2012/13 Quality Account

Quality, safety and experience of care Health and equity for all populations Best value for health system resources QA Version 1.1 Page | 1

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Opening Statements Page 3

Our Commitment to Quality and Service Improvement Providing Feedback

Executive Summary Page 4

Background Page 6

Section 1 Introduction Page 7

What quality means to us

Section 2 Our Performance in Review Page 9

Part 1 Our Focus on Patients and Consumers Page 11

Feedback and Experiences of Care 13

Reducing the Risk of Harm 15

Part 2 Our Focus on Services Page 19

Child Health / Tamariki Ora 21

Primary Health Care 27

Mental Health and Addictions 32

Maori Health and Whanau Ora 37

Section 3 Our Performance Ahead - Priorities for Improvement Page 42


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Our Commitment to Quality and Service Improvement

WE WANT YOUR FEEDBACK

We welcome your feedback on this, our first, Quality Account. We have a brief survey to help us with this if you would like to use it, at Survey Monkey. Otherwise, you can email your feedback to us at this address: [email protected]

Your feedback will be used to help us in developing our future Quality Accounts. We appreciate your thoughts and comments.

From the Chair and General Manager, Central Primary Health Organisation

We are pleased to have partnered with the DHB

in presenting the first combined account of our

progress in the quality of care we provide and

some of things we are going to do to continuously

improve the experience of care for our patients,

so that the right care is delivered at the right

time and place.

Bruce Stewart (Dr), Chair

Joe Howells, General Manager

From the Chair and Chief Executive, MidCentral District Health Board

Everyone in our community experiences health

care services in one way or another throughout

their life. As a publicly funded health and

disability service we are committed to ensuring

that that experience is as good as it can be.

This quality account is one way that we have to

not only show how well we’re doing but also to

show that we don’t always get it right. Our

commitment to making improvements in the quality

of care that we provide to our community is

without question – we rely on you, together with

our staff, to help us get it right.

Phil Sunderland, Chair

Murray Georgel, Chief Executive

From the Chief Medical Officer, MidCentral DHB and Clinical Director, Central PHO

Across our district we have thousands of people

with health care knowledge, skills and dedication

who arrive at work every day committed to

providing the right care for the people they see.

This quality account highlights some areas where

we do very well and other areas where we plan to

make improvements.

Ken Clark (Dr), Chief Medical Officer

Chiquita Hansen, Clinical Director

https://www.surveymonkey.com/s/mdhbourperformance

mailto:[email protected]

Quality, safety and experience of care Health and equity for all populations Best value for health system resources

QA Version 1.1 Page | 4

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We, MidCentral District Health Board (DHB) and our primary health organisation - Central PHO, are pleased to present our first snapshot account of the quality of services we provide. This publication highlights some of the key results of our performance as well as profiles just some of the service improvements we have undertaken in the 2012/13 year. We hope that this review of our performance provides you with some information that supports your confidence and trust in the quality of services we deliver. Our efforts to improve our services in response to your experiences of care are also highlighted. More of our financial and non-financial results for the year can be found in each of our Annual Reports, and a lot more information is also available on our respective websites (www.midcentraldhb.govt.nz and www.centralpho.org.nz).

Earlier this year we developed a quality improvement framework across our health services. This framework encompasses four key elements that support our service improvement programmes toward achieving our outcomes and vision for our district, as shown in the following figure.

We could not possibly encompass all that we would like you to know about. We have focused on some key performance measures of quality and safety together with highlighting some of the feedback and experiences of care by our patients and consumers of our hospital, community health and primary care services. We have also focused on four priority service areas – Child health, Primary health care, Mental health and addictions, and, Maori health because of their district wide functions and impact; where we have made improvements in access, responsiveness, timeliness and specific improvements in services for people with certain health conditions. In these service areas, our improvement strategies focused on getting it right, being consumer and community and focused, being up to the job, and, being willing able to learn – the four elements of our quality improvement framework that are aligned to the dimensions of the New Zealand Triple Aim for the health sector: improved quality, safety and experience of care, improved health and equity for the population, and, best value for health system resources.

Getting itright

Being consumer

and community focused

Being up to the job

Being willing and able to

learnOutcomes



The following table summarises our key priorities for improvements against the goals of the Triple Aim. In reviewing our performance for the year, this Quality Account highlights our achievements and what we need to improve in these areas.

Improved quality, safety and experience of care

Improved health and equity for all populations

Best value for public system resources

Reducing risk of harm Increasing access to services Better integration and coordination of services

Increasing consumer involvement Reducing waiting times Building capability with knowledge and skills

Better management of long term health conditions

Reducing avoidable hospitalisations Developing leadership and clinical networks

Protecting health and well being Enhancing capacity of primary health care, child health and mental health services

Better alignment of resources

Reducing variation in health care practices Reducing disparities in health status Better use of information

The focus for improvements next year addresses shortfalls in our performance results and are aligned to the four elements of quality improvement framework of

Getting it right Being consumer and community focused Being up to the job Being willing and able to learn

We wish to thank all who have contributed to this Quality Account and for the commitment that is shown in improving the quality and safety of services provided to our community by a vast number of staff and range of health care providers throughout our district.

Finally, we would welcome any feedback you may wish to provide on our first Quality Account. Details of how best to do so are included on the earlier page with our Opening Statements.


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Whoarewe–MidCentralDistrictHealthBoardandCentralPHO

MidCentral District Health Board (DHB), a Crown entity, is one of 20 District Health Boards in New Zealand that plans, manages, provides and purchases publicly‐funded health services for the population of our district. This includes contracting for the provision of primary care services, hospital services, public health services, aged care services, and health services provided by non‐government organisations and other providers including Maori health providers.

Important roles in delivering health and disability services are undertaken by public health units, primary health organisations and general practices, radiology and laboratory services, non‐government organisations, hospitals and a range of health professionals including doctors, nurses, physiotherapists, social workers, dieticians, technicians, community pharmacists and the like.

The provision of primary health care services is managed on the DHB’s behalf through the Central Primary Health Organisation (PHO) – an organisation funded by us to support the provision of essential primary health care services through general practitioners (GPs) and general practice teams to people who are enrolled with the PHO. The aim is to ensure GP services are better linked with other primary health services to ensure a seamless continuum of care, in particular to better manage long term conditions, and to support better links with our hospital (MidCentral Health), specialists and associated services.

For more details about who we are and what we do refer to our websites at www.midcentraldhb.govt.nz and www.centralpho.org.nz

Whoareyou–aprofileofourpopulation

Our district covers the Otaki ward of the Kapiti Coast district, the territorial local authority districts of Horowhenua, Palmerston North City, Manawatu andTararua districts of the mid‐lower North Island.

We have an estimated population of 171,200 people living in our district; 1 slightly more females than males, about 35% are under the age of 25 years, 48%aged between 25 and 64 years, and 17% are aged 65 and over. Our population tends to be similar to the national average, but with a slightly higherproportion of older people

We have a similar proportion of Maori and a lower proportion of Pacific people in comparison to the national average, with a growing proportion of Asianpeople living here. There is proportionately more Maori living in the Otaki, Horowhenua and Tararua districts, than there is in the Palmerston North andManawatu districts

We have a slightly higher proportion of people in the more deprived sections of the population when compared to the national average

1 Estimated population based on medium projections to June 2013 from NZ Census 2006 base –Statistics New Zealand



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1.0 What quality means to us

There are many definitions of quality, both in health care and in relation to other areas of work. A working definition of quality guides us in our understanding of the services we deliver and helps us to design and shape the interventions and measures aimed at improving outcomes for the individuals and communities we serve.

New Zealand has adopted a three-pronged approach to quality improvement – the New Zealand Triple Aim – that we are using as a foundation for our work. It has three dimensions:



Best value for public health system resources

The NZ Triple Aim, as illustrated, shows that health care improvement is focused not only on individuals (patients, consumers), but also the populations we serve and the broader public health system. We use these three dimensions as goals that we work toward in planning, delivering and improving the health and disability services in our district.

1.2 Our Quality Improvement Framework

Quality improvement is about measuring how well we are doing against what is expected, then working together on ideas to get better results. Building on the NZ Triple Aim, we have developed our Quality Improvement Framework as a way to approach our quality improvement programmes, focusing on four interconnected themes. These are, in summary:

Getting it

right

Being

consumer and

community

focused

Being up to

the job

Being willing

and able to

learn



In “getting it right”, we believe that you the patient and community deserve care, when it is required, that is based on best available evidence and provided within the funding we get. We are obliged to demonstrate efficient use of our resources and that they are applied effectively using accepted standards of practice to obtain the desired results for our patients and communities. One strategy in delivering the best possible care to patients is evidence-based medicine, which is defined as “the integration of best research evidence with clinical expertise and patient values.” Together with our skilled staff, we will adopt new techniques, equipment and protocols, such as the Map of Medicine® Collaborative Clinical Pathways, to bring the best possible care that we can afford to patients.

“Being consumer and community focused” means having the patient/consumer at the centre of all that we do. Our priority is to meet the needs of the people we serve based on a clear understanding of their health care needs and the health status of our population. Telling us about your experience of the care you receive helps us to better understand current problems, review what needs to change, monitor the impact of change, help with informed choices and improve care. We exist in a wider community and need to ensure that we connect with a range of communities that contribute to the health and wellbeing of individuals and our population.

In “being up to the job” we are ensuring that we have the right systems for having the right people in the right place, at the right time, doing the right things. We support a culture of teamwork and leadership so that you receive safe, quality care and that our workforce is valued for their professional efforts. By working together and by providing ongoing learning opportunities, you can be confident that our staff are selected and developed to be competent, considerate and fit to practice, in fit-for-purpose facilities using appropriate materials and equipment in order to provide excellence in health care.

“Being willing and able to learn” means that we take continuous quality improvement as “a way of life” in all that we do. We do this by having a common purpose in continually reviewing our performance, learning from our mistakes and having the courage to be innovative. A willingness to share information about what works and what doesn’t is based on a shared understanding of what ‘good quality’ health care is and a common measurement system which reflects this understanding.

Applying these themes to all our activity will ensure that our work is progressively improving to meet your needs as well as MidCentral DHB’s vision for our district’s population of “quality living – healthy lives”.

Getting it right

Being consumer and

community focused

Being up to the job


learn



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What is this About? This publication of our first Quality Account for the MidCentral District Health Board (DHB) region is borne out of a desire to provide meaningful and transparent information to the people of our district about our progress on all things non financial for the July 2012 to June 2013 year. In other words, our focus is on quality, safety and experience of care as opposed to a single focus on the financial results. We know that robust financial management goes hand in hand with quality and safety of care – at a system-wide as well as individual level. It’s about getting a balance and demonstrating the importance of quality care being at the centre of what we do and that the health of our population improves. This report highlights some of what we have achieved against what we had planned, some of the successes and what we have learned and what we plan to do to further improve. Additional information about our performance, including the results of the national Health Targets, can be found on our website at www.midcentraldhb.govt.nz as well as at www.health.govt.nz/new-zealand-health-system/my-dhb/midcentral-dhb. MidCentral DHB and the Central Primary Health Organisation (CPHO) have worked in partnership to bring together information that spans the primary health care, community and hospital based services that you come into contact with during your interaction with our health and disability support services. This Quality Account does not cover all aspects of quality and safety in health care but focuses on a few that are high priorities for all of us. This next section is about our focus on patients and consumers and the importance of receiving feedback, learning from feedback and making improvements. This section also has a focus on reducing the risk of harm from serious adverse events with a focus on reducing falls that occur in our hospital. Our Focus on Services includes some key results and information on our performance improvement activities in relation to Child Health/Tamariki Ora, Primary Health Care Services, Mental Health and Addiction Services and Maori Health and Whanau Ora. In reviewing our performance in these service areas, we have included a number of performance measures to illustrate our progress toward our goals, linked to the things that are important to improving the quality, safety and experiences of care, improving health and equity for our population, and, delivering best value for public health system resources.

What Were Our Priorities for 2012/13 Every year we develop an Annual Plan for our DHB that is underpinned by legislative requirements and direction from Government, and in response to the assessed health needs of our community and priorities for improvement – all within the funds that are available.

http://www.midcentraldhb.govt.nz/

http://www.health.govt.nz/new-zealand-health-system/my-dhb/midcentral-dhb



The Annual Plan identifies the actions required to deliver improved services against the range of national, regional and local priorities for 2012/13, covering:

• Building clinical integration of services across the whole system • Strengthening primary care development and networks • Improving clinical effectiveness and quality of services • Better managing unplanned, urgent care together with shorter stays in the Emergency Department • Shorter waiting times for surgery, cancer and cardiac services • Increasing immunisation coverage for children • Earlier identification of health risk and improved management of long term conditions, in particular cardiovascular disease and diabetes • Promoting successful quit attempts for people who smoke tobacco • Supporting coordinated wrap around services for older people • Increasing access to specialist child and youth mental health and addiction services • Promoting whanau ora centred services • Providing value for money with efficient service delivery models and investment in future service developments and infrastructure These can be summarised in the following table, expressed as the priorities for improvements against the goals of the Triple Aim. In reviewing our performance for the year, the next sections of this Quality Account highlight our achievements and what we need to improve in these areas.

Additional information about our performance over the 2012/13 year can be found in our Annual Report, at www.midcentraldhb.govt.nz/Publications.



Best value for public system resources

Reducing risk of harm Increasing access to services Better integration and coordination of services

Increasing consumer involvement

Reducing waiting times Building capability with knowledge and skills

Better management of long term health conditions

Reducing avoidable hospitalisations Developing leadership and clinical networks

Protecting health and well being Enhancing capacity of primary health care, child health and mental health services

Better alignment of resources

Reducing variation in health care practices

Reducing disparities in health status Better use of information


2.1 Our Focus on Patients and Consumers

What is this about?

Evidence shows that patient safety improves when patients are involved and have more control in their own care. Understanding patients’ needs is crucial to good service delivery so that the patient’s needs drive the care delivered rather than the other way around. By listening to, and involving patients, we can find out what really matters and improve the experience of health care. This is about a partnership and ‘doing with’ rather than ‘doing for’ or ‘to’. Patient and family centred care means that:

People are treated with dignity and respect

Health care providers communicate in a way that is meaningful for the patient/consumer and ensures that full and unbiased information is shared fully with the patient/consumer

Patients and their families are full partners and decision-makers in their own care as well as the design of the health care system, in partnership with the health care team

We are committed to upholding the Code of Rights and to implementing all reasonable actions to ensure that we do. The Code of Rights establishes the rights of consumers, and the obligations and duties of providers to comply with the Code. See http://www.hdc.org.nz/the-act--code/the-code-of-rights This section focuses attention on how well we’re doing with involving our patients in the care we provide and responding to the feedback and concerns that you tell us about. It is also about bringing the safety of health care services that we deliver into focus through reporting what we do and how well we’ve done to reduce the risk of harm.

Margaret’s Story: One Patient’s Journey

“Just who is in charge” is the question I was left trying to answer after Frank died.

Frank was referred to at least 10 services over six months. No one had the complete or up-to-date picture of his health needs or followed up on the things we had questions about.

The most frustrating issue was that no one person or service was identified as being the key point of contact or had access to all of Frank’s information. I found myself being the carer and advocate, and in the position of coordinating Frank’s care with limited access to all the information. Frank believed that the health professionals knew what they were doing and did not want me to interfere. In order to co ordinate care a considerable degree of health literacy is required. I suggest that the average person does not have this.

The outcome to Frank’s journey was never going to be any different but the quality of the journey should have been very much better.

What needs to change?

1. Communication within and between services and across hospital and community needs to improve

2. Far greater clarity of just who is in charge, meaning who is the person/service that I need to contact for most things. Written information for patients and families is essential.

3. User friendly services are required, e.g. we could not get blood tests taken from Frank at home as we did not meet the criteria and no other option was available.

http://www.hdc.org.nz/the-act--code/the-code-of-rights



Some examples of feedback from patients and consumers

“I wasn’t kept up to date about when I would go

home from hospital”

“Appointment was on time, was barely seated in waiting room before being called to do tests, then back to waiting room and specialist appeared almost straight away”

“Nursing staff addressed me by name and all interaction with them was professional but friendly and efficient. Acknowledged my complex medical needs and ensured I saw orthopaedic specialist who was very good explaining all my options and helped me set future health goals”

“I felt rushed and found after the appointment I

couldn't remember properly what had been

said to me”

“Keep patients informed of any delay in seeing the health

professional - sitting there and not knowing is most

frustrating”

“I have found that changing appointment times has been very easy. This has been important so I can take time off work. Staff explain treatment options well.”

“We were very pleased with our experience at the hospital. The staff provided very good quality care and we were given choices rather than being told what to do”.

“I would appreciate more simplified clear (lay persons) language and written info about what we have discussed in appointment. Sometimes we get too much information and it is hard to work out what was actually done or needs to be done. Too many different opinions from each health professional - needs some sort of co-ordination, written in language we understand”

“Treatment in ED was excellent, in spite of a frantic

and busy night for staff. Organisation of tests eg. CT, MRI, etc was fast! All good!”

“You did very well in making sure I was safe and secure enough to

go home. I have been very grateful for the equipment

provided to help me at home” “One receptionist in particular at my general practice is rather rude to me when I am making appointment for my children with Maori names, it is very insulting”

“Got sick of answering same questions by each person dealing

with me. Should be one admittance form that follows patient wherever

they go. Communication between all parties was useless”

“I like the new system at my general practice, my family always sees the nurse first and only sees the doctor if nurse thinks it is necessary. The nursing service is excellent”

“There is a lack of information about what's wrong. When wanting another appointment

to coincide with another appointment at hospital it took 3/4 hr to arrange (another family member had appointment the day

after) - save on travel expenses”

“Was not satisfied with advice given by different GP 2 weeks

ago who failed to acknowledge my significant pain.”

“I look after my elderly Mum and having access to Healthline after hours has been

really helpful and avoids me taking my Mum to City Drs or up to ED”



2.1.1 Feedback and experiences of care

Feedback and experiences of care is conveyed to us in a number of ways by our patients, family and whanau, friends, media, staff and other health care providers – in fact anyone that we come into contact with – whether informally or formally. There are common themes that arise from reviewing this feedback (through the complaints process, letters we receive, the surveys that patients or family complete, submitting suggestions and feedback on the “Tell us what you think” form or via our website and the compliments we receive). These are:

Having simple, meaningful information, on time

Communicating honestly, clearly, frequently and listening carefully

Timeliness of appointments, transfer of care and responding to change without undue delay

Being respectful and protecting dignity

What did we improve? In response to this feedback, some of the improvements we have made include:

Some examinations within the hospital’s x-ray department require a patient to drink an oral contrast which outlines the bowel. To make this more palatable, the contrast is mixed with a cordial flavour and normal tap water. Recently, two patients have completed “Tell us What You think” forms and suggested that a cold or chilled drink would help the horrible taste and improve the ability to swallow. Acting on this feedback, Medical Imaging placed a water cooler in the oral preparation area which now gives patients a choice of water temperature that can make drinking the litre of fluid more tolerable. Since this has been implemented, we have received positive feedback from patients. The two patients who made the suggestion were contacted as part of the follow-up and were extremely pleased that their suggestions had been acted upon and that it would improve the drink for other patients.

In STAR 2 (an Assessment, Treatment and Rehabilitation ward) a new information brochure has been developed that now includes detailed information about doctors rounds, how goals are set, family meetings and who is in the team caring for you or your relative.



We, MidCentral District Health

Board, pledge we are open to:

Working in partnership with patients,

consumers, families and whanau

Change, improvement and innovation

Supporting an honest, transparent, and

respectful culture

Listening carefully and communicating

clearly

Acknowledging mistakes and learning

from them

Working as a team and across teams

Working across the primary and

secondary sector

Using evidence-based practice

Sharing and learning from successes

(Our commitment to “Open for Better Care”, June 2013)

Another ward is trialling a process whereby the patient and/or family could be more routinely involved in planning for discharge and included in other processes where decisions about care and discharge are discussed. This trial will be evaluated toward the end of 2013 and will include patient feedback.

A guideline for setting up and managing family meetings was developed for all staff following feedback from a family that they had not had the opportunity to meet with staff caring for their relative. The guideline recommends who should be invited to a family meeting, in what situations a meeting should be held and what to inform patients and families with regard to opportunities for have a meeting.

Feedback was received from a family that a relative in hospital did not receive a special mattress to assist with prevention of pressure sores quickly enough. As a result of that feedback a process was implemented whereby all those patients requiring a special mattress would receive it within 24 hours of the request being made. In addition, a large number of our mattresses were replaced with higher quality mattresses so that the need for special mattresses was reduced.

Face-to-face interpreting services as well as the existing telephone interpreting service are now available for General Practice Teams in the district.

Education for General Practice teams regarding interpreters and working with refugees.

O800 telephone line for people to ring that don’t have a GP and need assistance to find one.

What is our focus for improvements in 2013/14? Participating in the development of consumer experience indicators, which is being led by the Health

Quality and Safety Commission. Undertaking a review of how we engage with and seek feedback from patients, families and others

in our community. The outcome of this review will inform us about how to provide more opportunities for you to tell us about our services, give us ideas about things that could improve and to make comment on things we are planning and things we are reviewing to see how well they worked. We will also be looking at how we improve the range of surveys we do to ensure the questions asked are relevant and that ways to participate are easy for everyone.

Continuing to look at new and better ways to communicate and share information including utilising

the continually changing technology as part of this. Continuing to improve our coordination of services to ensure that you have greater clarity of who is

leading the care you require and that you know “who is in charge”.



2.1.2 Reducing the Risk of Harm

Serious Adverse Events

What is this about?

Serious adverse events are events which have generally resulted in harm to patients. For example an event which has led to significant additional treatment, is life threatening, has led to an unexpected death or major loss of function. Falls resulting in bone fractures are the most commonly reported serious adverse events; they are therefore a focus for us and are featured in this section.

The process of reporting and reviewing serious adverse events is about improving the quality and safety of our health and disability services. Not all events are preventable, but many involve errors that should not have happened. Reviewing these events in an open, systematic and comprehensive manner allows us to learn from our mistakes and focus our attempts to reduce avoidable harm from health care.

What were our results?

The number of incidents which have occurred is not in itself a good indicator of a hospital’s safety. A high number of incidents might mean staff are actively reporting events or the hospital is seeing more patients or has more complex cases. A low number of reported events may mean they are not being reported as often as they should be, or it may reflect a very successful risk-management programme within a hospital. International literature does not support the use of the number or rate of reported events as a way of judging a hospital’s safety, as there is considerable variation in the rates of reporting, not just in the rates of events. Therefore, a wider view of the whole system needs to be taken when considering the safety of hospital and health care services

We reported 21 serious adverse events that occurred in the 2012/13 year. This is an increase of 6 events compared to the 2011/12 year. Notably, the majority of the serious adverse events were related to falls, as was the case for all DHBs (47% of all reported events in 2011/12 related to serious falls). Of the total 21 events reported by us for this year, 11 (52%) were falls in hospital that resulted in a fracture. The other 10 events included: delayed or missed diagnosis, delayed treatment and incomplete assessment leading to harm and/or contributing to a death. Our focus on falls in this review is because they are the largest number of serious adverse events. It does not mean that there is no focus on the other events or that improvements are not being made as a result of those events.

Our focus on reducing the incidence of falls All falls that are reported in the hospital setting are reviewed to see if anything could have been done to prevent the fall or reduce the injury. Particular emphasis is put on the more serious falls resulting in fractures. Our hospital and associated services has a Falls Reduction programme which is led by a group of clinical staff focused on developing and monitoring improvements. There is no single solution to reducing falls – a wide range of activities is required.



The introduction of a practical “falls card” – Be Alert – Falls Hurt – that is designed to sit at the back of staff ID tags, provides reminders and advice about ways to help reduce falls. It has become such an important part of the falls reduction programme that other DHBs are now using it. We also have an “April No Falls Day” each year on the 1st of April which is geared toward raising awareness among staff as well as patients and their whanau/families about falls and how they can be reduced.

Bed alarm systems have been purchased and put in place to alert staff when a patient at risk of falling attempts to move from the chair or bed. Beds that can be set to very low heights are also being trialled to see if they could help reduce injury from falls.

We have established a process and system to ensure that we include an assessment of risk for falling as a routine part of our clinical assessments and that we have appropriate things in place with patients that will contribute to reducing that risk.

We have been participating in the National Patient Safety Campaign called “Open for Better Care”. The first topic that this campaign focuses on is preventing injury from falls. A wide range of activities is being promoted not only in hospitals but also in rest homes and the community. These activities include testing new systems for making it very obvious that a patient in hospital is at risk of falling by having colour coded alert signs available. Another activity is promoting the administration of vitamin D which strengthens bones and subsequently reduces injury from falls. Our Pharmacy Advisor undertook an evaluation of the programme that we commenced in 2010 in collaboration with ACC. A summary of his evaluation is provided in the side box.

Getting the best out of Vitamin D for people in Rest Homes. Andrew Orange, Pharmacy Advisor, MidCentral DHB

Context, planning and activity

Vitamin D improves muscle strength and balance and helps to reduce the number of falls in older people living in Aged Residential Care (ARC) facilities and being admitted to hospital.

From May 2010, MidCentral DHB worked with ACC on a two year project to improve the use of vitamin D in ARC residents in the MidCentral district by raising awareness with ARC staff, prescribers and other health professionals, residents and their families, of the benefits of Vitamin D.

Information on the benefits of vitamin D, prescribing guidelines, and quarterly reports on the use of vitamin D, were provided to ARC staff with similar information sent to prescribers.

Results and impacts of the activity

Vitamin D utilisation by ARC facility residents increased from 15% to 74%. This increase corresponded with a 32% reduction in fracture presentations to MidCentral Health’s Emergency Department, a 41% reduction in fracture admissions to hospital, and an estimated $0.54 million return on investment over the first 18 months of the project.

Lessons learnt and next steps

This project showed that simple and cost-effective changes to therapy based on good quality information and robust guidance can quite quickly benefit ARC residents. It also showed that getting things right out of hospital can result in significant benefit for hospitals.

Next steps for this project are to find a way to achieve similar results for people not in rest homes. This involves making sure we can identify who will get the best out of vitamin D.



Quality and Safety Markers

What is this about? Quality and Safety Markers were introduced this year across all District Health Boards to track the level of harm and cost associated with a particular health issue. The first set of Quality and Safety Markers, published by the Health Quality and Safety Commission in June 2013, look at three critical areas of safety and quality. These are:

Preventing harm from falls

Health care associated infection

Perioperative harm (harm during or after surgery) Simple quality and safety interventions and use of best practice can reduce the risk of harm. We have a range of programmes and interventions in place that have made a difference to patient safety and ensure that we provide cost effective high standards of care. We have extensive knowledge, skills and commitment to delivering excellent patient care. However, we know that some patients are still being harmed, sometimes with serious and long term consequences. We have a number of measures that show what we have done to make care safer and by tracking the actual level of performance. The markers chosen reflect processes that should be carried out almost all the time.

What were our results?

Reducing harm from falls

•78% of hospital patients aged 75 and over - for Maori and Pacific patients, aged 55 and over - were assessed for risk of falling. The goal is 90%

•92% of patients assessed as being at risk of a fall have an individualised care plan which addresses their falls risk. The goal is 90%

Reducing health care associated infections

•72% compliance with good hand hygiene practice. The goal is 70% increasing to 80% over time.

•82% compliance with procedures to prevent central line associated blood stream infections when inserting catheters into blood vessels near the heart. The goal is 90%

Reducing perioperative harm

•96% of operations had all three parts of the surgical safety checklist completed to reduce harm during or after surgery. The goal is 90%



What is our focus for improvements in 2013/14?

We will be continuing our focus on reducing harm from falls, as they have a significant impact on the individual, their family, and the hospital services. This will include:

Increasing the number of patients who are assessed for risk of falling in hospital and who subsequently have a care plan in place that identifies what needs to be done to prevent that patient from falling.

The Falls Action Group will expand to cover the community setting, including rest homes. Strengthening the focus outside of the hospital may reduce the

risk to patients when in hospital as well as help to reduce the risk of them falling that might then lead them to being admitted to hospital. A guide to best practice for prevention of falls and injury from falls is being developed. This will direct staff to the best options to follow for each patient,

give immediate access to additional information and contact details for referring high risk patients for other assessments. This guide will be used both in the hospital and in other health services. The guide will be ready for use by December 2013 and will evaluated by the end of 2014 to find out what difference it made.

Establishing a Fracture Liaison Service. This is about putting prevention programmes in place for individuals and groups who are at risk of fracture

particularly hip fractures. It is likely to involve orthopaedic surgeons, geriatricians, general practitioners and others who work with people who are at risk of fracturing bones.

Continuing to actively participate in and promote the “Open for better care” campaign locally. The aim of the campaign is to enable health and disability

services to ensure everyone is doing the right thing and doing it right first time. There are four key topics to this campaign: reducing harm from falls, health care associated infections, surgery and medication.

Implementing a system and process in community health care settings to assist with reporting and investigating serious adverse events and other

incidents, and the subsequent improvements made. This new system is the same as that which is already in place in the hospital. It helps us to better identify and understand these events, increasing our ability to learn from them and to make improvements that we can then share across all services regardless of the setting.


2.2 Our Focus on Services

What is this about?

We are looking at improving health service delivery for our community, in particular for population groups that have higher health needs, use a range of health and disability services or who are at risk of developing illnesses or longer term health conditions. We want to focus on care that is delivered across all settings and not just in the hospital or at your doctor’s rooms. The four services/populations that are highlighted in the following pages are a high priority for us and for those who use our services. The Government has also identified these four areas, among others, as high priorities when setting direction and funding for us. We have made many improvements and more are planned but there are many more things that could still be done. We will highlight where we have done well, where we still have work to do, what that work is, when that work is planned and how you can contribute.

Which services and why?

We have chosen to focus on four different services/populations in this review.

1 Child Health Services/ Tamariki Ora

This is about improving the health and safety of our future generations. We need to bring all health services that support children and their families closer together and make sure we get the best possible outcomes for our children. This includes making sure children, adolescents and their families can have their say about the services we provide now and what they see as the best options for coming years. We are working on reducing rates of avoidable hospitalisations, ensuring all eligible children have the health checks to which they are entitled, increasing immunisation rates and ensuring newborn babies are registered with a health provider. Our Child Health programme of work is led by a strong clinical network with representatives from health, education, police, social sector agencies and non-Government organisations. By working together with we can support better coordination and integration of child health services. In the coming year we will be focusing more on implementing aspects of the Government’s Child Action Plan that aims to improve the health, safety and wellbeing of our most vulnerable children.

2 Primary Health Care Services

This is about your health provider that you go to first in the community and may be your doctor, nurse, pharmacist, plunket nurse etc. We want to make sure that more services are provided closer to where you live and work. This means more health services need to be grouped together in one place to make it easier for you to use these services. It is also about more services being provided to people who have chronic health problems like diabetes and respiratory disease so that they don’t need to go to hospital as often. We also want to make sure that hospital staff and health providers in the community work closely together sharing information to better understand your health needs.



3 Mental Health and Addiction Services

This is a local priority particularly in respect of services for youth. About 3% of our population are known to have serious mental illness and about 20% of our population will be affected by mental health issues. Mental health and addiction services are not always in the right place at the right time or delivered in the way that suits the patient and/or their family. We are aiming to build on the range of services available in the community to improve access. This will help the services to be more responsive and better coordinated when working across the health, social and justice sectors. We also aim to involve consumers more in our service developments as well as build the capability of our collective workforce to address service gaps. We will be using the Ministry of Health’s Mental Health Service Development Plan “Rising to the Challenge” as a guide to addressing service gaps and improving performance over the next five years.

4 Maori Health and Whanau Ora

Maori make up 19% of the district’s population with a high proportion living in the Horowhenua and Otaki area. Maori feature at a higher rate in illness/disease statistics such as heart disease, diabetes and respiratory conditions. They do not however feature highly in accessing health services early, particularly where there is opportunity to prevent or reduce the impact of these diseases. It is important therefore that improvements are focused on developing services that are more acceptable and accessible to Maori. We are also supporting implementation of Whanau Ora together with the Ministries of Maori Development (Te Puni Kokiri), Social Development and Health. Whanau Ora is an inclusive approach to providing services and opportunities to all families in need across New Zealand, empowering whanau as a whole rather than focusing separately on individual family members and their problems. It is about whanau setting their own direction; driven by a focus on outcomes, are self-managing, living healthy lifestyles, participating fully in society, confidently participating in te ao Maori (the Maori world), economically secure and successfully involved in wealth creating, and are cohesive, resilient and nurturing.2

2 Whānau Ora Fact Sheet, May 2013, Te Puni Kokiri



2.2.1 Child Health Services / Tamariki Ora

What did we want to achieve?

Every newborn child in our district engaged with well child health services resulting from early enrolment

Fewer hospital admissions for vaccine preventable diseases and ambulatory sensitive conditions

More children can access specialist care closer to home

All eligible children receive their Before School Check

Better integration and coordination of child health services

How well did we do? The following selection of measures show how we monitor aspects of access to health care services, equity for our population groups, and value for public health system resources against the main things that we want to achieve. The experience of care received by children and their family, caregiver or whanau is drawn from feedback and surveys that we use to help us evaluate and improve our services. We provide some examples in the section below.

Having an approach that focuses on preventative programmes such as the immunisation programme, the health checks before children start school, and ensuring access to effective primary health care and evidence based practice through integrated clinical pathways for certain conditions for example, we can contribute to reducing unplanned hospital admissions for conditions or illnesses that could have been avoided and free up those resources for specialist acute interventions.

Enrolment of children in health services

• At the end of June 2013, there were 10,171 children aged 0 – 4 years enrolled with Central PHO. Based on population estimates (medium projections), this represents 88% of all children estimated to be living in our district at that time.

• During the 2012 year, there were 7,537 pre-school children (aged 0 – 4 years) enrolled with the community based child and adolescent oral health service – an increase of 2,084 children compared to 2011. At 65% of this population group, we were pleased to have well exceeded our goal (53%)

• At the end of June 2013, there were 2,345 children aged 2 years enrolled on the National Immunisation Register



Increasing immunisation coverage

• 93% (2,022) of the 2,173 eligible infants had had their primary course of vaccinations (6 weeks, 3 months and 5 months) by the time they reached the milestone age of 8 months; an excellent result exceeding the national goal of 85%. The goal increases to 90% by the end of June 2014.

• The immunisation coverage rate for each ethnicity and deprivation index group was 90% or more ensuring more children received their vaccines for preventable diseases and reducing the potential for future hospitalisations for treatment of these diseases

Before School Checks for target population

• The national goal is for 80% of the eligible children to be seen as close to their 4th birthday as possible for the series of health checks to which they are entitled so children are not hampered by health conditions that may limit their ability to learn when they start school

• We achieved a coverage rate of 83%, delivering 1,972 Before School Checks. 516 were for children living in areas of high deprivation – 89% of this target group – a good result. Both of these coverage rates were slightly better than the national rates (80%) for the 2012/13 year

• To further improve equity of access to these health checks, we aim to increase the number of Maori, Pacific and Asian children being seen and will continue to work with all child health services, early education centres / kohanga reo, Maori health providers, Immunisation coordination team and general practice teams to ensure we can reach these children

Reducing ambulatory sensitive (avoidable) hospitalisations (0 – 4 year old)

• Latest results to March 2013, indicate that admissions to hospital for certain conditions in the 0 – 4 year old age group increased over the previous 12 months – a reversal of the more recent trend

• These were for conditions like asthma, gastroenteritis, eczema, cellulitis, respiratory infections (including pneumonia) and dental conditions

• There were 562 admissions to hospital for these types of conditions over the 12 months to March 2013. This represents a standardised rate of 4,743 per 100,000 population compared to a national rate of 4,407/100,000 (or 108% of the national rate).

• Our rates for Maori children are lower than the national rates for Maori; this could indicate an issue of access to health services rather than an absence of these conditions

Getting It Right

Improving access

Because of the relatively high number of children being admitted to hospital and being seen by school-based health services for eczema and atopic dermatitis it was clear that some service improvements could be made. The nurse-led Community Children’s Eczema Service was

established for all children/tamariki in our district, with clinics provided in Palmerston North, Horowhenua and Tararua. On average 60 children are seen per month across the district.

Getting it right



“The children's Eczema service was great. We have an awesome plan to keep my daughter’s eczema

under control and we have had no hospital admissions since the last few times in 2012. It is not easy to have a child with eczema as we have

to apply creams day and night which can be stressful but I know it is for the best and it has paid

off. My daughter now scratches less and she is getting more sleep too. I would recommend the

Eczema Clinic to anyone who I know would need it as they would benefit from it. Thank you for all your help”. (Parent of child from Tararua)

The Children’s Eczema Service aims to:

Provide eczema management, advice and education to children and their families/caregivers

Provide direct access to the service from community referrers: Plunket, Iwi/Maori providers including Tamariki Ora Nurses, General practice teams, Public Health, Paediatricians and Dermatologists

Provide children and families affected by eczema with improved access and choice of provider

Focus clinical resources where they are most needed

Improve parent/caregiver satisfaction and outcomes; an improvement in children’s skin conditions by reducing the SCORAD (Eczema Severity Score) and reducing upset, embarrassment or self consciousness because of their skin and effects on friendships.

A first visit of up to 90 minutes includes education, management advice and the development of an action plan. A phone contact and a follow up visit occur 12 weeks later, before referral back to their general practice team. This service gives health professionals in the community direct access to a nurse to provide clinics and education to children with eczema. Latest data from consumer feedback surveys and the Life Quality Index is very positive.

The service works directly with the hospital-based dermatology service and has established a pathway for referring complex and urgent cases. This relationship between the nursing team and the dermatology specialist has now resulted in all referrals from Primary health care being seen by the Children’s eczema service first and the nursing team determines whether the child and family needs specialist dermatologist assessment.

Reducing waiting times and improving access

It is estimated that there are about 400 children aged up to 16 years with an Autism Spectrum Disorder (ASD) in our district. Not all are diagnosed or necessarily require help from specialist services. However, in response to high caseloads, a growing waiting list and unacceptably long waiting times, in January 2013 we increased the number of specialist health professionals available to provide services to children with an autism spectrum disorder and their family. The Child Health public forum held in late 2011 provided families with a supportive environment in which to discuss opportunities for service improvement in future years. Families believed the Child Development Service to be genuinely under resourced and were very vocal about their request for additional services. Our Child Development Service was not able to meet the demand for the range of diagnostic, intellectual and behavioural assessments, treatment interventions and coordinated support requirements for this group of children and their family on top of those required for children with other disabilities. It was evident that there was a need for better access to a greater range of disability services, and further evidenced by needs uncovered in implementing the national guidelines for Autism Spectrum Disorder.



By the end of June 2013, we had reduced waiting times from an average of 26 weeks (in some cases, much longer) to within 37 days on average, and the time to confirmation of diagnosis and then receiving their finalised development and service coordination plans also reduced significantly. Referrals are being managed better with very few children now on a waiting list. The ASD Coordinator makes earlier contact with the referrer and families and keeps them up to date with the referral and progress throughout the families’ engagement with the service. We are currently recruiting staff to supplement resources for speech language therapy that will further enhance the multidisciplinary team approach to support children and their families living with ASD.

Being Consumer and Community Focused

Newborn enrolment programme

This is a new initiative for connecting newborn babies with key health services. The programme goal is to encourage and support early enrolment and engagement of families/caregivers following their baby’s birth with these services:

General practice teams

Well Child/Tamariki Ora provider

National Immunisation Register

Child and Adolescent Oral Health Services

Universal Newborn Hearing Screening and Early Intervention Programme (UNHSEIP)

This programme aligns closely to Government direction which is focused on seeing every newborn baby linked to their entitlements. A specific position is in place to support this initiative aimed at helping to navigate and link babies and their families with health services.

In starting up this programme we discovered from a snapshot taken in 2012/13 that about 1 in 5 (20%) babies born in our maternity unit did not have a GP identified before they left hospital and that 30% had not decided on a well child service provider at that time (59% identified Plunket). By putting in some systems to reduce this rate, including following up individual families to discuss options as well as updating records, we are now confident that almost all babies will have a GP that their family, caregiver or whanau can take them to when needed. This has proven to be valuable information as a basis for developing the Newborn Enrolment programme, which is due to commence from October 2013. Having a GP and being enrolled with the PHO is a first step in connecting babies to the health services they are entitled to, and aligning the newborn hearing screening programme, immunisation register, pre school enrolments for oral health and delivering well child services.

Being consumer and

community focused

Whakapūpūtia mai ō mānuka kia kore ai e whati

Cluster the branches of the manuka so that they will not break



Being Up to the Job

Reducing hospital admissions

Two well attended Child health forums have been held by the community child health team. The forums provide an opportunity for individuals, community groups and clinicians to come together to plan how to improve health outcomes for our district’s children. Updates are provided to the participants on a range of topics such as recognising the unwell child, the development of the Collaborative Clinical Pathways for child

health and maternal mental health.

Six child clinical pathways have been developed for community-based and hospital services. One is a pathway to manage vomiting and diarrhoea (gastroenteritis) in children. This pathway has been developed to ensure children get easy access to the right care and consistent information from pharmacies, general practice teams and hospital staff. Since introduction of the ‘Gastroenteritis in Children’ pathway in November 2012, community pharmacies provided care to 43 families and in 42 instances provided oral rehydration therapy for children, meaning fewer hospital admissions and visits to GPs.

Pathways for management of eczema, constipation, chronic and acute asthma and urinary tract infections in children have also been developed. A further six conditions are scheduled for pathway development: bronchiolitis, enuresis, impetigo, scabies, pneumonia and upper respiratory tract Infections. In addition, work has commenced on the development of a behavioural pathway so that children with behavioural issues are seen by the right provider the first time.

By establishing these clinical pathways with community and hospital based health professionals and our consumers, we are confident that up to date knowledge and skills will be consistently used in assessing, diagnosing and treating health conditions. We also expect to contribute to reducing the number of ambulatory sensitive (avoidable) hospitalisations as a result of implementing these pathways of care.

Being Willing and Able to Learn

Protecting our babies from serious disease and illness – Immunisation

Childhood immunisation is a key priority and we have been successful in achieving all immunisation targets. An Improving Immunisation Coverage Group meets monthly to monitor progress, co-ordinate activities and determine what support and action is required. The Immunisation Coverage Group is linked to general practice, public health and well-child providers

and has been the key to our success through working together, discovering what works best and learning from each other and our experiences. Detailed, up to date data is used to inform the group’s activities and the focus for improvements that take advantage of the broad range of group members’ knowledge of the community and what is likely to work best.

Being up to the job


learn



What is Our Focus for Improvements in 2013/14? Rolling out the ‘health home’ newborn enrolment programme to include more services to which children are entitled

Promoting and supporting the use of clinical pathways for children and checking that these are making a difference

Reducing the numbers of children who are admitted to hospital for certain conditions by diagnosing and treating them earlier and closer to home

Extending the community-based child health team to increase the range of services available to families in the community

Advancing components of the Government’s Children’s Action Plan 2012:

o coordinate information/advice around sudden and unexpected death of infants and shaken baby prevention programme o develop an integrated work programme alongside Child Youth & Family and Police to work towards reducing child assaults across the region o explore options for a primary care based Family Violence Intervention Programme o implement the National Child Protection Alert System

Aligning our quality activities to the new national Well Child / Tamariki Ora Quality Improvement Framework



2.2.2 Primary Health Care Services


More people can access integrated primary health care services closer to home

Fewer people are admitted to hospital for avoidable illness / health conditions

More people with long term conditions better manage their health

Health professionals deliver high quality evidence-based care

How well did we do? One way of measuring access to primary health care and the effectiveness of the general practice teams is by seeing how many people in our district are enrolled with primary health services and by monitoring the rate of admissions to hospital that are mostly avoidable if conditions such as diabetes, heart and breathing problems were diagnosed and treated early enough in the primary care setting. These are known as Ambulatory Sensitive (avoidable) Hospitalisations.

We also measure how well we’re doing in reducing the risk of people developing long term illnesses, such as heart disease, breathing problems and diabetes, and, supporting people to quit smoking. If people do have diabetes, then we want to make sure that they have good blood sugar levels and well developed self-management skills. The following table provides some of the facts and figures around these key areas.

Increasing enrolments with the Primary Health Organisation

• 152,873 people in our district were enrolled with the primary health care services - just over 89% of the estimated population at the end of June 2013 - a small increase compared to 2012.

• The proportion of the estimated Maori population enrolled is lower than expected at 81% (26,535). The goal is 95%

Reducing avoidable hospitalisations

• There were 3,318 admissions to hospital for conditions that could be avoided for people up to the age of 74 years. This represents a standardised rate of 1,996 per 100,000 population compared to a national rate of 1,888/100,000 (or 106% of the national rate).

• Avoidable hospitalisations for Maori were much lower than non Maori ethnicity groups over this same period (74% of the national rate for Maori). When compared to the rate for all ethnicities though, the standardised rate was much higher for Maori (2,202/100,000) than non Maori.



• The main conditions for which people were admitted to hospital included: angina and chest pain, cellulitis, asthma, pneumonia and respiratory infections, and, diabetes and heart attacks in the 45 – 64 year old age group

Assessing risk for heart disease

• At the end of June 2013, of the 45,583 adults in our district who were eligible, 30,809 (67.6% against a goal of 75%) had had a cardiovascular disease risk assessment in the last five years

• By the end of June 2014, the goal is to have 90% of eligible people having had a heart health check - that's at least another 10,230 people

Supporting people to quit smoking

• At the end of June 2013, 67.1% (11,954) of the enrolled population who smoke and seen by primary health practitioners (17,823) were offered brief advice and help to quit smoking. The goal is 90%

Maintaining good management of diabetes

• By the end of June 2013, 75% (3,584) of the people with diabetes who had had an annual review during the year had good diabetes management (a blood glucose level of equal to or less than 64 mmol/ml)

• Rates for Maori and Pacific people with diabetes need to improve - 64% and 53% respectively. The goal is 75% for all population groups

Getting It Right

Partnering with general practices

In furthering the development of effective primary health care services, during the 2012/13 year we began developing an ‘accountability and incentives’ framework to support and motivate general practice teams to better meet the needs of their enrolled populations. General practice teams have long been saying that they know they can attain achievable health improvements in their communities if they have the time and resources to change their model of care and an incentive structure to support them to do so. Through a co-design methodology, we

have built the ‘Partnering with General Practice for Improved Health Outcomes’ framework. It is underpinned by a ‘Practice Development Plan’ which is prepared by the general practice team on the basis of an analysis of the practice’s population and identifying priority health gains as well as the priorities for change the practice wishes to achieve. The Practice Development Plan will incorporate three types of improvements that will be measured over time – structural, process and outcome.

Getting it right



The Partnering with General Practice for Improved Health Outcomes framework is being tested with Tararua Health Group, applying the Practice Development Plan approach as a proof of a concept; this work will continue into the 2013/14 year. It is anticipated, once proven, that other IFHCs or general practice teams with a population size of around 16,000 under their umbrella will take up this supported development programme for improvement over the coming years, with the expectation that primary health care services will be more directly accountable for improved health and equity for its population, provide better value for public health system resources, and deliver improved quality, safety and experience of care for their patients and community. A publication on our website offers more information on this programme – see www.midcentraldhb.govt.nz/Publications/All Publications/Documents/PartneringGeneralPractice


Access closer to home

Integrated Family Health Centres (IFHCs) are about health professionals from many disciplines, community and hospital working together to provide easy access to coordinated quality care closer to where people live. By aligning services to each community they can be designed to meet the particular needs of that community and address any identified gaps. IFHCs have been established in Otaki, Horowhenua, Te Waiora

(Foxton, Shannon and Himatangi), Palmerston North, and, Tararua (Dannevirke and Pahiatua). One in Feilding and two more in Palmerston North are in the development phase.

IFHCs support general practitioners (GPs) to provide team based care to their patients. This is important as our ratio of GPs for the size of our population is at the lower end compared to the rest of New Zealand. Recent general practice patient focus groups identified most participants were happy to see the nurse practitioner or practice nurse as their ‘first port of call‘.

We have strong Clinical Networks for Urgent Care and for Long Term Conditions in our district with representatives from primary health care including general practitioners, consumers and families, NGOs, whanau ora and Maori health providers, secondary services and St John Ambulance services. The Network Groups have held a number of community forums throughout the year, which provided valuable opportunities to hear directly from our consumer groups what’s working well and not so well. The Groups have developed a number of initiatives to improve systems and processes, access to services, self-management support, and co-designing services to meet the identified community needs.

Being consumer and

community focused

“The community voice at forums held throughout the district was strong, with the community providing a large amount of high quality feedback about their experiences accessing urgent health care. Themes that recurred throughout the Urgent Care Community Forums related to: information, education, after hours care, decreasing costs, transportation, interpreters, models of care, funding models, service integration, and accessibility. The Urgent Care Community Forums have provided a strong foundation for the Urgent Care District Group to build their health care quality and service improvements work plan incorporating the consumer perspective. The work plan will be used to drive urgent care quality improvement planning over the 2013-2014 year.”



Enhanced Care Plus patient – “I have had excellent help and care and am very pleased with the results; health

and fitness have improved remarkably with a substantial weight loss.”

“I find the actual assessment fantastic and do believe I make a difference. We do help those in need”. (Practice nurse)

Being Up to the Job

Partnering with patients

General Practice teams offer a package of care (Enhanced Care Plus) to patients who would benefit from support learning to live well with a long term health condition such as diabetes, heart disease or breathing problems. This involves doctors, practice nurses and PHO chronic care teams (nurses, dieticians, physical activity educators, smoking cessation coaches) with particular skills in chronic care management working

together with patients and their family or whanau to improve quality of life from the patient’s perspective. The package involves comprehensive health assessment and planning for better health and wellbeing.

Patients and health practitioners are asked about their experience of this programme. Both expressed a high level of satisfaction. The survey asks both the clinician and patient a range of questions about what’s important to them and how well we did in those areas. Of most importance to the clinician and patient was offering treatment choices, talking about medicine problems, and developing a plan of what to do when not well.

Patients self-rated health status at the end of participating in programme showed 76% considered their health to be the same or better than it was a year ago. This is a very positive finding amongst people living with one or more chronic conditions.

The results of this survey, while still showing room for improvement, are encouraging. It suggests that the comprehensive health assessment being used by the practitioners help to better identify patients’ issues and needs and that by working in partnership with patients in developing their plan, the patient (and their family or whanau) is more likely to succeed in improving their health and wellbeing on a daily basis.

Early indications of the Enhanced Care Plus programme strongly suggest that by being better at managing long term health conditions in partnership with patients and their family or whanau, we are contributing to reducing the number of acute admissions to hospital.


Clinical pathways and networks

Collaborative Clinical Pathways are computer-based maps which are used in primary health care and hospital services as a guide to the best treatment options for patients at each stage of their care. They are used as a rapidly

accessible check of best practice, mostly used by frontline clinicians such as your doctor or nurse and as a tool to assist in planning and development of health services across the district.

Being up to the job


learn “The Map is definitely a major step forward for us and the specialists at the hospital. It will make referral criteria much clearer and support us with suggestions of what we should do at various points in patient

care. The great thing is that it is available on our MedTech system with a mouse click, and we can work through with the patient in the room

guided by what the international best practice suggests. General Practice in the MidCentral district is very excited about this system”.

(General Practitioner)



Over 200 clinicians from hospital and the community have developed 34 Collaborative Clinical Pathways across 17 health conditions using the “Map of Medicine” web-based system. Feedback from clinicians has been overwhelmingly positive. Over 1,750 health professionals across the district have registered with Map of Medicine including aged residential care providers, community pharmacies and general practice and hospital services.

By using these common pathways of care we can ensure that practitioners are kept up-to-date with evidence-based care and patients can expect effective, appropriate treatment and an efficient referral process when this is required.

Collaborative Clinical Pathway development is supported by Clinical Network Groups. These involve a range of primary health care practitioners, secondary / specialist and allied health care professionals, Maori/Iwi health providers, and others working in partnership with consumers to learn about and lead service developments, performance improvements and planning services across our district. Clinical Network Groups hold occasional public forums to ensure the group has a good understanding of community issues and that the community voice is included in quality and service improvement planning for services. Clinical Network Groups are in place for: Palliative Care, Urgent Care, Child Health/Tamariki Ora, Mental Health and Addictions, Long Term Conditions, Cancer, and, Older Persons.

What is Our Focus for Improvements in 2013/14? Reducing admissions to hospital by diagnosing and treating some conditions earlier, closer to where people

live

Bringing hospital and community health and disability services closer together through Collaborative Clinical Pathways and Clinical Networks

Increasing heart health and diabetes checks

Promoting and supporting people to quit smoking

Strengthening team based care in preventing and managing long term conditions

Improving the management of acute care across the district



2.2.3 Mental Health and Addiction Services


• More people needing specialist mental health and addiction services can access them

• Shorter waiting times to be seen for non urgent mental health and addiction services

• Better integration and coordination of services

• An enhanced, knowledgeable and responsive workforce

• Fewer admissions to hospital

How well did we do?

There are two key measures that we use to monitor how well we’re doing with ensuring that people have access to specialist mental health and addiction services and that people do not wait too long for a non urgent appointment. (The Mental Health Emergency Team still sees people as soon as possible after they’re contacted with a request for an urgent assessment or intervention). We also monitor how well we’re doing with supporting consumers with a recovery-focused approach, to stay well and manage their mental illness through good relapse prevention planning and effective community-based mental health services, reducing the need for repeat admissions to hospital.

Increasing access to specialist mental and addiction services

• Over the 12 months to the end of June 2013, 5,751 people were seen by specialist mental health and addiction services (3.4% of the population) - around 2% more than the number seen last year. Of the total number of people seen, 1,565 (27%) were Maori.

• The number of young people aged up to 19 years accessing the services increased to 1,643 (29% of the total); about 3.5% of this population group.

Reducing non urgent waiting times

• Over this same period, 70% of 1,834 people referred for non urgent mental health or addiction services were seen within three weeks. We had a goal of 75%, which increases to 80% by the end of June 2015. 89% (1,626) were seen within eight weeks, meeting our goal of 80%, which increases to 95% next year. Waiting times for alcohol and other drug services include referrals to non government organisations providing these services (such as the Youth One Stop Shop, MASH Trust and Whakapai Hauora). Waiting times for specialist mental health services alone showed that 83% of people referred were seen within 3 weeks and 97% within 8 weeks – achieving our goal.



Getting It Right

Shorter waiting times

One of the key activities to improve access to services, as well as to reduce non urgent waiting times, was to introduce a “Single Point of Entry” to the general adult mental health services; this service commenced in March 2013. The aims are to:

provide a single, streamlined process for all referrals to the adult mental health services

help with a more tailored response to individual needs

provide support between referral and choice appointment

enhance clinical safety and improve outcomes for service users and families

ensure all referrals are appropriate

It is too soon to formally evaluate the effectiveness of this service but there has, so far, been mixed feedback from patients; varying from frustration at the process by not being able to see a psychiatrist immediately, to appreciating that our service is able to arrange for someone to be seen in a timely manner. Also, efforts to tailor appointment times for new patients to meet their requirements have not resulted in a significant reduction in the “did not attend” rates, despite reminders and phone contact before the appointment time.

Improving relapse prevention planning

• This measure focuses on people with a longer term serious mental illness; identifying early relapse warning signs, what service users/consumers can do for themselves and what services can do to support them.

• At the end of June 2013, 90% of 442 people with a long term serious mental illness had an up to date relapse prevention plan in place. Our goal is 95%.

• The rate for Maori consumers was slightly better at 93%, although this measure concerned only 84 Maori consumers

Reducing acute readmissions to hospital

• Unplanned, acute readmissions to hospital within a short period of time can be avoided

• Over the year, 11.9% (80) of 670 patients had an acute readmission to hospital (mental health unit) within 28 days of their discharge from the mental health inpatient unit, achieving our goal of less than 15%. This was an improvement on the rate for the previous year (12.6%) and in past years when rates were even higher at between 19% and 27%

• Our rate compares favourably with others in the country, which averages at around 15%

Getting it right



Yes, the service has been a huge help in our situation. My children have been diagnosed instead of ignored and through this we have learnt coping skills which is of great help for

all of us and for the kids’ future

Another key change was to strengthen options for children at risk of developing conduct disorders to access specialist assessment and treatment interventions. The Child, Adolescent and Family Mental Health Service worked with Education and the Child, Youth and Family Services to provide a comprehensive interagency intervention, based at Special Education Services, to address conduct problems / antisocial behaviour and associated mental health problems in children and young people. So far, 21 children and their families have been registered with this service.

A key achievement for the team delivering the service has been to increase access to families who may have been described as difficult to reach, and to retain these families in the service. Improved relationships between services involved and joint facilitation of the Incredible Years programme (a best practice intervention provided to caregivers of children with behaviour problems) is now provided via a group modality over a 14 week period.


Increasing access to services

A weekly clinic held at Radius Medical, The Palms Health and Wellness Centre (Integrated Family Health Centre) was introduced at the end of August 2012. This

service supports: reducing stigma and discrimination - “any door is the right door” providing care faster, sooner and in a more convenient manner enhancing and streamlining access to secondary services meeting needs of clients in a more proactive way developing relationships between services sharing educational opportunities facilitating access to mental health expertise in a primary setting providing, or arranging for, earlier intervention for people experiencing emotional and mental

distress

Eighty clients have been referred to the service so far, receiving face-to-face assessments, consultations or telephone contact. There has been a relatively low rate of non attendances and cancellations of appointments. The majority of feedback for those referred has been positive in that the clinic is more accessible and less stigmatising; patients are often surprised that there is no cost involved as they are used to paying when visiting a GP practice. Mental health services shared care and packages of care programmes have been boosted. A GP liaison service has been retained, which combined with greater involvement of specialist services, is seeing a far higher level care being provided to mental health clients by their general practice teams.

The specialist Alcohol and other Drug Service is working with Central PHO to support the transition of clients on the opioid substitution treatment programme who are in a stable phase of their treatment from secondary care to primary care settings. So far, 82 clients are registered with this shared care programme.

Being consumer and

community focused



The aim is to better support access to the range of health care services needed for people on this programme that can be facilitated by their general practice team in a more holistic way.

The Alcohol and Other Drug Service has co-located one of its medical officers to work with the primary sector and to provide education and support for increasing awareness of addictions in the primary domain. The service has also dedicated a full time position to support clients transferring their ongoing treatment to general practice teams. While progress has been slow to date, there has been an increase in the number of clients transferred to primary care. This work will continue into the 2013/14 financial year.

We have strong Clinical Network for Mental Health and Addictions in our district with representatives from primary health care including general practitioners, consumers and families, NGOs, whanau ora and Maori health providers, Pacific fono, youth workers, secondary services, Police, Justice sector and Work and Income. The Network Group members held a number of community forums throughout the year and developed work groups to progress the suggested community initiatives (seven initiatives) to improve systems and processes, referral and treatment pathways and the interface across age groups and the continuum of care (including for example crisis respite services, suicide prevention strategies, youth alcohol and drug issues).

Being Up to the Job

Strengthening skilled workforce, building capability

Non Government Organisations (NGOs) in the mental health and addiction sector need better support to use frameworks that help to inform their service performance, workforce capability and their links to better identify whether services they provide really contribute to the process of recovery. Implementing the ‘Let’s

Get Real’ framework supports this approach. It describes the essential knowledge, skills and attitudes required to deliver effective mental health and addiction treatment services; building a workforce that supports recovery, is person centred, is culturally capable and delivers an ongoing commitment to assure and improve the quality of services for people.

An NGO Primary Workforce Leadership group - ‘Connected Workforce Te Hononga Kaimahi’ consisting of leaders and managers from each NGO and primary mental health area has been established. This group has developed a 5-year work plan that focuses on developing the workforce, organisational and sector development and leadership development. A workforce training schedule has been established, starting with a capability assessment of each Primary NGO provider using the ‘Lets Get Real’ framework. Development of Guidelines for children presenting with Eating Disorders to support staff who may not be familiar with the particular issues and needs of these children. The Child, Adolescent and Family Mental Health Service has developed a “care bundle” check list for children who present with Eating Disorders. Based on the literature for best practice, a care bundle is a term related to the Choice and Partnership Approach (CAPA) model and refers to collecting best practice information into a “bundle” to provide guidance to clinicians on how to best manage a presenting problem. The care bundle for eating disorders in children provides guidance for referrals, assessment, treatment interventions and recommendation on discharge and follow up.

Being up to the job




Benchmarking for performance improvements

We have been participating in the implementation of the Key Performance Indicator Framework for New Zealand Mental Health and Addiction Services that is being used as a means to improve outcomes for service users. The model of benchmarking includes all DHBs and some partner NGOs collaborating to identify the DHBs that perform best in agreed activities, highlighting the range of best practices and the

methods they used, and, the level of performance achieved which may then become the benchmark against which performance is compared. Under this model, continuous quality improvement is an incremental process grounded in measurement and data analysis, learning and development. Whilst the national benchmarking forums provide an opportunity to discuss and compare performance results, the real focus and benefit comes from learning from others doing well and identifying what needs to change.

As a result of this programme, we have steadily reduced our mental health unit readmission rates from a high of 27% to 12% by looking at the model of service delivery and making some changes in the inpatient unit. Just as importantly, we have significantly improved our collection rates for the Health of the Nations Outcomes Scale (HoNOS) suite of measures for each patient before, during and after their care journey. This information makes a difference in helping to improve treatment and care planning with consumers and that what is being done meets their needs and achieves positive outcomes. The improved HoNOS collection rates have been attributed to a number of factors, including: making HoNOS more relevant and useful to clinicians and providing training in HoNOS to all staff building on the use and monitoring of HoNOS into every level of the organisation, from the CEO to administrative staff having an energetic and focused coordinator to help with training, providing feedback and monitoring performance having good Information Technology support

What is Our Focus for Improvements in 2013/14? Developing our improvement plan in response to the national “Rising to the Challenge” service development plan

Increasing the participation and involvement of consumers and making better use of feedback from consumers

Establishing an integrated, evidence-based supported employment service model, in collaboration with Whaiora Trust Employment and Vocational Service

Improving the range and quality of perinatal and infant mental health services available to pregnant women, mothers and babies

Extending the Choice and Partnership Approach model

Developing a screening tool for young people presenting to ED with possible alcohol and drug issues and to support ED staff with appropriate assessment and referral options


learn



2.2.4 Maori Health and Whanau Ora


More Maori whanau are enrolled and engaged with primary health care services

More Maori whanau have healthier nutrition and increased physical activity

Maori whanau gain better health and wellbeing through promoting and supporting Whanau Ora

Rates of tobacco smoking by Maori are reduced

More Maori have heart and diabetes checks

More Maori women participate in breast and cervical screening

More whanau are supported to build on their knowledge and skills in managing their own health

How well did we do?

There are several key measures that we use, including the national health indicators, to monitor progress toward the goals for improving Maori health outcomes and reducing disparities amongst our population groups. Our priorities were focused on increasing enrolment rates, cardiovascular disease risk assessments, breast and cervical screening, help to quit smoking and promoting physical activity and better nutrition (also see Child health / Tamariki Ora section). Our results are outlined below.

Increasing numbers of Maori enrolled with Central Primary Health Organisation (PHO)

• At the end of June 2013, there were 26,535 Maori enrolled with the PHO – an increase of 301 over the year, representing 17.4% of the total enrolled population. As a proportion of the estimated population identified as Maori, the enrolment rate was lower than expected at 81%. The goal is 95%

Increasing breast screening and cervical screening coverage rates for Maori women

• Breast and cervical screening rates have increased for Maori women although still behind the rates for the total eligible women. For breast screening, 65.1% (1,356) of 2,083 Maori women aged between 50 – 69 years have been screened in the last 2 years; the goal is 70%.

• For cervical screening, 64.4% (4,230) of 6,570 Maori women aged between 25 – 69 years have been screened in the last 3 years. This rate is slightly above the national average (63%), but remains behind the goal of 80%.



More Maori men and women have heart and diabetes checks

• At the end of June 2013, 58.0% (4,004) of the 6,900 eligible PHO enrolled Maori population were recorded as having had their risk assessed for cardiovascular disease (including diabetes and stroke – the heart health check) over the last 5 years. This was an increase of 1,502 risk assessments over the year. The goal was 75%, which increases to 90% of the enrolled population by the end of June 2014.

• Our rate was well below the average rate across all DHBs (63%) though. We still have a long way to go to improve these rates.

Better help for smokers to quit

• Helping people to quit smoking has long term health benefits. The target was to achieve 90% of the enrolled population who smoke and were seen in primary health care settings to be offered advice and support to quit smoking. By the end of June, we achieved 67.1% (11,954) in total however our rate for delivering advice and support to Maori was less at 64.8% (3,062). This was a big improvement over the year, but we still have a long way to go with this goal.

More people have healthier nutrition and increased physical activity

• General practice teams have physical activity educators and dieticians available to patients referred for help with improving their health and management of long term conditions. Over the year, just over 30% (1,382) of the total number of individuals seen by these practitioners were Maori, achieving our goal but now needing to increase this further.

• The inaugural Whanau Fit programme hosted by Sport Manawatu had 147 (70%) participants identified as being of Maori or Pacific Island descent, exceeding our goal for this year (see below)

Getting It Right

Improving access

It is important that Maori models of practice are used by all those who work alongside whanau. They are also important in creating service delivery that meet the clinical and cultural needs of whanau. Through this approach we will be improving accessibility for whanau to the right services for their needs. We want to encourage whanau to build their skills so they are not dependent on services to ‘fix’ things for them. Our whanau have the ability to improve their own position for themselves in a way that works for them.

Te Waiora (Foxton Integrated Community Health Centre) is an example of partnership in action between Te Runanga o Raukawa and Central PHO. With the involvement of the local community, Te Waiora is a service centre that will provide health and social services to the wider Foxton, Shannon and Himatangi Beach communities. Its foundations are in nga kaupapa tuku iho and clinical expertise. Te Ohu Auahi Mutunga is a collective of Iwi and Maori Health Providers and Central PHO delivering quit smoking services throughout our district. Te Ara Whanau Ora is the process being used to work with whanau to support them on their quit smoking journey. The service has a specific (although not exclusive) focus on assisting Maori, Pacific and pregnant women to quit smoking.

Getting it right



“This has been the first fitness programme I have seen to the end; it was awesome and well run!! Also I’ve stopped eating potato chips and started exercising with my son, all because of the Whanau Tri programme. Thanks Sport Manawatu and the Health Board, Whanau Tri has been life changing!”

In order to achieve the ultimate goal of a Smokefree 2025, strategies such as increasing referrals by at least one extra person per week to the service, whanau referring other whanau members and utilising whanau who have successfully been on this journey to assist others are being considered.

Being Consumer and Community Focused Increasing heart health checks, promoting physical activity and better nutrition

Te Kawei Whakaheke involves combining cultural and clinical approaches to providing heart health checks for Maori and Pacific men in community locations. At the launch of the Tararua IFHC in May, a health expo was organised and Te Kawei Whakaheke partnered with

clinicians to deliver heart health checks to Maori and Pacific men attending. The ability to engage with Maori and Pacific in these kinds of community settings has been very successful and shown that by taking these types of initiatives people feel more comfortable and are more likely to engage with health professionals. Te Kawei Whakaheke worked alongside Sport Manawatu at the inaugural Whanau Tri held in Palmerston North in March 2013, hosting their heart health check tent at the same time. Over 50 people took the opportunity to have a free heart health check.

The Whanau Tri Programme delivered by Sport Manawatu actively engaged 210 participants, 70% of whom identified as being of Maori or Pacific Island descent. Sport Manawatu ran weekly training programmes in Otaki, Shannon, Dannevirke and four separate programmes in Palmerston North. Classes were held in the evenings at locations considered convenient to the community. While the content delivered was identical across all programmes, each group developed its own unique culture and environment.

The ultimate Whanau Tri event was a resounding success attracting over 600 participants in total ranging from 2 to 70 years of age, of many ethnicities and abilities – most of whom were female. Sport Manawatu stated that a key success factor was their link with organisations such as Te Kawei Whakaheke, Whakapai Hauora, Raukawa Iwi Medical Services, Rangitaane o Tamaki nui a Rua Inc. and Muaupoko Tribal Authority to promote the programme through their networks to help reach the priority groups. The overall programme was a success on a number of levels, with participants going on to complete their first triathlon, gaining confidence and a passion for physical activity and sporting events, and most importantly, improving their health status. Overall Body Mass Index average amongst the group dropped from 32.18 to 31.42 and 64% of participants tested showed some improvement in their cholesterol levels. 99% of the respondents to the post event survey confirmed they were more active now than they were prior to Whanau Tri. The success of the Whanau Tri is due to the fact that it is a physical activity and health promotion programme wrapped up in a sporting context.

Being consumer and

community focused



“I just wanted our whanau to be happy and for us to be positive role models for our

kids”

“It’s (Te Ara Whanau Ora) encouraging. We are all good at

something”

Whanau Ora Provider Collectives:

• Te Hono ki Tararua me Ruahine Whanau Ora Collective

• Te Tihi o Ruahine Whanau Ora Alliance

Working on their respective Programmes of Action

For more facts and information on Whanau Ora go to: www.tpk.govt.nz/en/in-focus/whanau-ora

“Mana Ririki training has affirmed my own practice by providing a Māori approach to parenting previously lacking. Kei runga noa atu Te Whakatipu Ririki”

Being Up to the Job Building knowledge and skills

The Whanau Ora Navigators role is to assist whanau in their journey toward achieving whanau ora. Advocacy, brokerage and coaching are the key skills required for this role. The Whanau Ora Navigator assists

whanau members to develop skills and knowledge which build on their strengths and develop the confidence to realise their aspirations as a whanau. The Navigators use Te Ara Whanau Ora (a process for working with whanau based on te whare tapa wha and whanau

outcome goals) when working with whanau to capture their aspirations and identify their own solutions and what supports and services are required to assist them achieve their goals. Navigators help to identify any barriers to accessing services and what is required to simplify access to services for whanau within the community. They also encourage whanau to look within themselves

for the strengths to make change and progress.

Tikanga Whakatipu Ririki

This project was in response to a call from Maori parents for parenting programmes to be relevant and steeped within the traditional notions of parenting which are embedded within Maori culture. The programme was delivered by Te Ririki, culminating in a presentation and graduation of participants. The programme is a train the trainers focus aimed at developing a pool of expertise that will go back to their communities and train others in the Te Ririki delivery. This has been a valuable training for our district to help prevent Maori child abuse, and most importantly, to develop a professional body of trainers for our district. Feedback from participants in the programme has been positive.


Developing and supporting Whanau Ora

The Whanau Ora Strategic Innovation and Development group has recently been established with representatives from a wide group of service providers in the district including Iwi and Maori providers, the Whanau Ora collectives, youth sector, Health, Education, NZ Police and Te Puni Kokiri. The group anticipates that representatives from Housing, Justice and the business sector will also join the group.

The cross sector representation within this group reflects services that whanau use and is focused on: • providing a coordinated strategic direction to whanau ora initiatives across the district • developing and implementing innovative service delivery solutions • learning from each others’ experiences and building on successes together


learn

Being up to the job



“It is real awesome seeing Maori participating and learning about this course. There are Maori who don’t really know about the pills they are taking, what they are entitled to, medical aids etc., the difference between a GP, doctor and specialist.”

Improving self-management of health conditions

A kaupapa Maori self-management programme for whanau was delivered with great success and was a part of the Stanford Living a Healthy Life Self-Management course. This programme was held on two marae in Horowhenua and was well attended by whanau.

We know that through the feedback from course participants that these courses had great benefits for our whanau and improved their knowledge of how to better manage their own health needs. We also know that holding these courses in places where Maori feel comfortable and supported such as marae and venues that are based on kaupapa Maori principles is usually more successful.

What is Our Focus for Improvements in 2013/14? Supporting the development of mature Whanau Ora Provider Collectives

Improving service delivery options for Maori and whanau

Further increasing the coverage rates for breast and cervical screening for Maori women

Further increasing heart health and diabetes checks, promoting quit smoking, physical activity and better nutrition

Increasing uptake of entitlements to well child services with earlier engagement (see Child health Tamariki Ora section)



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Our Priorities for Improvement In addition to the improvements identified in each of the previous sections, we are focusing attention on the following components of the DHB’s overall quality and safety programme: Strengthening quality improvement and safety practices across the district by taking steps to ensure services work more closely together, providing more

opportunities to receive feedback from patients, ensuring that adverse events continue to be reported according to the national policy and that improvements continue to be made

Quality improvement in endoscopy services by reducing waiting time to at least 50% of people with an accepted referral for a colonoscopy being seen

within the national thresholds (14 days or 42 days depending on urgency, or 84 days for a surveillance/follow up colonoscopy), increasing specialist nursing services and introducing a rating scale that includes patient feedback . This will improve the process for patients then being able to access other services in a more timely way by being able to have the essential investigations completed on time.

Maternity Quality and Safety programme by improving communication and teamwork across the district, looking at options for a primary birthing unit in

Palmerston North, streamlining referrals to maternal mental health services and ensuring all women can access quality antenatal services across the district.

Implementing the national Well Child / Tamariki Ora quality improvement framework, with a range of key performance indicators focused on screening

and referral for vision and hearing deficits, learning and development issues, oral health status and coverage of 4 year old children having health checks Surgical site infection programme. We will reduce infections following knee and hip joint replacement surgery by 5% as a result of implementing national

protocols for these procedures Implementing the national medication safety programme and increasing partnerships with community pharmacists in delivering primary health care

services Reducing waiting times and improving the patient pathway of care through implementing the faster cancer treatment programme (Additional information can be found in MidCentral DHB’s 2013/14 Annual Plan at www.midcentraldhb.govt.nz)

http://www.midcentraldhb.govt.nz/



Between July 2012 and June 2013, in our district, eevveerryy ddaayy, on average….

1 person was admitted to the Intensive

Care Unit

2 people were admitted to the Coronary

Care Unit

3 babies had a hearing screening test

6 babies were born

6 children had a B4 School check

14 young people dropped into the Youth

One Stop Shop

18 people had an MRI scan

25 adolescents had a dental check

27 people had an operation at Palmerston

North Hospital

78 people were discharged from

MidCentral Health hospital care

107 people were seen by the chronic care

team

111 people attended the Emergency

Department

168 people were seen by community mental

health and addiction services

217 people attended an outpatient

appointment at MidCentral Health

228 items of equipment were issued by

Enable New Zealand

245 people were seen by the District Nursing

service

1,249

people received aged residential care

services

1,811 people consulted their general practice

team

2,238

people received home-based support

services

2,241 laboratory tests were done in the

community

7,769 medicines were dispensed in the

community

and were delivered by…

41 general practices 40+ non-government organisations 35 rest homes

32 community pharmacies 22 dental practices 8 optometry practices

6 Iwi/Maori providers 1 public hospital 3 Integrated Family Health Centres

2 community radiology services 1 primary health organisation 1 laboratory



www.midcentraldhb.govt.nz