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DISTRICT NURSES SERVICES REVIEW

JULY 2017

1.0 INTRODUCTION

1.1 Background

Key to Nelson Marlborough District Health Board’s (NMDHB) Health for Tomorrow strategy is the goal of ‘improved quality, safety and experience of care’ requiring NMDHB to focus on providing coordinated, safe and quality care that delivers the right configuration of hospital and community services using an integrated, multi-agency approach. NMDHB needs to do this while living within its means as reflected in the ‘best value for public health service resources’ goal.

To enable the implementation of these strategies NMDHB is currently considering what investments need to be made into primary and community services. Integral to this process is to ensure that the primary and community service infrastructure is efficient, stable and sufficiently resourced to be able to meet service delivery requirements, and are appropriately integrated with and supported by hospital services.

The district nursing service provides advanced nurse-led care for patients and their families delivered predominately within their own home and supports the transition of care between acute and specialist hospital care and community services.

District nursing service patients are those:

▪ Who are at risk of further deterioration in their personal health status;▪ Where provision of care in their normal environment would not further

compromise their health status; and▪ Where care cannot be provided by their general practice or lead maternity carer1.

The forecasted growth of an aging population and a larger proportion of people who have health issues that are more complex and chronic in nature require models of care responsive to these challenges.

Within this health ‘back drop’ the key district nursing service objectives are to:

▪ Prevent avoidable hospitalisation and enable early hospital discharge;▪ Provide support at home for patients with short and long-term health conditions;▪ Promote patient self-care and independence; and▪ Focus on home and community-based healthcare services to meet the specific

needs of Maori and Pacific people’s.

As such, the purpose of this review is to consider the capacity and capability of the district nursing service and how it interacts within the wider configuration, capability and capacity of the NMDHB now and into the future.

1 Ministry of Health Specialist Community Nursing Service Specification, 2004.

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A review team was established to understand the district nursing service environment and obtain the various stakeholders views on unmet needs, any barriers to efficient and effective service delivery and identify opportunities for improving the overall provision of district nursing service across the district. The review team was comprised of: Mark Heslop – Consultant: Mark is a Director of Alma Consulting Limited

which has provided consultancy services to the Health sector since 2008 working with DHB and NGO providers. Mark applies his strategic, operational and financial skills to assist health providers to identify ways to increase capacity, improve utilisation and increase operating efficiency in order to be able to meet the growing demand for health services; and

Karyn Sangster – Subject matter expert: Karyn is currently Chief Nurse

Advisor Primary and Integrated Care at Counties Manukau Health. Karyn has an extensive background in community nursing and has held a number of voluntary position within the New Zealand Nurses Organisation (NZNO) professional group as Chair of the District Nursing section and Chair of Primary Healthcare Nurses Advisory Council; and

Rosemary Minto – Subject matter expert: For over 16 years Rosemary has

been working as a Practice Nurse and Educator. Rosemary is a Nurse Practitioner working currently in a very low-cost access practice in Tauranga. Her recent professional roles include past Chair of the NZ College of PHC Nurses, NZNO and NZNO Vice President and Board member.

The review team is very appreciative of all the information and time provided by the numerous stakeholders who were interviewed as part of the review. These comprised: ▪ District nursing service nurses from Marlborough, Murchison, Golden Bay,

Motueka and Nelson; ▪ Support Works; ▪ Focus groups (consumers2, General Practitioners3, NMDHB Board members4, Te

Piki Oranga5, Hospital Nurses2; ▪ Primary Health Organisations2; and ▪ NMDHB management.

1.2 Findings

From the series of interviews that were completed we have observed a number of themes that apply to district nursing service generally, and other observations which are more specific to a particular district nursing location. The general observations are split into “People” and “Systems” followed by some specific observations regarding Golden Bay and Wairau.

2 Marlborough and Nelson. 3 Marlborough, Nelson and Motueka. 4 Marlborough. 5 Nelson.

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Typically, service reviews focus on what needs to change, what are the inhibitors to better service delivery, what are the frustrations etc. This is the nature of service reviews and as such they tend to have a negativity bias which can be debilitating for staff. As such, we thought it appropriate to make the following comments at the outset:

▪ Across the district it was clear there was a high level of care, compassion and commitment of the district nurses to their roles which the review team commends accordingly; and

▪ The high level of regard in which the district nursing team is held was equally

clear from the consumer group meetings and other anecdotal comments made to the review team.

Be that as it may there are numerous observations from the stakeholder feedback that if adequately addressed could take the district nursing service in Nelson, Marlborough and Tasman region from good to great. These observations are detailed in Section 5 and the opportunities for improvement are detailed in Section 6.

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The findings of the analysis undertaken have been detailed in the following sections:

Section Contents Page 2.0 District Nursing in New Zealand 5 3.0 District Nursing in the Nelson Marlborough Tasman

District 7

4.0 Finances 25 5.0 District Nursing Observations 28 5.1 The People Observations 28 5.2 The System Observations 30 5.3 Golden Bay Observations 32 5.4 Wairau Observations 33 6.0 Recommendations 35 6.1 The People Recommendations 35 6.2 The System Recommendations 42 6.3 Golden Bay Recommendations 48 6.4 Wairau Recommendations 49 6.5 Conclusions 54

Appendices Appendix A – Health Hub Main Objections & Mitigates 57

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2.0 DISTRICT NURSING IN NEW ZEALAND

The role of the district nursing service, which has been provided in New Zealand for over 100 years, is to support patients in their own community by providing a comprehensive range of nursing services that are primarily home based. The district nursing service in collaboration with primary and secondary care services, provides home based nursing care which can enable early discharge and prevent hospital re-admission for patients who require a professional nursing service delivered by generalist and specialist nursing services. These services typically include acute and chronic complex wound care, intravenous (IV) therapy, percutaneous endoscopic gastroscopy, PEG6 feeding, ostomy, continence and home oxygen therapy. The aging population and emphasis on community based care in recent years particularly since the implementation of the Primary Healthcare Strategy (2001), has meant there have been a number of services established to maintain people in their own home. This has resulted in the district nursing service moving away from basic nursing care, such as assisting with hygiene services, to a more specialist service that involves increasingly complex and technologically advanced care. Evidence suggests that the demand for district nursing services will continue to grow and so it is of vital importance that a consistently high level of service is delivered by nurses who, for the most part, work autonomously, and in some regions in isolation. The establishment and maintenance of evidence-based clinical guidelines, service evaluation and setting clear role definitions will do much in shaping the role of the service both now and in to the future7. Referral criteria are seen as a key factor in ensuring appropriateness of patients who are referred from other health practitioners8. Demand for district nursing services has increased in recent years in response to an increase in an older people population with co-existing age-related co-morbidities. In addition, the pressure to avoid hospital admissions has increased and the length of hospital stay has decreased leading to the district nursing service caring for sicker, older, and more frail patients with increased multiple healthcare needs9. Consequently, it is appropriate that the role of the district nursing service be made more visible and clearly articulated to ensure effective and efficient service delivery, and reduce inappropriate referrals. There is also the opportunity to develop new models of care to be more flexible and increase responsiveness to new and emerging healthcare needs within the community. The incumbent Government accepted the Horn Report (2009) recommendation of, ‘better, sooner, more convenient primary healthcare in New Zealand’. Subsequent national and regional policies from this have and will continue to impact on the district nursing service with the attendant earlier hospital discharges, a greater focus

6 Percutaneous endoscopic gastrostomy. 7 While, 1999. 8 Jarvis, Mackie & Arundel, 2006. 9 Goodman, Ross, McKenzie & Vernon, 2003.

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on hospital avoidance and greater demands for community based services such as IV10 antibiotics and advanced wound care management. The 2016 New Zealand Health Strategy refreshes the previous strategy developed in 2000: builds on this strategy and introduces five strategic themes to provide a focus for change. These strategic themes are detailed in the figure below:

Although the district nursing service has a primary health role focus the service does not provide initial patient health services.11 Patients are referred into the service from other healthcare providers and the district nursing service acts as a ‘bridge’ between primary and secondary services by providing a rapid response that strengthens the primary and secondary care links. This community care ’bridge’ is illustrated in the following diagram (NZNO, 2008)

10 Intravenous. 11 New Zealand College of Healthcare Nurses (NZNO), 2008.

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3.0 DISTRICT NURSING IN THE NELSON, MARLBOROUGH

and TASMAN DISTRICT

What is the population size and growth in the district? Awareness about the population size and projected growth in the district provides an indication of expected demand for health services in the future and the role that district nursing services will play. NMDHB covers the top of the South Island, including Golden Bay, Murchison, Nelson, Picton and Blenheim. NMDHB serves an estimated resident population of 144,500 in 2015 (2013, Statistics New Zealand estimate) with a catchment area that encompasses 3 territorial authorities. These include Nelson City (445 km2), Marlborough district (12,484 km2) and Tasman district (9,771 km2). A breakdown of Nelson, Marlborough and Tasman population size based on the 2013 census and forecasted growth is detailed below:

Population size and growth

Population size and growth 2013 to 2033

Area 2013 2033 2013-33 growth

2013-33 % growth

% growth pa

NMT 142,150 156,200 14,100 9.0% 0.4%

NZ 4,442,215 5,338,400 896,200 16.8% 0.8%

Marlborough 44,640 47,200 2,500 5.3% 0.3%

Nelson 48,670 55,000 6,400 11.5% 0.5%

Tasman 48,840 54,000 5,200 9.6% 0.5%

Projected growth (%) in population by locality 2013 to 2033, NMT and NZ

Percentage growth in 5-yearly groups

Aged 75+ population size and growth 2013 to 2033

Area 2013 2033 2013-33 growth

2013-33 % growth

% growth pa

NMT 10,900 26,500 15,600 140% 4.5%

NZ 335,900 758,600 422,700 130% 4.2%

Marlborough 3,670 8,300 4,600 130% 4.2%

Nelson 3,790 8,600 4,800 130% 4.2%

Tasman 3,430 9,700 6,300 180% 5.3%

Nelson

Tasman

Marlborough NM

NZ

0%

1%

2%

3%

4%

5%

6%

7%

2013/18 2018/23 2023/28 2028/33

Popu

lation

gro

wth

(%)

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The district population is growing at about half the rate of New Zealand, with 9% growth expected to 2033, compared to 17% for New Zealand. By 2033 Nelson, Marlborough and Tasman is projected to have an additional 14,050 residents living in the area:

Locality Rate of Growth to 2033

Additional Residents

Nelson 11.5% 6,350 Marlborough 5.3% 2,500

Tasman 9.6% 5,200 Of particular significance to the district nursing service is that growth is expected to be highest in the older populations. The districts 75+ population is expected to more than double, a slightly higher rate than for the country. Tasman is projected to have the largest 75+ growth, and the largest percentage growth: nearly tripling by 2033. Care of the elderly will be an increasing proportion of NMDHB’s work.

What is the population ethnicity in the district? The ethnic composition of a population is important as it provides insight into the level of need and the service requirements to ensure access and outcomes are fair

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and appropriate. Ensuring NMDHB’s services are sensitive to ethnic and cultural backgrounds that exist within the district is important for enhancing access and improving health outcomes.

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The district has a significantly lower proportion of Māori (10%) and Pacific (1%) people in comparison with the national average. Marlborough holds the largest number of Māori and Pacific people at 5,100 and 700 respectively. Most of the population (85%) are considered ‘Other’ compared with 67% across New Zealand. The Other population is largely made up of Europeans with small numbers of people with Middle Eastern, Latin American and African origin. At the locality level, the Other population make up over 80% of Marlborough and Nelson, and 90% of Tasman. The Asian population in the district is 4,500 with just under half residing in Nelson. This population accounts for the third largest ethnic group after Other and Māori. Asian (105% growth), Pacific (99% growth) and Maori (36% growth) are projecting the largest percentage growths in the district by 2033. Where is district nursing provided in Nelson, Marlborough and Tasman? District nursing is provided from five sites in the district: four are managed by NMDHB (Nelson, Wairau, Motueka and Murchison) with Nelson Bays Primary Health Organisation (Nelson PHO) managing Golden Bay district nursing through the Golden Bay Community Health Centre.

Population ethnicity

NMT population projections by ethnicity

NMT ethnicity

ERP 2013

% 2013

ERP 2033 % 2033

2013-33 % growth

% growth pa

Asian 4,590 3% 9,400 6% 105% 3.6%

Māori 13,980 10% 19,000 12% 36% 1.5%

Other 121,440 85% 123,600 79% 2% 0.1%

Pacific 2,060 1% 4,100 3% 99% 3.5%

Māori 13,980 10% 19,000 12% 36% 1.5%

Non-Māori 128,090 90% 137,100 88% 7% 0.3%

Population by ethnicity, NMT and NZ, ERP 2013

Net international migration by locality for NMT, 2008 - 2013

Marlborough -710

Nelson 210

Tasman -850

NMT -1360

Asian3%

Maori9%

Other87%

Pacific1%

Asian12%

Maori15%

Other67%

Pacific6%

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District nursing data has been provided by the DHB from which we have generated the following volume analysis. We note that there appears to be some oddities identified in the analysis which needs further investigation but is not considered material in terms of the subsequent observations and recommendations.

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District Nursing Volumes 12 Months Ended December 2016 & FTE as at June 2017 DNS

Locations12 Number of home and

clinic visits

Nursing FTE

Number of

nurses

Visits to

FTE13

Clerical support Services Provided14

Nelson/Wakefield /Tapawera

26,99215 10.46 13 2,580 Clerical - 0.8 FTE (all patients including Motueka are admitted through this hub)

General nursing, specialist nursing, complex wound care, IV therapy, enteral therapy, home oxygen, stoma, continence, enteral feeding, oncology and palliative care (Wakefield and Tapawera only)

Wairau

20,33316 10.65 17 1,909 Clerical – 0.2 FTE (administration support supplied by Allied Health hub (responsible for answering phones, making up file, entering data and ordering)

General nursing, specialist nursing, complex wound care, IV therapy, enteral therapy, home oxygen, stoma, continence, enteral feeding, CPAP17

Motueka

11,542 3.4 6 3,395 Clerical – 0.6 FTE (provides reception for the entire Community Health services)

General nursing, specialist nursing, complex wound care, IV therapy, enteral therapy, home oxygen, stoma, continence, enteral feeding, oncology and palliative care

Murchison 212 0.518 1 212 Clerical – 0.05 FTE (provides reception for the all Murchison Health Centre services

General nursing, specialist nursing, complex wound care, IV therapy, Community InterRai assessments, home oxygen, stoma, continence including assessments, oncology and palliative care

Golden Bay 3,716 2.5 419 1,486 General nursing, specialist nursing, complex wound care, IV therapy, enteral therapy, home oxygen, stoma, continence, enteral feeding, oncology and palliative care

12 The respective geographic boundary areas are provided in detail on pages 21 and 22. 13 Does not include travel time between home visits. 14 Services provided are as per the MOH service specifications for Specialist Community Nursing Services (DOM101), Home Oxygen Therapy (DOM 102) Services Stomal Therapy Services (DOM 103), Continence Services (DOM104), Enteral Feeding (DOM 109) and Palliative Services (M80012) that is sometimes provided. 15 Includes Nelson Paediatrics district nursing visits of 81. 16 Includes Wairau Paediatrics district nursing visits of 10. 17 Continuous Positive Airway Pressure (CPAP). 18 Estimated nursing FTE as district nursing is part of the practice nurse role. Patients are encouraged as much as possible to attend clinic rather than home visits. 19 One staff member is currently on maternity leave until 31 Dec 2017. Three casuals are available to provide additional support.

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FYE2016 visit volumes are detailed in the chart below by location:

Visits combine both patients coming into district nursing clinics and home-based visits. NMDHB does not keep a keep a record of the split between clinic and home-based visits. What are the main functions and scope of district nursing across the regions? The district nursing service provides specialist and allied nursing care for patients in the community who, without this service, are at risk of deterioration in their personal health status. The primary functions of the district service are to: ▪ Enable early discharge from and prevent avoidable admission to hospital; ▪ Minimise the impact of a health problem on the individual and to facilitate the

return to, or improvement to their overall function and health status; ▪ Support individuals with long term chronic health problems or conditions; ▪ Promote individual selfcare and independence; ▪ Improve the health of Māori by delivering services that best meet their needs;

and ▪ Provide palliative care where services are not provided by other agencies. There are eight main sub-groups of patients who require district nursing input: 1. People who may or may not require a stoma: Patients who have an ostomy either

temporarily or permanently or require surgery where there is potential for a stoma;

Golden Bay, 3,716, 6%

Marlborough, 20,323, 33%

Motueka, 11,542, 18%

Nelson, 26,911, 43%

Paeds-Nelson, 81, 0%

Paeds-Wairau, 10, 0%

NMDHB - By Location - District Nursing Visit Volume and % - FYE 2016

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2. People with continence problems: Patients who have an indwelling urinary

catheter either short or long term; 3. People requiring home oxygen: Patients who have been assessed by a respiratory

physician and would benefit from home oxygen therapy; 4. People requiring IV therapy: Patients who require IV therapy including

antibiotics, fluids, nutrients or other IV medication which will help to improve their overall health;

5. People with chronic or recurring wounds: Patients whose wound is not showing

signs of improving after three weeks or they have a new wound and a history of a non-healing wound. Patients can also be referred to the service for Doppler assessment and compression therapy. There are also contractual agreements for providing wound care for ACC patients under certain conditions including complex wounds and inability to attend primary care clinics;

6. Oncology services: Patients with symptoms associated with their condition such

as constipation and skin integrity, and, in some cases, follow up for patients who have received chemotherapy who have attended a consultant clinic. Oncology service delivery varies: in Nelson, Stoke and Richmond the service is provided by Nelson Community Oncology. Oncology services in the rural regions of Tasman, Murchison, Golden Bay, Motueka/Mapua, Wakefield and Tapawera are provided by the district nursing teams in those rural areas;

7. Palliative Care: Nelson, Stoke and Richmond palliative care is provided by

Nelson Tasman Regional Hospice Trust. All of Marlborough palliative care is provided by Marlborough Hospice Trust. Palliative care in the rural regions of Tasman, Murchison, Golden Bay, Motueka/Mapua, Wakefield and Tapawera are provided by the district nursing teams in those rural areas; and

8. Gastrostomy services: Patients who require percutaneous endoscopic (PEG)

feeding and follow up. Some of the services provide meals-on-wheels, CAPD20, CPAP and BiPAP21 support. What does the district nursing acuity of care look like across the district? We have reviewed district nursing volume in six monthly intervals FYE222015 and FYE2016 which is illustrated in the chart below by location:

20 Continuous ambulatory peritoneal dialysis (CAPD). 21 Bi-level positive airway pressure (BiPAP). 22 For-Year-End.

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As can be gleaned from the chart above volumes are not growing materially across the district. In fact, over the two periods volumes have fallen slightly in Motueka and Marlborough and risen marginally in Golden Bay and Nelson. Of greater import is reviewing district nursing contact time with patients over the period which is summarised in the chart below23.

23 Although included in the chart Paediatric volumes for Wairau and Nelson are immaterial and have not been detailed.

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

6 Mths Jun 2015 6 Mths Dec 2015 6 Mths Jun 2016 6 Mths Dec 2016

Nu

mb

er

of

Vis

its

NMDHB - By Location - District Nursing Visit Volume - Six Monthly FYE 2015 + FYE 2016

Golden Bay Marlborough Motueka Nelson Paeds-Nelson Paeds-Wairau

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Contact time has increased over the two years across all locations although the volume of visits has been relatively flat. This is reflective of the increasing complexity of district nursing care in the community. Table 1 District Nursing Contact Time by Location FYE2015, FYE2016 Q1 YTD2017

Golden Bay, 41,445 Golden Bay,

41,980

Golden Bay, 36,465

Golden Bay, 49,520

Marlborough, 204,580

Marlborough, 211,930

Marlborough, 202,655

Marlborough, 206,735

Motueka, 82,810

Motueka, 83,835 Motueka,

86,425

Motueka, 98,410

Nelson, 222,585

Nelson, 233,965

Nelson, 252,400

Nelson, 254,665

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

6 Mths Jun 2015 6 Mths Dec 2015 6 Mths Jun 2016 6 Mths Dec 2016

Co

nta

ct T

ime

NMDHB - By Location - District Nursing Contact Time (minutes) - Six Monthly FYE

2015 + FYE 2016

Golden Bay Marlborough Motueka Nelson Paeds-Nelson Paeds-Wairau

CAPD visit, 2,110, 0%

Complex Wound Visit, 109,875, 10%

Continence Visit, 66,220, 6%

Continence/Catheter, 31,560, 3%

CPAP Visit, 3,790, 0%

Doppler Assessment, 1,060, 0%

Enteral Feeding, 4,405, 0%

General Visit, 83,155, 7%

General Wound, 590,315, 52%

General/Catheter, 19,260, 2%

Home Help, 10, 0%

Home IV Visit, 33,790, 3%

Home O2 Visit, 16,215, 1%

Mastectomy / Prosthesis Visit, 0, 0%

Oncology Visit, 41,540, 4%Palliative Care Visit, 84,485, 7%

Palliative Oncology, 1,545, 0%Social Work, 30, 0%

Stoma / Ostomy Visit,

29,355, 3%

Stoma Visit, 5,200, 0% Visit Type TBA, 0, 0%Wound/Mastectomy, 3,640, 0%

NMDHB - District Wide - District Nursing Contact Time - FYE 2015

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The increasing percentage of time spent on complex wound care (yellow) compared with other district nursing services indicates an increasing acuity and complexity of patients in the community. The main services provided by the district nursing service are: ▪ General wound; ▪ Complex wound; ▪ Continence visit; ▪ General visit; ▪ Palliative care; and

CAPD visit, 81, 0%

Complex Wound Visit, 12,877, 21%

Continence Visit, 4,549, 7%

Continence/Catheter, 1,353, 2%

CPAP Visit, 223, 0%

Doppler Assessment, 35, 0%

Enteral Feeding, 431, 1%

General Visit, 4,161, 7%

General Wound, 25,207, 40%

General/Catheter, 2,362, 4%

Home Help, 0, 0%

Home IV Visit, 1,406, 2%

Home O2 Visit, 929, 1%

Mastectomy / Prosthesis Visit, 63, 0%

Oncology Visit, 3,734, 6% Palliative Care Visit, 3,020, 5%

Palliative Oncology, 1, 0%

Social Work, 0, 0%Stoma / Ostomy Visit, 1,327, 2%

Stoma Visit, 500, 1% Visit Type TBA, 1, 0%

Wound/Mastectomy, 323, 1%

NMDHB - District Wide - District Nursing Contact Time - FYE 2016

CAPD visit, 14, 0%

Complex Wound Visit, 7,364, 49%

Continence Visit, 935, 6%Continence/Catheter, 295, 2%

CPAP Visit, 45, 0%

Doppler Assessment, 8, 0%

Enteral Feeding, 125, 1%

General Visit, 618, 4%

General Wound, 2,488, 17%

General/Catheter, 574, 4%

Home Help, 0, 0%

Home IV Visit, 339, 2%

Home O2 Visit, 199, 1%

Mastectomy / Prosthesis Visit, 3, 0%

Oncology Visit, 734, 5%

Palliative Care Visit,

701, 5%

Palliative Oncology, 0, 0%

Social Work, 0, 0%

Stoma / Ostomy Visit, 315, 2%Stoma Visit, 130, 1% Visit Type TBA, 0, 0%Wound/Mastectomy, 41, 0%

NMDHB - District Wide - District Nursing Contact Time - YTD 2017

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▪ Oncology visit. The average contact time of service delivery varies between the locations as detailed for the main services below24:

24 At Murchison district nursing is part of the practice nurse role. As such the district nursing contact time data is not separately identified.

Golden Bay, 22 Marlborough, 22

Motueka, 15

Nelson, 18

0

5

10

15

20

25

30

Cont

act

Tim

e FY

E 20

16 (m

inut

es)

Location

General Wound Visit FYE 2016

Golden Bay, 26 Marlborough, 26

Motueka, 17

Nelson, 22

0

5

10

15

20

25

30

Cont

act

Tim

e FY

E 20

16 (m

inut

es)

Location

Complex Wound Visit FYE 2016

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Golden Bay, 28

Marlborough, 15

Motueka, 13

Nelson, 11

0

5

10

15

20

25

30

Cont

act

Tim

e FY

E 20

16 (m

inut

es)

Location

Continence Visit FYE 2016

Golden Bay, 22

Marlborough, 16

Motueka, 13

Nelson, 16

0

5

10

15

20

25

30

Cont

act

Tim

e FY

E 20

16 (m

inut

es)

Location

General Visit FYE 2016

Golden Bay, 27

Motueka, 20

Nelson, 25

0

5

10

15

20

25

30

Cont

act

Tim

e FY

E 20

16 (m

inut

es)

Location

Pallative Care Visit FYE 2016

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How do people get into the district nursing service? Patients enter the district nursing service that is provided in their geographical location through a referral process from their general practitioner (GP), practice nurse, ACC, hospice or in-patient ward. In some of the rural areas patients refer themselves to the service if they have an acute problem with a stoma or recurrence of a chronic wound that has previously been treated by the service. Patients need to meet the criteria for inclusion in the service as determined by district nursing contractual agreements. As such there needs to be demonstrable clinical benefit for the patient to be referred to the district nursing service that is unable to be provided by another health service or other means of treatment. If a referral is received that is inappropriate the referrer is contacted by telephone and directed to the service that will best meet the patients’ needs. In 2013 NMDHB established a single district wide web based referral centre (Care Coordination Centre). The Care Coordination Centre captures all health referrals by email or fax, supported by direct telephone access. A flow chart summarising the Care Coordination Centre process and service inter-agency relationships is detailed below.

Golden Bay, 20

Motueka, 13 Nelson, 13

0

5

10

15

20

25

30

Cont

act

Tim

e FY

E 20

16 (m

inut

es)

Location

Oncology Visit FYE 2016

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C.A.R.E.S.

Expert Clinical triagePhysical health& Mental health and

Addictions (Wairau), paediatrics, young people, older persons mental health(1-2 hrs turn around)

Attention to covering health literacy, health promotion

and prevention

Rapid responseA)Crisis referrals mental healthB)Acute demand physical health

Onward service provider Falls risks identified and highlighted Quality of referrals checked e.g. patient consent, admin details,

appropriate service request, urgency identified Other services involved Confirm right care in right place at right time

Flag complex referrals for a more coordinated response

MDT A) Mental health and addictions – 2/wk (Wairau)B) Physical health(Wairau) - 1/wk C) Paediatrics and young peopleD) Palliative careE) High and complex needsF) Chronic pain

Onward service providers in liaison with client’s GP include: Primary mental health, suicide prevention, Kawai St clinic, psychiatrist, Geriatrician, PT, OT, SLT, Orthotics, Social Work, Podiatry, Community rehab team (Wairau), Support Works, District nursing, Orthotics, Home Based Support Services (HBSS), Asthma Nurse, Arthritis Nurse, Community nutrition, Cardiac rehab, Respiratory rehab, Falls prevention, PATHS, NGOs, Multicultural centre, Arthritis group education, Hip and knee surgery groups,

Green prescription, Meals on Wheels, Chronic pain service, Breastfeeding support, diabetes education, health liaison services, etc

ERMSRapid mobile response Initiate CCMS

Web Portal

Work and Income

General Practice SelfNMDHBIncluding

outpatients

St JohnsBUPA

ACC NGOsCommunity

servicesPalliative care and hospice

Mental health Older persons,

Paediatrics, Young people, requests for

interpreters etc

Electronic form

Not yet

Care Coordination Centre

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District nursing referrals are forwarded onto the appropriate district nursing location and triaged by an Associate Charge Nurse (ACN). The referral form states how urgently the patient needs to be seen. If there is any query about this the CAN or the coordinating district nurse will contact the referrer and resolve any queries. Patient contact is almost always established within 24 hours either by telephone or by visit. In the more isolated rural areas when care is not required urgently the patient is contacted by telephone on the day of referral and a visit time is set up to coincide with other visits to that area. What happens once a patient is in the district nursing service? Once accepted to the district nursing service the patient is triaged, details are entered into the database and the patient is allocated to a district nurse depending on their geographical location. This allocation is conducted by the CNM in most locations although Wairau has a co-ordinating nurse, who amongst other responsibilities allocates the workload. In Golden Bay the district nurse on duty picks up the referrals as they come in. The nurses are responsible for a geographical area each day and are allocated patients who live in that area although there can be variation depending on the workload. Continuity of care is maintained wherever possible but due to the need to balance the workload and predominately part-time nature of the workforce the patient may have a number of different nurses involved in their care. As such it is most important that all documentation, including the care plan, is complete and clearly describes what treatments have been provided and what is expected on the next visit. Across all locations this information is written on clinical note paper and available in the paper based patient notes. A number of patients also attend district nurse led clinics which are held either in: ▪ the Richmond health hub for Nelson/Wakefield and Tapawera patients; or ▪ Motueka Community Health Centre; or ▪ Golden Bay Community Health Centre for Golden Bay patients; or ▪ District nurse clinic at Wairau Hospital for Marlborough patients. These clinics are predominately for wound management and are timed to coincide with patients’ work or lifestyle commitments. Most services also run specialist clinics each week for patients with chronic wounds or who require doppler assessment for venous insufficiency, stoma and continence. Other care categories where appropriate also access clinics such as medication and intravenous therapy. The daily district nurse work schedule and clinic profile for the main locations are detailed below:

Location Geographic25 Clinics Nelson/Wakefield/Tapawera 1. City

2. Port Tahuna 3. Richmond 4. Stoke 5. Wakefield 6. Tapawera (casual)

Wound clinic operates at Richmond Health Hub Monday to Friday on a rotating roster

Motueka 1. South Wound clinic operates at

25 Boundaries are flexible and dependent on workload and acuity.

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2. North 3. Clinic 4. Oncology (Wednesday +

Thursday)

Motueka Community Health Clinic Monday, Tuesday, Thursday and Friday. ACC and Doppler assessments are normally completed in clinic by the lead wound nurse

Wairau 1. South 2. Town 3. Rural 4. Picton 5. Clinic

Daily DN led clinic at Wairau 08:00 – 16:30 Mon-Fri. Weekends by prior arrangement. Picton clinic daily by prior arrangement. SCN – specialist wound clinic held in outpatients Wairau Tuesday and Wednesday 08:00 – 16:30

Golden Bay 1. Upper Takaka (south) 1. Takaka (central township

and nearby environs) 2. Kotinga/Rangihaeata/

Patons/Onekaka/Parapara 3. Mangarakau/Patarau (west) 4. Milnethorpe/Collingwood/ 5. Rockville/Bainham/Puponga

(north) 6. Pohara/Ligar/Tata/Awaroa

Wound clinics are available from Monday to Friday and utilised when required

Murchison 1.South Boundary Road 2.East Lake Rotoroa/Howard Valley/Hope Saddle 3.North Matiri Valley 2. 4.West Iron Bridge

Clinics are available on demand, Monday to Friday. Murchison District Nursing is integrated into the Primary Health Centre service and is demand driven and managed by the Charge Nurse Manager and covered by the duty Practice Nurse at the Health Centre as needed.

The initial patient assessment is conducted by the registered nurse (RN) allocated to the patient and is separate to in-patient assessments. There is little formal communication sharing between various service providers. The assessment form contains demographic, medical history and general health details, the reason for referral and what initial treatments are required. Patient Assessment At the initial assessment patients are provided with: ▪ An introductory letter of what the district nursing service offers and their hours

of work and contact details; and ▪ A copy of the patients’ Code of Rights and Responsibilities’. Risk Assessment A patient assessment is completed along with the patients’ social situation and other agencies also providing support. Any known risks are identified during the assessment such as falls, nutritional risk, pressure area risk and health and safety concerns. The discharge plan is also included in the assessment plan along with a re-

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assessment plan. The care plan is completed within three to seven days depending on the complexity of the situation. Complex Wounds - For patients who have a complex and/or chronic wound an additional wound assessment occurs which includes information about the nature of the wound, the level of pain, and any factors that are delaying healing. A wound mapping chart is included along with an anatomical diagram detailing the position of the wound on the patient. Stomas - Stoma patients are seen at pre-operative clinic where a care plan is developed in partnership with the patient which is kept in the in-patient notes with highlighted expected progress outcomes for the ward nurses to follow. Leg Ulcers - For patients who have leg ulcers the ulcer is assessed using the New Zealand wound care assessment form. Wounds are photographed or mapped and a running record is kept of progress including a progressive assessment and dressing plan. Patient Management Patients are given handouts about their condition which are either developed by the district nursing service or by the consumable product suppliers. Patients are assessed at each visit by the district nurse and clinical progress notes are written. Patients are kept up-to-date at these visits with an outline of treatment progress to date, care plans and expected outcomes. The district nursing service is often asked to assess aged-care residents in relation to wound and continence management. In this instance, the service provides advice only and the aged-care facility manages the actual care. Stoma therapy is provided in aged related residential care settings. How do we manage the district nursing service across the region? Detailed below is the current management structure for district nursing across Nelson, Marlborough and Tasman along with a summary district nursing FTE26 and number of staff.

26 Full Time Equivalent.

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Chief Executive

General Manager

Strategic, Primary &

Community

Service Manager

Charge Nurse Manager

District Nursing District

Wide

Associate Charge Nurse

Manager

Wairau

Associate Charge Nurse

Manager

Nelson/Tasman

Team Leader

Motueka

NMDHB – District Nursing – Current Leadership &

Management Structure

Wairau Nelson/Wakefield/Tapawera Motueka

Director of

Nursing & Midwifery

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4.0 FINANCES

The costs and revenues of the district nursing services are captured in three cost centres: District Nursing Nelson (5068), District Nursing Blenheim (5068) and Motueka Community Health (4369): ▪ Prior to 2015/16 the Motueka cost centre also included the Allied Health

personnel based in Motueka and all Motueka Community Health facility costs are captured in this cost centre;

▪ The Murchison district nursing costs are captured in the Murchison Hospital and health cost centre and are not separately identifiable from the total nursing costs; and

▪ The Golden Bay district nurses’ personnel costs are met by Nelson Bays Primary Health as part of the Golden Bay Community Health Centre expenditure.

Summarised below are the consolidated results of these three cost centres for the three years ended 30 June 2016 and the budget for 2016/17:

Commentary: Revenue ACC revenue has increased by 41.4% over the two-year period ended 30 June

2016. YTD 22 February 2017 results annualised indicate a further 7.7% increase in 2016/17; and

Internal revenue is allocated to the Nelson cost centre (for Nelson and Blenheim

district nursing services) and to the Motueka cost centre as per the Funder/Provider Arm price volume schedule.

District Nursing - Actual Actual Actual Budget

($'000's) 2013/14 2014/15 2015/16 2016/17

ACC Revenue 393 542 556 561 149 38.0% 13 2.5% 5 1.0%

Other Revenue (0) 3 1 37 3 (1501.5%) (3) (80.9%) 36 6059.1%

Internal Revenue - 5,973 6,083 5,336 5,973 - 110 1.8% (747) (12.3%)

Revenue 393 6,518 6,639 5,934 6,126 1560.2% 121 1.9% (705) (10.6%)

- - -

Senior Nurses 355 356 292 468 0 0.1% (64) (18.0%) 176 60.4%

Registered Nurses 1,806 1,800 1,750 1,560 (7) (0.4%) (49) (2.7%) (191) (10.9%)

Enrolled Nurses 161 127 121 143 (34) (21.3%) (5) (4.1%) 21 17.5%

Health Service Assistants 8 14 13 19 6 72.1% (2) (11.2%) 6 48.7%

Allied Health Personnel 95 55 (0) - (40) (42.1%) (55) (100.3%) 0 (100.0%)

Support Personnel 6 6 6 6 (1) (11.5%) 0 2.0% (0) (4.3%)

Management & Admin 60 62 151 159 2 3.4% 89 143.0% 8 5.4%

Total Personnel Costs 2,492 2,419 2,333 2,354 (73) (2.9%) (86) (3.6%) 21 0.9%

Outsourced Services 47 71 80 67 24 51.3% 8 11.6% (13) (16.0%)

Treatment Disposables 1,114 1,096 1,113 1,020 (18) (1.6%) 17 1.6% (93) (8.4%)

Patient Appliances 658 609 724 683 (49) (7.5%) 116 19.0% (42) (5.7%)

Other Clinical Supplies 197 167 138 56 (30) (15.2%) (29) (17.3%) (82) (59.2%)

Facilities 142 99 152 157 (43) (30.2%) 53 53.0% 5 3.3%

Transport 84 74 99 112 (10) (12.0%) 24 33.0% 14 13.8%

Other Infrastructure 64 122 50 48 58 89.9% (72) (59.0%) (2) (4.7%)

Total Expenditure 4,799 4,658 4,689 4,497 (141) (2.9%) 31 0.7% (192) (4.1%)

Net Surplus/(Deficit) (4,406) 1,861 1,950 1,437 6,267 90 (513)

Movement

2014-15 2015-16 2016-17

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Nursing Personnel Whilst salary costs increase each year with the MECA increases overall there has

been a 6.6% reduction in total nursing costs due to a 6.5% reduction in FTE and a reduction in the average cost per FTE:

This FTE reduction has occurred in Blenheim:

Registered nursing average salary costs in Motueka are higher due to the nurses being on call and as a result there being a call allowance and higher overtime payments:

District Nursing - Consolidated Actual Actual Actual

($'000's) 2013/14 2014/15 2015/16

Senior Nurses 355 356 292 (64) (17.9%)

Registered Nurses 1,806 1,800 1,750 (56) (3.1%)

Enrolled Nurses 161 127 121 (40) (24.6%)

Health Service Assistants 8 14 13 4 52.8%

Total Nursing Personnel 2,331 2,296 2,176 (155) (6.6%)

Movement

2 Year

District Nursing - Consolidated Actual Actual Actual

Nursing Personnel 2013/14 2014/15 2015/16

Senior Nurses 3.0 2.8 3.2 0.2 7.0%

Registered Nurses 21.7 21.3 20.5 (1.2) (5.5%)

Enrolled Nurses 2.9 2.2 2.0 (0.9) (29.8%)

Health Service Assistants 0.2 0.3 0.2 0.1 30.7%

Total FTE 27.8 26.7 26.0 (1.8) (6.5%)

Movement

2 Year

District Nurses Blenheim Actual Actual Actual

FTE 2013/14 2014/15 2015/16

Senior Nurses 2.0 1.8 2.8 0.8 40.0%

Registered Nurses 9.0 8.2 6.6 (2.3) (25.8%)

Enrolled Nurses 1.4 1.4 1.1 (0.2) (18.3%)

Health Service Assistants 0.2 0.3 0.2 0.1 30.7%

Total FTE 12.53 11.67 10.84 (1.7) (13.5%)

Movement

2 Year

Motueka Community Health Actual Actual Actual

FTE 2013/14 2014/15 2015/16

Registered Nurses 3.5 3.3 3.5 (0.1) (2.0%)

Movement

2 Year

District Nurses Nelson Actual Actual Actual

FTE 2013/14 2014/15 2015/16

Senior Nurses 1.0 1.0 0.4 (0.6) (60.2%)

Registered Nurses 9.2 9.8 10.4 1.2 12.9%

Enrolled Nurses 1.5 0.8 0.9 (0.6) (39.9%)

Total FTE 11.72 11.72 11.68 (0.0) (0.3%)

Movement

2 Year

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Clinical Supplies

Overall there has been a minimal increase in clinical supplies over the two-year

period:

The Nelson increase in patient appliances is in ostomy supplies; and The reduction in the Nelson and Blenheim other clinical supplies is due

reductions in the pharmacy cost allocation. Infrastructure Overall there has been a modest increase in infrastructure costs over the two-year

period:

In Nelson facility costs for the Richmond hub have been charged to district nursing service in 2015/16 and there has been an increase in the internal transport charge; and

In Blenheim facility costs have reduced due to the reduction in the Picton facility

space.

District Nursing - Actual Actual Actual

Nursing Personnel 2013/14 2014/15 2015/16 Nelson Blenheim Motueka

Senior Nurses 117,824$ 127,192$ 90,416$ ($27,408) (23.3%) 87,497$ 90,823$

Registered Nurses 83,410$ 84,326$ 85,571$ $2,161 2.6% 85,349$ 83,386$ 90,445$

Enrolled Nurses 55,360$ 56,371$ 59,485$ $4,125 7.5% 54,799$ 63,408$

Health Service Assistants 43,606$ 44,442$ 50,954$ $7,348 16.9% 50,247$

Average Cost per FTE 83,940$ 85,985$ 83,792$ ($148) (0.2%) 82,991$ 83,279$ 90,445$

2015/16Movement

2 Year

DNS Consolidated Actual Actual Actual

Clinical Supplies 2013/14 2014/15 2015/16 Nelson Blenheim Motueka

Treatment Disposables 1,114 1,096 1,113 (1) (0.1%) (7) 10 (4)

Patient Appliances 658 609 724 67 10.1% 72 (6) 1

Other Clinical Supplies 197 167 138 (59) (29.8%) (39) (25) 5

Total Costs 1,969 1,872 1,976 7 0.4% 26 (22) 3

2 Year MovementMovement

2 Year

DNS Consolidated Actual Actual Actual

Infrastructure 2013/14 2014/15 2015/16 Nelson Blenheim Motueka

Facilities 142 99 152 10 6.8% 19 (15) 5

Transport 84 74 99 14 17.0% 17 (0) (2)

Other Infrastructure 64 122 50 (14) (22.0%) (0) (12) (2)

Total Costs 291 295 300 10 3.4% 36 (27) 1

Movement 2 Year Movement

2 Year

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5.0 DISTRICT NURSING OBSERVATIONS

5.1 The People Observations

5.1.1 Staffing Resource

The increasing complexity over the last two years and thus time required for each

patient (as detailed in Section 3.0 above) has meant that there is now insufficient

district nursing resource to adequately complete consultations within regular

working hours particularly in Nelson, Golden Bay and Wairau:

Some of the district nursing service locations are increasingly being forced to

prioritise patient care based on the level of patient acuity due to the heavy case

workload;

A number of district nurses are often working through their breaks and staying

after hours in order to complete case notes;

Staff are hesitant to take entitled leave as there is insufficient staffing cover to

back fill their position; and

Staff have no time to engage in non-clinical activities for example, visiting and

training GP practice nurses and aged residential care staff in wound care and

specialist care, training other district nurses and hospital staff in specialist

district nursing care and engaging in their own professional development.

It is well accepted that when staffing levels are insufficient patient care outcomes are

also affected. Nurses focus on getting through the workload and often do not pick up

signs of deterioration on points of early intervention. In addition, less time is spent

on assessment and the focus is on the task required.

Staff under workload pressure also have increased sick leave and exacerbation of long

term conditions and/or physical injuries. Staff also report an impact on their family

life and work satisfaction.

5.1.2 Communication, cohesiveness, direction and leadership

Although the district nursing service is well known to other care providers and well regarded for the services they provide the current relationships within the service and with other agencies have developed over time and are ad hoc and informal: There are no clear lines of connection between district nurses, line managers,

other health providers to facilitate improving work environments and/or patient care. In addition, the district nurses are too time poor to develop any of these connections; and

Other primary and secondary provider input appears to occur mainly when problems arise: planning and monitoring processes are minimal. There is no platform where ideas can be shared to address any community care delivery issues or ideas for improvement.

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The district nursing teams in the various locations operate predominately as separate teams. There are elements of ‘us and them’ and there is minimal interaction between the teams or opportunities to share ideas or resources. This is particularly so for the PHO district nursing service at Golden Bay as there is no clear linkage with the other district nursing teams. The following comments from district nurses also indicate a need for greater communication, cohesiveness, direction and leadership within the district nursing teams: “Feel we’re not being listened to”; “Feel our service is ‘invisible’”; “Do not have any ‘line of sight’ to the DHB’s strategic objectives and what they

mean for district nursing”; “There is too much focus on the task and not on us as individuals”; “Expectations are not communicated effectively”; “There is a lack of feedback, positive or negative”; “We do not feel they have an effective connection to their nurse managers and

leaders”; “Feel isolated and unsupported”; “Communication, when it happens, is on a need to know basis”; “We are ‘kept in the dark’ about issues that have bearing on our roles”; “At times decisions are made first then we are asked for feedback”; and “We do not feel we have a part to play in the decision-making process ‘decisions

are done to us not with’ us”.

5.1.3 Professional development and nurse educators Typically, the ways in which services maintain and develop the knowledge base and professional skills of nurses are through continuing professional development (“CPD”). However, at Nelson, Marlborough and Tasman a number of district nurses did not have a professional development programme at all. In addition, due to a lack of staffing resource, many did not have the time to be able to attend any form of CPD. Aligned to the inadequacy of continuing professional development there is an absence of nurse educator roles in the district nursing service. Nurse educators also act in a coaching role. 5.1.4 Workforce planning Today DHB’s in New Zealand are confronting the reality of a nursing workforce that is rapidly aging at a time when healthcare demands are increasing. NMDHB is no different.

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District Nursing Location Average Age Band27 Wairau 50-54 Nelson 47-51

Motueka 56-61 Golden Bay Unavailable

Regarding management of these risks for the district nursing workforce we note that: There does not appear to be any workforce planning across the district or

evidence of proactive initiatives to build a future district nursing workforce or a plan in place that focuses on retaining district nurses longer in the workforce so that expertise can be shared and their knowledge transferred;

There are potentially looming retirements particularly of specialist district nurses that without adequate succession planning could result in significant lost knowledge to the district nursing service particularly in Wairau in complex wound, stoma and respiratory specialist care; and

There is concern that the current work environment does not encourage the aging district nurses to stay on, nor for new nurses to be eager to enter the district nursing service.

5.2 The System Observations

5.2.1 IT and hardware in district nursing service

The current IT, hardware and systems are not enabling the district nursing service to be as efficient as it could be. In particular:

There is no one platform to maintain patient records that the district nurses

could maintain patient notes and be used or accessed by other services, including GP’s, that are providing episodic care to the patient. The absence of a one electronic patient record is frustrating for all the care providers as each often does not know what the other service may be doing which in turn can lead to uncoordinated healthcare, for example, multiple visits by different services, the GP unaware of the patients’ status of care and frustrating for the patient due to uncoordinated home or clinic visits and having to repeat information to each care provider; and

The lack of IT hardware also inhibits basic access to online information systems in an easily attainable way. District nurses are unable to enter patient notes or gain access out in the field. Everything is done manually with district nurses: only recently have some district nurses been provided smart phones which enable them to take better clinical photographs, then the manual process of printing off photographs still must take place for attaching to the manual files after the district nurses have written up the patient notes upon returning to base. There is no interaction with any clinical IT, network or internet via the smart phones currently. In addition, there are insufficient smart phones so that district nurses must share within teams: this is frustrating and inefficient for the district nursing staff.

27 District nursing at Murchison is part of the practice nurse role and is intertwined with the hospital as such Murchison has been excluded from this table.

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5.2.2 Admission and discharge of patients to and from the district

nursing service Admission and discharge criteria of patients to the district nursing service need to be clarified and applied consistently across the district. For example, the discharge of patients back to the ‘medical home’, the GP, is often protracted and some patients remain on district nursing caseloads without acknowledgement of associated ‘duty of care’ for these patients. 5.2.3 Documentation Patient and patient related documentation across the district is not standardised and the ACC capture of nursing interventions is variable. Secondary discharge notes and referrals to the district nursing service are often inconsistent and incomplete. This requires district nurses to follow up with the referring agency to fill-in gaps in information and/or clarify aspects of care to be provided.

5.2.4 Data capture and key performance indicators Data capture within the district nursing service is limited and does not contain sufficient detail to be able to provide management meaningful tactical and strategic information. For example, we were unable to determine the split in district nursing visits between home and clinic based nor could we determine district nursing travel time by location.

In addition, there is a lack of key performance indicators across the district with which to be able to determine how effectively (or not) district nursing is achieving key objectives, provide operational feedback to the district nurses and management and be able to identify the operational effect of any change in service delivery or a shift in the environment within which district nursing operates. 5.2.5 Workplace planning and workload management tools There is no way to measure the level of patient acuity, complexity and related staff time within the district nursing service. A workload management system would allow work load allocation, scheduling and alignment to the various contract systems and development of patient acuity for district nursing would enable services to achieve staffing methodology and undertake FTE calculations and assessments.

5.2.6 Health and safety support Community nursing particularly rural district nursing has a number of workplace health and safety challenges particularly in terms of geographical, physical and organisation environment that community nurses work across. Rural district nurses are more vulnerable to occupational injury, work instigated disability, and are at higher risk of experiencing prolonged work absence due to

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workplace health and safety issues28. District nurses must travel long distance to and from each patient's house that may often be time-consuming and exhausting. To add to their difficulties, the road conditions in some parts of NMT areas are not always well developed or maintained particularly over winter. Both the geography and climate of these rural areas can increase the vulnerability of the district nursing workforce. This leads to the district nurses typically working in isolation for long periods and in the majority of cases without adequate communication as: Cell phones have not been supplied; and For those who have their own cell phones in many rural areas there is no cell

phone coverage;

The lack of communication in some rural areas has health and safety issues for the district nurses, for example the inability to communicate in the event of a vehicle breakdown or accident or home visit violence. Some district nurses take family members with them on call when visiting at night in rural locations for safety.

5.3 Golden Bay Observations

In 2013 the Golden Bay Community Health Centre was established in Takaka on the

site of the former NMDHB owned community hospital, incorporating the existing

hospital services with primary care services and age-related care services which had

previously been provided by the Joan Whiting Memorial Trust Rest Home. Nelson

Bays PHO was contracted to manage the centre and took over employment of the

NMDHB community hospital staff including district nursing in 2011 as a prelude to

establishing the Health Centre.

Every observation detailed above is equally germane to district nursing in Golden

Bay. Of particular concern is the level of under staffing and sense of isolation or

disconnection from the rest of the district nursing service at the DHB and apparent

low morale. The review team noted the following:

After the devolvement of district nursing to Nelson Bays PHO there has been little or no clinical support from the DHB since the devolvement;

It is very hard to organise GP clinical support;

28 Franche RL, Murray EJ, Ostry A, et al Work disability prevention in rural areas: a focus on

healthcare workers. Rural Remote Health 2010; 10:1–24.

Position FTENumber of

Staff

Registered Nurse1 2.50 41 One RN staff is on maternity leave until 31 Dec 2017.

Three casuals are available. There is no dedicated clerical

support

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Typically, every day the district nurses in Golden Bay exceed paid hours, skip breaks and are unable to take leave or train or be trained as there is insufficient resource to manage the current case load – there is not enough clinical time;

There is little in the way of administration support; There is a lack of standard equipment such as blood pressure cuffs, blood sugar

tests, thermometers etc.; No smart phones; and There have been four managers in as many years. There is an organisational risk if the standard of care and access to resources continues to reduce over time.

5.4 Wairau Observations

In early 2014 NMDHB advised they needed space at Wairau Hospital to allow

relocation of staff during refurbishment of the Arthur Wicks building. That in turn

allowed the Marlborough PHO and the NMDHB to consider how a collective of

health professionals, with a common set of goals and ambitions, might locate

together and enable enhanced and effective care for the community at large. The

benefits of collaborative working, engagement with individuals across a spectrum of

skills and responsibilities and the pathway to a degree of "one stop shop" that a single

Health Hub might bring to a central location, were in line with government

policy. The concept of community co-location and integrated family health centres

was a policy priority.

The goal was to implement this model in Blenheim moving towards increased:

▪ Integration of some primary and secondary services, as well as across provider

groups - both by physical collocation and/or virtual integration;

▪ Financial sustainability by sharing some back-office costs and resources;

▪ Addressing workforce issues and realities;

▪ Coordinated care to minimise waste and duplication; and

▪ Ability to deliver health outcomes that improve the health status of the

Marlborough population.

A building at 22 Queen Street in Blenheim central business district owned by the

Marlborough District Council was leased. On executing the original lease for the

Health Hub the PHO and NMDHB were given first right of refusal over the old movie

theatre building adjacent to the Phase 1 of the Health Hub. The intent was to secure

the option for growth in a central location which in turn would underpin Phase 1,

help meet growing demand from providers and allow for staged growth.

The PHO’s risk participation was 50/50 with the NMDHB. The Health Hub was officially opened in April 2015. The current services being operated from the Health Hub are:

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Marlborough Primary Health; NMDHB Public Health Services: health promotion, health protection and public

health nurses; Barnardos; Diabetes Marlborough; Asthma Marlborough; NMDHB Child and Adolescent Mental Health; NMDHB Child Development Services; Community Midwives; Psychologist; and NMDHB Sexual Health

Phase 2 which is expected to be completed over the next 18 months involves redevelopment of the old movie theatre space to accommodate:

Support Works; Older Persons Mental Health; Pacific Trust; Te Piki Oranga; Te Puni Kokiri; Migrant Centre; English Language; Specialty nurses: cardiac, respiratory and diabetes; Audiology; Physiotherapist; General practice29; Pharmacy29; and Family Planning.

Earlier this year the Board announced that the district nurses at Wairau Hospital would be part of Phase 2 services to shift into the Health Hub. This proposed relocation has met with resistance from some of the district nurses and community.

29 In negotiation. Name withheld for the moment.

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6.0 RECOMMENDATIONS

6.1 The People Recommendations

6.1.1 Establish a Transition to Care Liaison role at both Nelson and

Wairau Hospitals

Over the past few decades the leading causes of death have changed from infectious

and acute diseases to chronic and degenerative illnesses including cardiovascular

diseases and cancer, respiratory diseases, diabetes’ and Alzheimer’s disease. These

conditions also cause severe disability and is a common factor leading to the need for

long-term care.

A growing body of science suggests that patients coping with multiple chronic

conditions or complex therapies are particularly vulnerable to breakdowns in care.

Sometimes there is a ‘care gap’ when patients are transferred between hospital and

home. Typical factors in a ‘care gap’ which contributes to a negative care quality and

cost outcomes are insufficient communication between providers in healthcare

agencies and patients, inadequate patient education, poor continuity of care and

limited access to health services especially after discharge.

Ideally the responsibility for nursing services beyond the hospital to the home and

from the home to the hospital should occur without any break in its continuity.

To minimise the risk of ‘care gaps’ and to support and improve the continuity of care

we recommend establishing a Transition to Care Liaison role at both

Nelson and Wairau Hospitals.

We see both roles being full-time positions. Principal responsibilities for the

Transition to Care Liaison role would be to:

▪ Coordinate complex discharges across the region. This role would sit alongside

and access all other healthcare providers both secondary and primary along the

patient journey;

▪ Identify patients who can be cared for in the community and facilitate the care

package, including linking the patient to enable to health teams with the skills

and knowledge for this occur effectively;

▪ Complete district nursing care in the wards so that district nurses do not need to

come into the hospital;

▪ Act as the ‘go to’ person for the district nurses across all locations including

Golden Bay, for example, when there are issues with a complex discharge that

needs to be managed such as access to specialist wound care products;

▪ Identify emerging or changing care so that the district nurses are prepared for

and adopt new technology;

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▪ Increase efficiency in transferring patients to home based care by ensuring the

district nursing team are prepared to receive them and have the required

equipment, skills and resources to meet the care needs of the patient;

▪ Be the face of the district nursing service in the hospital; and

▪ Work with the Community Healthcare Provider Forum (see

Recommendation 6.1.4 below) to address any system wide issues, develop

further innovations and support continuous improvement to the healthcare

system.

Benefits are:

▪ Improved coordinated patient care;

▪ Improved level of communication and collaboration within and between district

nursing and other health provider agencies;

▪ Improved sense of cohesiveness;

▪ Improved admission and discharge of patients to and from the district nursing

service;

▪ Underpins the ‘one team’ strategic theme of the 2016 Health Strategy and

supports an integrated multi-agency care system; and

▪ Facilitates the NMDHB Health for Tomorrow goal of providing a ‘consistent

experience across the network of services to meet people’s health and care needs’.

6.1.2 Management of district nursing service should be part of

ambulatory care if established

The 2016 Health Strategy provides us what a better, more ‘fit for the future’ system

could look like. This wider view was captured in the Strategy:

‘All New Zealanders live well, stay well, get well, in a system that is people

powered, provides services closer to home, is designed for value and high

performance and works as one team in a smart system’

What are the implications for district nursing?

District nursing has a critical and pivotal role to play in delivering and supporting

health service closer to the patient and supporting the wider healthcare team to

promote recovery and health outside a hospital setting, closer to or in the home.

In particular, there are two factors that underpin ‘closer to home’ healthcare:

▪ One team – Adopt a more cohesive team approach across the health and

disability system: an integrated multi-agency approach to healthcare; and

▪ Innovation and continuous improvement – Seek improvements and

innovations, monitoring and evaluation of what the system is doing, and sharing

and standardising better ways of doing things.

39 | P a g e

So, what is the best management and leadership structure for district

nursing to foster closer to home, one team and a culture of innovation

and continuous improvement?

Management and leadership are distinct concepts although in practice there is

significant overlap and inter-connection between management and leadership roles.

Management is centrally concerned with operational aspects of planning, organising

and monitoring service delivery. In contrast, leadership is fundamentally about

creating a long-term strategic vision and enabling people to work towards change. It

involves developing a shared sense of mission tackling political, organisational and

resource barriers, and inspiring and motivating others.

Effective management in complex environments requires leadership but leaders are

not necessarily managers.30

Management - Essentially district nurses provide patients with treatment for acute

illness, and preventative healthcare on an ambulatory basis. This operational reality

should be reflected in the management structure.

Leadership – The primary goal here is to promote one team and innovation

and continuous improvement to support seamless healthcare ‘closer to

home’. It is logical that leadership should reside in Primary and Community which

oversees hospital, primary and community healthcare providers.

We are aware that NMDHB management is in early discussions of establishing an

ambulatory care unit that would be managed by an Associate Director of Nursing and

who would be reporting to the General Manager Strategic, Primary & Community. In

our view, this is logical and would provide a better ‘home’ for the district nursing

service. Assuming establishment of an ambulatory care unit as discussed above we

recommend that the district nursing service should fall under

ambulatory care.

6.1.3 Review district nursing staffing resource including dedicated

clerical administration support across the district

Over the past three years there have been two substantive reviews of the district

nursing service in Nelson, Marlborough and Tasman. Overall district nursing has

reduced by 1.8 FTE over the past two years with a further reduction budgeted

2016/17 of 0.9 FTE.

District nursing in Nelson, Golden Bay and Wairau are exhibiting signs of being over-

worked and understaffed. Main indicators are:

▪ Having to prioritise patient care which may have patient safety issues;

▪ Majority of district nurses work through their breaks;

▪ Working after hours to write-up patient notes;

30 Kotter, 1996.

40 | P a g e

▪ Insufficient staffing cover to allow district nurses to take entitled leave and

engaging in continuing professional education;

▪ Insufficient time to engage in non-clinical activities for example visiting and

training GP practice nurses and aged residential care staff in wound care and

specialist care, training other district nurses and hospital staff in specialist

district nursing care; and

▪ In particular, noticeable high levels of stress and low morale of district nurses

interviewed in Nelson, Golden Bay and Wairau district locations.

The reality is New Zealand is faced with the challenges of (1) the increasing cost of

healthcare with new technologies, (2) more complex treatments and (3) the rising

population of elderly who are more dependent on health services to maintain their

quality of life. To help meet these challenges the 2016 Health Strategy was developed

with its five strategic themes for future healthcare:

In addition, a key principle of the NMDHB Health for Tomorrow Strategy is

integrating care and services across the whole of system to provide seamless core of

the highest quality where services will be inter-connected to fill gaps and reduce

duplication in service delivery.

District nursing has a critical and pivotal role to play in delivering these strategic

themes and principles as it is at the vanguard of services delivering healthcare to the

community. The district nursing service key objectives are:

Prevent avoidable hospitalisation and enable early hospital discharge; Provide support at home for patients with short and long-term health conditions; Promote patient self-care and independence; and Focus on home and community-based healthcare services to meet the specific

needs of Maori and Pacific people’s.

All New Zealanders

live well stay well get well

Closer to home

Ka aro mai ki te kāinga

Value and high

performance Te whāinga

hua me te tika o ngā mahi

One team Kotahi te tīma

Smart system

He atamai te whakaraupapa

People-powered

Mā te iwi heikawe

41 | P a g e

To meet these objectives and support the 2016 Health Strategy and the NMDHB

Health Strategy the district nursing must be sufficiently resourced in order meet

three operational objectives:

1. Deliver the right care, at the right time and at the right place;

2. Be able to work independently and inter-dependently as part of inter-disciplinary

teams and collaborate across the continuum of care; and

3. District nurses can be trained and provide strong education, training, research

and innovative support to primary, secondary and community healthcare

providers.

The reduction in FTE in district nursing has, in our view, reduced the capacity of the

district nurses to meet the first operational objective above with little or no capacity

at all to meet the other objectives of collaboration and education.

We recommend a thorough review of district nurse staffing levels

including dedicated clerical administration support across the district.

6.1.4 Establish a Community Healthcare Provider Forum

The lack of communication between the district nursing services and primary and

secondary care providers is impeding collaboration with other health professionals

across the continuum of care and the provision of seamless, integrated and

coordinated care to people.

The lack of communication also contributes to the lack of visibility and awareness of

district nursing services. Multi-disciplinary teams do meet periodically but these

meetings are clinical in nature where specific cases are discussed. There is no forum

where health care providers can bring challenges, issues, ideas for innovation and to

share experiences and knowledge.

When considering a teamwork model in healthcare an inter-disciplinary approach

should be applied. There is a natural tendency when adopting a purely multi-

disciplinary approach that each team member is responsible only for the activities

related to his or her discipline and formulates separate goals for the patient.

However, an inter-disciplinary approach coalesces a joint effort on behalf of the

patient with a common goal across all disciplines involved in the care plan. The

pooling of these services in an inter-disciplinary way leads to integrated

interventions.

We recommend establishing an inter-disciplinary forum of community

healthcare providers. To minimise the risk of the forum becoming too

cumbersome and unwieldy the forum should comprise a core group of healthcare

providers which can then draw in other agencies as and when required as illustrated

in the figure below:

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The benefits of a forum of this nature are numerous:

▪ Increased visibility of the district nursing service;

▪ Greater collaboration and integration between agencies and help underpin the

‘one team’ approach of the 2016 Health Strategy;

▪ Help address the issues of a ‘siloed’ approach to service delivery;

▪ Provide a forum for challenges and ideas for innovation;

▪ Cut down on time lost to misinterpretation;

▪ Support seamless transition of care between the hospital, community services

and home;

▪ Supports effective communication which fosters open communication: team

members feel confident that their opinions are heard. This will encourage input

from the entire team and the team can utilise all of its internal resources to solve

a challenge or develop an innovation;

▪ The forum will encourage dynamic change so that the community team can keep

up with evolving healthcare; and

▪ Each member is able to communicate effectively and better able to understand

other team members.

Public Health

Nelson PHO

Wairau PHO

Sexual Health

Mental Health (Older

persons)

Audiology

Mental Health (Child &

Adolescent)

Diabetes

Pharmacy

NGOsAT&R

Meals-on-

wheels

Transition to Care Liaison

Nelson & Marlborough

GP Marlborough

PHO

GP Nelson PHOSupport

Works

Golden BayDistrict Nursing

NASC (operating

CCC)

Allied Health

Core Community Health Care

Provider Team Forum

Ti Piki Oranga

43 | P a g e

A key enabler to establishing this forum is a shared record for all members of the

healthcare team (see Recommendation 6.2.2 below)

6.1.5 Establish both public and private social media networks for

community healthcare providers

Use of social media in healthcare for communication and treatment is growing and is

not likely to disappear. Although there are some challenges surrounding maintaining

privacy and confidentiality and the reliability of the material exchanged on the web,

the benefits to the general public and healthcare organisations outweigh the

mediums limitations31.

Common benefits of using social media in healthcare communication, education and

treatment are31:

▪ Increases interactions with others – Social medias one-to-many capabilities allow

healthcare providers to provide the general public medical advice without

compromising confidentiality. A well-crafted article on self-directed exercises,

medical device use, self-care etc. provides people with real-time advice to

correctly follow medical advice;

▪ More available, shared and tailored information – The community healthcare

providers can post various articles on topical healthcare topics and help educate

other healthcare agencies and the public;

▪ Increase accessibility and widen access – leveraging social media to connect with

other healthcare providers is an efficient way to expand the range of knowledge

and healthcare network;

▪ Peer/social/emotional support – Positive reinforcement and connection with

other healthcare providers supports collaboration within and between agencies

and in terms of the public help to meet their goals;

▪ Public health surveillance – Social media has the potential for complimenting

public health surveillance; and

▪ Potential to influence health policy – Statistics collected on social media and

healthcare shows that two thirds of physicians prefer an open forum as opposed

to a specialist, physician only online community for professional communication.

This shows that healthcare professionals are embracing social media’s

transparency and suggests that the open source of information is actually

improving the quality of care they are able to provide to their patients and the

public.

We recommend establishing private and public social media networks

for community healthcare providers.

31 Morouchos, 2015 The Six Benefits of Social Media in Healthcare.

44 | P a g e

These social networks will help underpin the community healthcare provider forum

(Recommendation 6.1.4) and will support greater communication and

connectivity within and between district nursing and other healthcare agencies.

6.1.6 Allocate more district nursing resource to supporting, educating

and training other community healthcare providers

One of the foundations for providing collaborative, integrated multi-agency care in

the community is continuing education of healthcare providers. The district nursing

service can play a pivotal role in providing education, training and expertise to other

agencies such as general practices, Maori and Pacific NGO’s and aged residential care

facilities. By reaching ‘upstream’ in the health continuum through education and

training the district nursing service can assist in:

▪ Identifying and removing health inequalities and promote community based

healthcare services to meet the specific needs of Maori and Pacific people;

▪ Co-ordinating care across service areas;

▪ Supporting, educating and training and developing other healthcare NGO

providers such as Ti Piki Oranga; and

▪ Supporting other healthcare providers to provide the right care, at the right time

and in the right place will help reduce costs in the long-term and provide more

appropriate patient-centred care.

6.2 The System Recommendations

6.2.1 Enhance data capture and establish key performance indicators for

the district nursing service

What gets measured, gets managed and what gets managed gets done. Key

performance indicators are quantifiable measures that an organisation uses to gauge

or compare performance in terms of meeting their strategic and operational goals.

Recent major advances in IT and increasing demands for health system

accountability and patient choice have driven rapid advances in health system

performance management. Health systems, however, are still in the relatively early

stages of performance measurement, and major improvements are still needed in

data collection, analytical methodologies and policy development and

implementation.

Measuring the performance of district nursing and the outcome of patient care will

assist in demonstrating district nursing service’s contribution to:

▪ District nurses leading care and contributing to healthy communities;

▪ Preventing people from dying prematurely;

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▪ Enhancing quality of life for people with long term conditions;

▪ Helping people to recover from episodes of ill health or following injury;

▪ Delay and reduce the need for care and support; and

▪ Ensuring that people have a positive experience of care.

We recommend implementing the following key performance indicators

for district nursing as a matter of priority across the district including

Golden Bay:

- Incidence of pressure ulcers;

- Leg ulcer wounds;

- Preferred place of care;

- Re-admissions within 28 days; and

- Rate of cancelled appointments.

In addition, we recommend the following additional data should be

captured:

- Number of referrals to district nursing service that are rejected by volume and

location;

- Number of incomplete discharge summaries by referral source; and

- Clinic and homebased visits by volume, contact time and by visit type.

6.2.2 Start utilising Health Connect South as an electronic platform for

patient records and upgrade IT and hardware for district nursing

The current IT, hardware and systems are not enabling the district nursing service to

operate efficiently.

Canterbury DHB has partnered with Orion Health to implement a web-based single

electronic medical record (EMR) to access patient records which is referred to as

Health Connect South.

Health Connect South will provide South Island based clinical staff with a single

repository for patient clinical records, streamlining and simplifying access to patient

information.

NMDHB as part of the South Island Alliance has started to implement Health

Connect South EMR in some areas.

We recommend that district nursing migrate all patient records on to

the Health Connect South as soon as practicable.

Utilising the EMR will provide a patient centric single point of access for patient

information. This in turn will deliver greater efficiencies and support improved

healthcare by:

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▪ Providing accurate, up-to-date and complete information about patients at the

point of care;

▪ Enable quick access by different agencies (including district nursing) to patient

records for more coordinated, efficient care;

▪ Helping providers more effectively diagnose patients, reduce medical errors, and

provide safe care;

▪ Improving patient and provider interaction and communication as well as

healthcare convenience;

▪ Helping all providers to improve efficiency; and

▪ Reducing costs through decreased paperwork, improved safety, reduced

duplication of testing and improved health.

To capitalise on migrating to the EMR we recommend that all district nurses working

in the community each have smart phones and mobile computer tablets with

networking capability. This will enable district nurses to enter patient notes,

photographs etc. while in the field and to be able to access the clinical network.

This will enable improved work process efficiencies: patient notes do not have to be

written up upon return to base and support improved quality of healthcare.

6.2.3 As part of implementing Health South district nursing needs to

conform all patient and patient related documentation district wide

Documents that need to be standardised are referrals and discharge summaries.

Once standardised the time spent by district nurses following-up incomplete referrals

and discharge summaries for information gaps and/or to clarify aspects of care to be

provided by the service will reduce.

6.2.4 As soon as practical implement the community module of

Trendcare

Trendcare is a workforce planning and management system that provides data for

clinicians, department managers, hospital executives and high-level healthcare

planners.

Trendcare is currently used in NMDHB and 15 other New Zealand DHB’s in the acute

setting. Since 2012 the District Nursing Advisory Group has been working with

Trendcare to develop a community module which will shortly be released shortly in

the next Trendcare version (3.6). The community module is automatically part of

Trendcare and does not need to be purchased as an addition.

We recommend implementing the community module as soon as the

next Trendcare version is released.

The advantages of the community module for district nursing are:

▪ Enables workload allocation and scheduling;

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▪ Configuration to plan and monitor inputted staffing predictions, measure these

and apply variance measures to inform staffing decisions;

▪ Determining patient acuity for district nursing will enable the service to achieve a

staffing methodology and undertake FTE calculations (Recommendation

6.1.3).

▪ Will link district nursing services to inpatient services – promoting care capacity

and demand management across primary and secondary services; and

▪ Visible and measurable service provision.

6.2.5 Install GPS tracking in all district nursing vehicles

The lack of communication in some rural areas has health and safety issues for the

rural district nurses in particular. Installing GPS tracking, amongst other things,

enables:

▪ Increased driver safety – the DHB can monitor a vehicles speed, location and

direction in real time;

▪ Geo-fencing – the DHB can create and set individual boundaries to demarcate a

specific area or road;

▪ Increased vehicle safety – the DHB can monitor the services and maintenance

details for vehicles ensuring safety and helping to reduce costs in the process;

▪ Panic button – Enable staff to alert the DHB if they should find themselves in

difficulty; and

▪ Lone worker alarm – a personal device to better protect district nursing who

typically are working alone or remote areas.

6.2.6 Actively promote continuing professional development and focus

on improved and more sustained education and support between

the nursing educators at Nelson and Wairau and the district nurses

District nursing is focused on meeting the health and care needs of people in their

local communities, they require particular competencies and flexibility of service

provisions and the ability to partnership with patients, carers and communities as

well as a range of other professional and voluntary workers and carers.

In terms of district nursing the 2016 New Zealand Health Strategy will only become a

reality in the Nelson, Marlborough and Tasman region if the service has enough

district nursing staff with the right skills, values and behaviour to deliver them, and a

work environment that supports professional nursing service delivery.

Currently there is no standardised framework for supporting district nurses to attain

skills, competencies and professional development required for their role. Well-

crafted continuing professional development is important because it delivers benefits

48 | P a g e

to the individual, their profession and the public. Continuing professional

development:

▪ Ensures nurse capabilities keep pace with the current standards of others in the

same field;

▪ Ensures that nurses maintain and enhance the knowledge and skills that they

need to deliver safe and quality care;

▪ Ensures nurses stay relevant and up to date both within their own profession and

with wide sector issues. Nurses are made aware of changing trends and

directions;

▪ Enables nurses to make a meaningful contribution to the care team, and become

more effective in the workplace. This supports career advancement and the

ability to move into new positions where nurses can lead manage, influence,

coach and mentor others; and

▪ Helps increase job satisfaction and for nurses to stay interested and interesting.

Delivering a ‘smart system’32 requires strong education, training and research

support for the district nursing workforce.

We recommend developing a framework and proactively promoting

continuing professional development for the district nursing service.

Nurse educators’ play a pivotal role in strengthening the nursing workforce, servicing as role models, coaching nurses and providing the leadership needed to implement evidence based practice. Coaching is increasingly being a vital ingredient in the success of individuals and organisations33. Coaching nurses has the potential to increase productivity, engender confidence and motivation, changes in behaviour and culture. NMDHB maintains nursing educators at both Nelson and Wairau who report to a nursing consultant who is responsible for nursing education and development district wide. However there seems to be a disconnect between these nurse educators and the district nurses. We are unclear whether the district nurses are failing to engage with the nurse educators or vice versa. We recommend focus on improved and more sustained education and support between the nursing educators at Nelson and Wairau and the district nurses. The nurse educators should support, educate and coach all registered nurses including working with district nurses and supporting their education in core competencies. Working under the direction of the nurse consultant the nurse educators should: ▪ Develop and deliver in-house nursing education programmes to prepare district

nurses to meet service requirements, technological advances and clinical

priorities across the service;

32 2016 Health Strategy. 33 Neale et al, 2009; Bueno, 2010; Jinks and Popovic 2011.

49 | P a g e

▪ Prepare policies, procedures and resources to assist district nurses with learning

and for reference to achieve safe practice, especially with new services and new

technology;

▪ Audit the effectiveness of the learning and safety of clinical implementation;

▪ Work alongside district nurses, coach and role model good nursing practices in

the service to assess competence assessment;

▪ Advise on professional district nursing practice issues to enhance practice

effectiveness and safe clinical outcomes; and

▪ Participate in workforce development planning to future proof the district

nursing workforce.

6.2.7 Develop a workforce plan for district nursing

District nursing has an aging workforce and succession issues. There does not appear

to be any workforce planning across the district or evidence of initiatives to build a

future district nursing workforce nor is there any plan in place that focuses on

retaining district nurses longer in the workforce so that expertise can be shared and

their knowledge transferred.

We recommend development of a workforce planning model for district

nursing that develops a programme for older nurses. This should include

flexibility of hours and shifts, ensuring work environmental design to better

accommodate older nurses and re-engagement of staff by revitalising the internal

motivation and self-reward that brought them into nursing.

While the retention of older district nurses in the workforce for as long as possible is

an important goal, inevitably they will begin to retire. We are concerned, that with a

large number of retirements occurring in a short period of time, younger nurses are

likely to be pushed into jobs that they are not prepared to do in a very complex

healthcare environment.

We recommend designing and establishing succession planning for

team leaders, associate charge nurse managers and specialist nurses’

positions.

An effective workforce planning management should include:

▪ Data – An analysis of the current health workforce in district nursing and the

needs of the future;

▪ Strategy – An overarching workforce planning approach;

▪ Planning – An approach to create pipeline to full future workforce needs; and

▪ Evaluation – the ability to monitor the effectiveness of the plan.

6.3 Golden Bay Recommendations

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6.3.1 Golden Bay district nursing service should form a closer working

relationship with NMDHB and its district nursing service. In

addition, Nelson Bays PHO in association with NMDHB should

review the district nursing resource and dedicated clerical

administration support at Golden Bay

Since 2011 Golden Bay district nurses operating from the Golden Bay Community

Health Centre have been employed by Nelson Bays PHO.

The place of employment of the district nursing role has been debated with the

introduction of the primary healthcare strategy since 2001. The professional practice

environment that allows district nurses to flourish and thrive is not currently

replicated in a primary care business model.

To build a flexible and responsive workforce that is able to respond to new and

emerging health needs and technology requires access to DHB skills and expertise.

Hospital specialists tend to view the district nurses as an extension of their wards and

have trust in transferring patients into their care as they know they have access to the

clinical products and equipment required. This enables the district nursing team to

transition patients from hospital to home safely as part of a whole of system

approach to patient care.

When district nurses are not part of the DHB team they have reduced access to

educational opportunities and clinical equipment including high cost wound care

products. They do not have access to the same level of clinical information or updated

local clinical procedure. This can lead to poor transition of care as the expectation

from the hospital services would be that all district nursing has the same knowledge

and are able to provide the same level of care. Additional support services are also

more complex to access as they are often seen as a cost to the business model. Having

district nursing employed within a DHB retains the ability to flex the role to increase

the care categories that can be delivered by the team as the healthcare needs of the

community change.

We recommend that the district nurses at Golden Bay form a closer

working relationship with NMDHB and its district nursing service.

Specifically, we recommend that the Golden Bay nurses:

1. Are represented at the Community Healthcare Provider Forum;

2. Have a direct link to the Transition to Care Liaison role at Nelson;

3. Are part of all district nursing training in the Nelson Tasman region; and

4. Have access to home-based support services.

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In addition, we recommend that Nelson Bays PHO in association with

NMDHB reviews both the district nursing resource and dedicated

clerical administration support at Golden Bay.

6.4 Wairau Recommendations

The district nursing service at Blenheim is based at Wairau Hospital. Prior to 2008

the district nurses operated from aging facilities across the Wairau campus and were

relocated to purpose built premises as part of the hospital rebuild.

The district nursing service is collocated alongside allied health. Similar to the other

district nursing locations service delivery is a combination of clinic and home visits.

The essential question for the review team is where is district nursing best located in

Blenheim? To answer this question, we need to understand the future direction of

healthcare delivery and the role of the district nurses service going forward.

As previously noted in 2016 the New Zealand Health Strategy was refreshed. This

Strategy was designed to address the changing health priorities and financial targets.

The aim of the Strategy and using opportunities including the potential of medical

information and communication technologies’.

Five strategic themes were established:

These are the cornerstones in establishing a health sector that understands people’s

needs and provides services that are integrated across sectors, emphasising

investment early in life, maintaining wellness, preventing illness and providing

support for the final stages of life.

All New Zealanders

live well stay well get well

Closer to home

Ka aro mai ki te kāinga

Value and high

performance Te whāinga

hua me te tika o ngā mahi

One team Kotahi te tīma

Smart system

He atamai te whakaraupapa

People-powered

Mā te iwi heikawe

52 | P a g e

It is self-evident that there is a growing need for high quality care to be delivered in

the community, including in people’s homes. Increasingly more services that have

traditionally been provided in the hospital will be provided in people’s homes and

will involve long-term relationships to support people to manage long-term condition

and co-morbidity in the home. District nursing will be key professionals in

coordinating and providing this care.

For district nursing, this means moving away from narrow, ‘siloed’ models of care

towards patterns of care that deal with people with a number of concurrent

conditions – this is referred to as integration of care and to be able to provide

integrated care to people in the community and collaborating and working in

partnership with other healthcare services is vital.

So, what is the best way to support inter-agency working?

Co-location is often cited as one of the factors that can help support effective inter-

agency working and has been widely used in primary and community care34. For

example, Brown et al (2003) describe the creation of an integrated health and social

team serving older people and their carers. In order to encourage greater

collaboration community-based offices were located in GP practices and sought to

bring together social workers, social work assistants, occupational therapists,

occupational therapy assistants and district nurses.

The benefits of co-locating healthcare providers are numerous:

▪ A smoother and clearer pathway for the patient;

▪ Greater access to the wider, multi-disciplinary team;

▪ Advances the knowledge, skills and practice of the healthcare teams;

▪ Increased knowledge sharing;

▪ Provides a platform for regular liaison between co-located partners which

increases the partners ability to meet patients’ healthcare needs, develop positive

working relationships and increase collaboration and new ways of working35;

▪ Informal communication between co-located partners can afford a better

understanding of colleagues and their roles and organisational pressures that

they may be under; and

▪ Formal communication particularly if supported by a robust IT system can allow

teams to develop integrated documentation or allow them to refer service users

to their partners more quickly than if based in different locations.

34 A-Z of Inter-Agency Working, Jon Glasby, Helen Dickinson 2013. 35 District Nursing Service Development in New Zealand, Ministry of Health 2011.

53 | P a g e

We note that co-location needs to be accompanied by development activities such as

team building through exercises, get togethers etc.: co-location per se may not always

lead to substantially closer inter-disciplinary working (Davey et al, 2005).

As outlined in the Ministry of Health 2011 District Nursing Service Development in

New Zealand paper there is growing evidence of innovations in district nursing

models of care across New Zealand of district nurses working extensively in

collaborative health provider relationships from across the continuum of care in

order to provide the whole sector with transitional care: the community care ‘bridge’

as illustrated below:

The Queen Street Health Hub is a joint venture between Marlborough PHO and

NMDHB and comprises a two-stage development. Phase 1 of the Health Hub was

officially opened in 2015. Over the next 18 months Phase 2 will be completed which

will involve redevelopment of the redundant movie theatre space. The current and

proposed co-located community healthcare services are:

Queen Street Health Hub – Current and Proposed Co-

located Community Healthcare Services

Currently - Phase 1 Proposed – Phase 2

Marlborough PHO

Public Health Services – Health

Promotion, Health Protection,

and Public Health Nurses

Barnardos

Diabetes Marlborough

Support Works

Older Persons Mental Health

Pacific Trust

Te Piki Oranga

Te Puni Kokiri

Migrant Centre

54 | P a g e

Asthma Marlborough

Child and Adolescent Mental

Health

Child Development Services

Community Midwives

Psychologist

Sexual Health

English Language

Specialty Nurses – Cardiac,

Respiratory and Diabetes

Audiology

Physiotherapist

General Practice36

Pharmacy34

Family Planning

The review team has visited the Health Hub on numerous occasions and spoken with

some of the managers and team staff. The themes to come from these meetings were:

▪ A relaxed and productive atmosphere;

▪ Communication within and between teams is easy; and

▪ Teams and individuals are co-operating and supporting each other.

Now that we have a better understanding of the future direction of community

healthcare and the role that district nursing needs to play let us return to the

essential question – where is district nursing best located in Blenheim?

After careful review of the Health Strategy, evidence of innovations and changing

models of care in district nursing across New Zealand, other district nursing models

overseas the resounding response to the location question is that district nursing will

best support the future direction of healthcare in Marlborough by being co-located in

the Queen Street Health Hub. Without a doubt, the current district nursing services

based out of Wairau Hospital is good but the inability to co-locate with multiple

agencies in a community setting will inhibit the district nursing from becoming a

great service.

6.4.1 The district nurses should be located as follows:

1. The specialist nurse in complex wound care to remain at Wairau

Hospital. Initially the specialist nurse would:

▪ Run complex wound care clinics at the Wairau Hospital;

▪ As required, provide medical intervention or oversight in

complex wound care clinics at Wairau Hospital outpatients and

wards; and

▪ Focus on educating and upskilling nurses at Wairau Hospital in

complex wound care.

Once a cohort of Wairau Hospital nurses is proficient in complex

wound care the specialist nurse would increasingly:

36 Yet to be named.

55 | P a g e

▪ Support complex wound care in the community in a range of

settings including aged residential care and general practice;

and

▪ Continue to provide medical intervention or oversight in

complex wound care clinics at Wairau Hospital.

2. The remaining district nurses including the specialist nurse in

stoma care relocate to the Health Hub when the fit-out is

complete.

Although outside our area of reference we note that allied health operates both community and hospital facing services at Wairau Hospital. The rationale for recommending relocation of the district nursing team to the Health Hub is equalling compelling for the community teams in allied health. However, we are aware of resourcing constraints in the allied health service (difficulty in recruiting additional allied health staff) which makes it difficult to draw a simple delineation between the community and hospital teams: staff cross over between primary and secondary patients to support each other. We suggest that once staffing resource is resolved in allied health that consideration is given to relocating the allied health community health team to the Health Hub alongside district nursing. Our recommendations regarding the relocation of the district nurses staff comes with the proviso that certain recommendations occur prior or as appropriate, concurrently with the relocation, namely:

▪ Establishing a Transition to Care Liaison at Wairau Hospital

(Recommendation 6.1.1); ▪ Bring the management of the district nursing services under Ambulatory Care

Service (Recommendation 6.1.2); ▪ Review district nursing and administration support staffing in Marlborough

(Recommendation 6.1.3); ▪ Establish the Community Healthcare Provider Forum (Recommendation

6.1.4); ▪ District nursing staff using Health Connect South for patient records and notes

and upgrade IT, and hardware for district nursing (Recommendation 6.2.2); and

▪ Promote continuing professional development and focus on improved and more sustained education and support between the nursing educators at Nelson and Wairau and the district nurses (Recommendation 6.2.6).

Should district nursing continue to be based at Wairau Hospital:

▪ It will continue to have a hospital facing orientation and will find it difficult to

shift to an integrated community based multi-agency model of district nursing care;

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▪ The intertwining of district nursing and hospital services has drawn in the specialist district nursing care such that these specialist services function more as an outpatient department that reaches into inpatient and emergency departments: typically these services in other hospitals are normally provided by specialist hospital nurses not district nurses; and

▪ The district nurses are co-located with only one other community based service (allied health). There is little meaningful interface with other community based providers currently.

For ease of reference we have summarised the main objections to relocating to the Health Hub along with corresponding mitigates in Appendix A.

6.5 Conclusions

Despite the numerous pressures and challenges before district nursing it is important

not to lose sight of how good the service is across the Nelson, Marlborough and

Tasman region. In our view, this is testament to the high degree of care, compassion

and commitment of the district nurses to their roles.

District nursing has a critical and pivotal role to play in delivering and supporting

healthcare nearer to people and supporting the wider healthcare team to promote

recovery and health closer to or in the home.

By understanding and evaluating the current reality of the district nursing service

situation and addressing the observations and the recommendations summarised

below we consider the district nursing service in the Nelson, Marlborough and

Tasman region can transition from good to great.

SUMMARY OF RECOMMENDATIONS

PEOPLE

6.1.1 Establish a Transition to Care Liaison role at both Nelson and

Wairau Hospitals

6.1.2 Management of district nursing service should be part of

ambulatory care if established

6.1.3 Review district nursing staffing resource including dedicated

clerical administration support across the district

6.1.4 Establish a Community Healthcare Provider Forum

6.1.5 Establish both public and private social media networks for

community healthcare providers

6.1.6 Allocate more district nursing resource to supporting,

educating and training other community healthcare providers

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SYSTEMS

6.2.1 Enhance data capture and establish key performance indicators

for the district nursing service

6.2.2 Start utilising Health Connect South as an electronic platform

for patient records and upgrade IT and hardware for district

nursing

6.2.3 As part of implementing Health Connect South district nursing

needs to conform all patient and patient related documentation

district wide

6.2.4 As soon as practical implement the community module of

Trendcare

6.2.5 Install GPS tracking in all district nursing vehicles

6.2.6 Actively promote continuing professional development and

focus on improved and more sustained education and support

between the nursing educators at Nelson and Wairau and the

district nurses

6.2.7 Develop a workforce plan for district nursing

GOLDEN BAY

6.3.1 Golden Bay district nursing service should form a closer

working relationship with NMDHB and its district nursing

service. In addition, Nelson Bays PHO in association with

NMDHB should review the district nursing resource and

dedicated clerical administration support at Golden Bay

WAIRAU

6.4.1 The district nurses should be located as follows:

1. The specialist nurse in complex wound care to remain at

Wairau Hospital. Initially the specialist nurse would:

▪ Run complex wound care clinics at the Wairau Hospital;

▪ As required, provide medical intervention or oversight in

complex wound care clinics at Wairau Hospital outpatients

and wards; and

▪ Focus on educating and upskilling nurses at Wairau Hospital

in complex wound care.

Once a cohort of Wairau Hospital nurses are proficient in

complex wound care the specialist nurse would increasingly:

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▪ Support complex wound care in the community in a range of

settings including aged residential care and general practice;

and

▪ Continue to provide medical intervention or oversight in

complex wound care clinics at Wairau Hospital.

2. The remaining district nurses including the specialist nurse

in stoma care relocate to the Health Hub when the fit-out is

complete.

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APPENDIX A – HEALTH HUB MAIN OBJECTIONS & MITIGANTS So, what has been the main objections to relocating to the Health Hub?

Various concerns and observations have been raised by some of the district nurses and some of community in Blenheim in terms of the proposed relocation. The main themes of the arguments and observations have been:

▪ There is no discernible benefit to the community – If one adopts a

narrow ‘siloed’ view of district nursing this observation is probably correct. However, when one considers healthcare as a whole rather than as parallel separate systems and consequently the future of healthcare in New Zealand is providing coordinated, integrated, multi-agency care in the community and people’s homes there is considerable benefit in locating district nurses in the community alongside other primary and community service providers;

▪ Insufficient parking for district nurses and patients – In Phase 2 of the

Queen Street Health Hub there will be approximately 37 dedicated car parks for the additional Health Hub staff, consumers and patients. We understand that these car parks will be exclusive to the Health Hub and will be ‘policed’ if necessary to ensure availability. We understand there will be sufficient car parking for district nursing staff and patients alike;

▪ Insufficient patient wheelchair access and disabled car parking – Both

the front and rear of the Health Hub will be reconfigured to enable disabled car parking at both entrances and close and easy wheelchair access;

▪ Security and safety concerns – Hours of operation at the Health Hub

currently are Monday to Friday from 8am until late at night (8pm-9pm) as often seminars are being run and/or some services continue to operate into the evening. From completion of Phase 2 the Health Hub hours of operation will extend to include Saturdays as some of the new services are expected to operate on the weekend. The expected extension to the Health Hub operating on Saturdays alleviates concerns over district nurses’ security and safety on the weekends;

▪ Insufficient access to consumables in a timely manner – Provision will

be made at the Health Hub in phase 2 to stock sufficient levels of district nursing consumables. We understand there would be approximately 30m2 of storage space available to district nursing which is similar in size to the current storage space at Wairau;

▪ Insufficient access to IV consumables and medications in a timely

manner – IV consumables and medications will be available from the pharmacy premises on site;

▪ District nursing will become disconnected from the hospital: the

patient pathway to and from the hospital will be adversely affected – This concern will be mitigated by firstly, maintaining the complex wound specialist district nurse support at Wairau Hospital during phase 1

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(Recommendation 6.4.1) and secondly, establishment of the Transition to Care Liaison at Wairau Hospital (Recommendation 6.1.1);

▪ Insufficient timely access to decision making in the wards – Clinical

decision making will continue to occur in a timely manner as hospital staff will continue to have the support of specialist district nurses; and

▪ Relocation is a waste of money – The estimated capital investment to fit out

rooms in the phase 2 rebuild is approximately $1,300k. This review is focused on what is the right configuration of hospital and community services needed to deliver healthcare in coordinated, integrated and multi-agency way that supports the 2016 Health Strategy and in particular ‘one team closer to home’. Without doubt avoiding hospitalisations, enabling early hospital discharge, providing support at home for patients with short and long-term health conditions, promoting self-care and independence generate significant cost savings for the secondary provider and the health system as a whole.

Capital expenditure is not the primary issue here: empowering people to be cared for in their own homes and in the community, is. We anticipate that the capital investment will be more than recovered as the evidence that district nursing reduces costs in the long-term and provides more appropriate patient centred care is overwhelming.

The Health Hub is too far to go and is in the wrong location – The

shortest driving distance and time between the Health Hub and Wairau Hospital

is 3.1 kilometres and 7 minutes respectively. In addition, as can be gleaned from

the map below the Health Hub is more centrally located to medical practices than

Wairau Hospital.

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Given the responses to the infrastructure concerns and observations above we do not

share the concerns that the Health Hub is poorly located and too far to go.