, especially if it’s urgent. Some of the money may have to be paid back, depending on individual circumstances in relation to income and asset limits.

For people needing urgent dental treatment, Work and Income can generally pay up to $300, or more depending on the person’s situation, but usually there can only be one payment in a year. ACC may also be able to provide help if dental treatment is needed because of an injury.

2.3 NZ Health Survey - 2016

As shown in Table 1 below, the results from the 2016 NZ Health Survey demonstrate the ethnic differences, principally in the lower number of visits to dental health care services and teeth removed due to decay in the last 12 months. The teeth removed due to decay in lifetime and all teeth removed due to decay may not fairly indicate the ethnic differences, given the Pacific and Maori populations are considerably younger than the European/Other population.


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Table 1: NZ Health Survey - 2016 - Adults Aged 15+

Ethnic Group Total % Maori % Pacific % Asian % Other %Dental health care worker visit in past 12 months 46.7 37.8 33.6 30.5 51.6Teeth removed due to decay in past 12 months 7.1 10.3 12.4 5 6.7Teeth removed due to decay in lifetime 45.8 52 45.5 32.3 46.7All teeth removed due to decay 6.6 7.5 0.8 1.9 7.3Usually only visits dental services for problems 53.2 69.8 75.4 67.6 46.7

2.4 Improving Oral Health Services for High Needs and Vulnerable Populations - Advice to the Chief Dental Officer and Ministry of Health – August 2012.

On the basis of consultation with its wider membership, the NZ Oral Health Clinical Leadership Network Group (the Group) recommended to the Ministry of Health that “Good Oral Health for All, for Life” was not being met consistently for New Zealanders who are most vulnerable and have the most complex issues. It found that the system had a number of issues including:

∑ Variation in service delivery∑ No common definition of high needs and vulnerable groups∑ Resource constraints∑ A range of clinical leadership capacity and capability across DHBs∑ A need for training to develop an appropriately skilled workforce.

The Group commented that Maori were particularly adversely affected. Maori have higher rates of disability, higher rates of medical conditions requiring complex dental care, and are disproportionately represented on measures of material disadvantage.

The Group recommended that the Chief Dental Officer and Ministry of Health work with DHBs and the profession to improve the equity and level of oral health service provision to high needs and vulnerable people through:

∑ Working with NZOHCLNG to engage and consult stakeholders∑ Promoting more consistency and equity of access of service∑ Promoting regional cooperation and planning∑ Building a skilled ‘fit for purpose’ workforce∑ Considering alternative pathways of oral health care for low-income adults∑ Monitoring progress in the provision of services to high needs and vulnerable people.

The Ministry of Health recently contracted the University of Otago School of Dentistry to update this advice (project priorities follow) and has advised it is expected to be available within the next year.

2.5 NZ Oral Health Clinical Leaders Network Group (NZOHCLNG) projects

The NZOHCLNG was formed in 2010 with the aim to support and develop clinical leadership in oral health, promote evidence-based and best-practice approaches to care, and to facilitate national consistency in service access. Dr Riana Clarke, National Clinical Director, Oral Health, advised that the NZOHGCLNG have prioritised three projects this year.

o High needs and vulnerable (HNV) populations project - aims to establish the current state of DHB Hospital Oral Health Services for the HNV Population in the North Island to support work previously done by the group in the South Island.


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o Oral health of older people - with more people living longer, NZOHCLNG will look at older people's oral health and held a workshop in Wellington in July last year to initiate conversations in this area.

o Clinical guidelines with a view to DHBs achieving consistency across the country for treatment of their eligible populations.

2.6 Healthy Smile Healthy Child

This 2008 oral health guide was published by the NZ Dental Association in conjunction with the Ministry of Health for well child providers. In discussing the risks factors for early childhood caries (ECC) it notes:

∑ Children from low-income families and those living in non-fluoridated areas are at increased risk.∑ Children born prematurely or at lower-than-normal birth weight, and children born with

developmental disabilities and disorders are more susceptible to dental decay.∑ These risk factors are not evenly distributed across the population. The Ministry of Health’s child oral

health data shows a clear disparity between the oral health of Maori and Pacific children and children of other ethnicities:

∑ Less than half the proportions of Maori and Pacific five-year-olds were decay-free when compared with children of all other ethnicities.13

∑ Maori and Pacific caries severity was twice that of children of all other ethnicities.

The data also reveals that children from non-fluoridated areas have higher rates of dental decay when compared to children from fluoridated areas. The paper notes that the direct and indirect effects of early childhood caries includes adverse health, social and development outcomes and poorer long term oral health. Preventive measures include diet, cleaning, fluoride and dental visits.

3. Low-Cost Oral Health Trials – Counties Manakau and Waitemata DHBs

Counties Manakau and Waitemata DHBs, with funding from the Ministry of Health, undertook trialsstarting in 2013 to 2015, to assess the viability of extending the use of community-based child oral health facilities and dental workforce to increase service accessibility to vulnerable adults (pregnant women upto nine months after child-birth). Both Trials had a positive effect on oral health outcomes, including improvements in self-care behaviours, increased satisfaction with oral health status, and reduced pain, self-consciousness, and disruption to diet and eating. These outcomes had considerable positive impacts for Trial women and their whānau. Child enrolment in community oral health services also increased as a result of the Trials.

The service experiences for women were positive, and seem to have changed the perception of dental care with more women intending to go to a dental service after the Trial. While this is a good outcome, the dental cost remain a barrier to attending oral health services for women and there was not a clear pathway in place for women to access dental care after the trial.

Both Trials increased the use of community oral health facilities. In both trials, the clinic time available was insufficient to meet the higher-than-anticipated referral numbers.

The average cost of a package of care including high frequency lower cost treatments, as well as the less frequent but more complex and costly treatments, was calculated as $871 for Waitemata and $1,413 for Counties Manakau. While some women were free of caries, others required up to 24 appointments for treatment, with the average being about 6. A significant limitation of the costing is that it was based on staff time and clinical supplies but didn’t include overhead costs of non-clinical supplies, facilities and administration.


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4. Dental Costs Modelling for High Needs and Vulnerable

The Ministry of Health has undertaken some modelling of dental service provision for high needs and vulnerable people.

Hypothetical 1: Publicly funded dental care for pregnant women

The Ministry has estimated the costs of offering free dental care (excluding Orthodontic care) to women through pregnancy and up to 12 months post partum (along the Waitemata and Counties Manakau Trial) as approximately $23 million (GST excl) per annum, and approximately $15 million per annum if one course of dental care was provided only to pregnant women in deprivation groups 9 and 10 (highly deprived).

On a simple population share, this equates to $690,000 and $450,000 per annum respectively, for the Hutt Valley. The relatively small increase in estimated expenditure required to include all pregnant women (increase of $8.2 million) reflects the disproportionately large representation of deprivation 9 and 10 women in the birthing cohort (29.3 percent of births) and the concentration of untreated coronal decay in high deprivation groups.

The Ministry notes that this option would be subject to workforce capacity and possible contractual arrangements – likely to be significant limitations. Since it is based on the Waitemata and Counties Manakau Trial, the costs are also likely to be underestimated by omitting overhead costs.

Hypothetical 2: Options for publicly funded dental care for older people

The Ministry has also estimated the costs of funding one-off packages of dental care for older people using various eligibility variables such as over 65, over 75, CSC, Care Plus, high needs (Maori Pacific, high dep), Aged Residential Care residents, people receiving home support, one-off course of care, one-off set of dentures, and a one-off subsidy of $250.

Putting aside the one-off costs of such a policy implementation, the ongoing annual national costs vary from $49m for a $2000 course of treatment for 80% of all over 65s with their own teeth, through to $1.3m for a $2000 care package for 80% of the over 75s in Care Plus with their own teeth. Many of the options have significant equity and value-for-money issues and there are likely to be workforce limitations.

5. Evidence base for dental treatment during pregnancy, parity and periodontal disease

There has been various evidence cited during the years that dental treatment for pregnant mothers has a significant positive impact on the health of the mother due to the hormonal changes occurring during pregnancy.

However, a recent meta-analysis undertaken by the University of Otago’s dental department1 has found that the impact on dental health of hormonal changes during pregnancy is “transient, without irreversible loss of periodontal attachment, and postpartum resolution can be expected for most women” and “the effects of pregnancy and parity (the number of children previously borne) are unclear”. The study notes that there are shared risk factors in periodontal disease and socio-economic position. Education, one aspect of socio-economic position, is an important determining factor for women's fertility rate, and damaging health behaviours. Women with higher educational attainment have fewer children and tend to have behaviours more conducive to good oral health. These confounding factors make it more difficult to establish cause and effect.

1 EL Morelli, JM Broadbent, JW Leichter, WM Thomson – Pregnancy, Parity and Periodontal Disease - May 2018


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6. DISCUSSION

Inequalities in dental service utilisation are both considerable and globally consistent. Unmet oral health need is greatest amongst deciles 9 and 10 in New Zealand, the most deprived 20% of the population. The evidence from the Waitemata DHB and Counties Manakau DHBs Trial, for whom most (65%) of the women were aged 18-29 was that the trials had a positive effect on oral health outcomes for both women and their whānau. Despite the greater awareness of good dental care and the intentions of Trial women, however, cost remained a barrier and there was not a clear pathway in place for women to access dental care after the Trial.

The focus on women in pregnancy and in the post-partum phase may be due to perception that pregnant women are more vulnerable to adverse oral health outcomes. The latest literature suggests the link is unclear and there are confounding factors of socio-economic position and education.

The total cost was between $871 and $1413 for a one-off package of care. The true cost, including overheads, appears to be more. Given that Hutt Valley DHB’s oral health services are at capacity, private dental services would likely need to be used for provision of high needs adult oral health services.

The package of care of $2,000 used by the Ministry of Health in its hypothetical options appears likely to be closer to the average cost of obtaining a one-off package of care for high needs people but may be an underestimate. As with any non-mandatory service provision, however, eligibility can be tailored to the funds available.

The following table shows the estimated costs of providing a one-off package of care for the following groups, based on $2000 per person. The ongoing costs are likely to be less for the people who receive care but there will be more people entering the group each year.

Table 1Costing of Oral Health Treatment Eligibility Options for High Need Hutt Valley Residents ($m)

EligibilityCSC* 18+

CSC Q5 Q4

(18+)CSC Q5 (18+)

CSC M&PI (18+)

Q5 M&PI (18+)

Q5 M&PI

(18-45)

CSC Q5 M&PI (18+)

Pregnant Women**

Numbers of people*** 19614 11187 6396 5741 8553 5152 3008 1965One-Off Treatment Package $39.2 $22.4 $12.8 $11.5 $17.1 $10.3 $6.0 $2.6*CSC Eligibility is expected to increase by about 13% in 2018/19 (90,000 / 684,923)

** Live and stillborn babies - cost estimated for deciles 9&10 using Ministry proportion***Numbers are based on PHO enrolment 2017 quarter 4

7. SUMMARY

The inequalities in dental service utilisation and oral health outcomes are both considerable and globally consistent. There have been trials in NZ to provide a service to low-income adults that resulted in better oral health but there has not been a subsequent pathway for adults to be able to continue to access such services. Beyond low-income adults as a population group with high oral health needs, we are not aware of a particular group of adults where the literature supports intervention.

There has been some public comment recently about the need for public provision of low-income dental services and it appears to be a strategic issue for the wider health sector. At present it is not a strategic priority for Hutt Valley DHB, and it would be beyond current resourcing, at any level of eligibility. It is important to acknowledge the work commissioned by the Ministry of Health that seeks to examine and promote the consistency of existing oral health services provided to low-income adults by DHBs.


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