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Consultation Information BookletWHANGAROA HEALTH SERVICES“PREFERRED MODEL OF CARE”FUTURE HEALTH SERVICEDELIVERY MODEL2013in conjunction withWhangaroa Health Services Trust, Te Tai Tokerau PHO, Te Rununga O Whaingaroaand Health Partners Consulting Group

Tena koutou nga morehu o nga maataa waka, maii te ao tawhito. Kei te mihi atu; kei te tangi atu kinga mate kua mene atu ki te po.Ratou nga manu tioriori o nga pari karangarangame nga kaka wahanui o te wao nui a Tane.E te hunga kua whakawhiti atu ki te Ao Wairua,tena koutou katoa. Kua tangihia, kua mihia, me ki,kua ea te wahanga ki a ratou.Koutou nga mahuetanga iho i a ratou ma, tenakoutou, tena koutou, tena koutou katoa.Ko te pae tawhiti, whaaia kia tataKo te pae tata, whakamaua kia Tina! Tina!2

Tena koutou katoa – Greetings to you allThe purpose of this booklet is to provide you with the informationyou need to discuss and understand the proposed changes tohealth services provided for the Whangaroa-based population andassociated communities.A complete copy of the “Preferred Model of Care” ConsultationDocument is available on the Northland District Health Boardwebsite – www.northlanddhb.org.nzThe challenges confronting the Whangaroa community and its localhealth services are reflective of those across Northland.Northland DHB’s role as the main funder of health services is tomake sure we get value for money and to purchase what we thinkdelivers the best health care services for the greatest number ofpeople.We acknowledge that change can bring uncertainty. Our objectiveis to give you the information to provide informed feedback, andtogether with us, plan for the future health service needs for theentire Whangaroa population.Kim TitoGeneral ManagerPlanning, Maori, Primary & Population Health3

Why has there been a review of Whangaroa Health Services?The Whangaroa Health Services Review was prompted by:• Whangaroa Health Services Trust’s (WHST) concern that itcould not continue the current types and level of serviceswithin the current funding provided by Northland DHB; and• Northland DHB’s concern that maintaining the current types ofWHST health services will be unaffordable, and that the level offunding for Whangaroa is also inequitable. Compared to otherparts of Northland, Whangaroa residents receive the highestlevels of Northland DHB funding per head of population.The Whangaroa Health Services Review encompassed allNorthland DHB-funded services delivered locally to the Whangaroapopulation, including those contracted directly with the WhangaroaHealth Services Trust, through Te Tai Tokerau PHO, other nongovernmentorganisations (NGOs) and Northland DHB hospital andcommunity services.Services provided by other NGOs, including Te Runanga OWhaingaroa (not funded by Northland DHB), were also considered.A Steering Group was established comprising representatives from:• Whangaroa Health Services Trust Trustees: Jannye Freeman(Chair, resigned during review), Helen Linnsen (newly electedChair during review)• Whangaroa Health Services Chief Executive: Garry Ware• Northland DHB: Kim Tito – General Manager, Planning, M ori,Primary & Population Health, Robert Paine – General Manager,Finance, Funding & Commercial Services• Te Tai Tokerau PHO Chief Executive: Rose Lightfoot, JohnWigglesworth – Board member4

• Te Rununga O Whaingaroa: Interim Chief Executive NormanMcKenzie• Health Partners Consulting Group: Stephen McKernan, ChrisMulesWith assistance from Health Partners Consulting Group thefollowing actions were undertaken to develop the preferred way oforganising and delivering health services.• Completion of a population, funding, and service profile ofservices delivered in and for the people of Whangaroa, toidentify population health needs and resource allocation, andfuture service improvement priorities• A literature review of contemporary models of care in smallrural and remote communities to identify best practice trends• Interviews with key stakeholders to highlight Whangaroa healthneed and service delivery issues and priorities for improvement• Stakeholder workshop to develop model of care options andidentify immediate actions.The review recommends redesigning the health services providedin Whangaroa to improve access to planned, preventive andprimary health care services, with a focus on achieving betterpopulation health outcomes for all people, and to live within thefunding available.Northland Health Services Plan 2012-2017The Northland Health Services Plan (NHSP) defines the challengesfaced by our health system and how we will respond. The NHSPincludes the need for local as well as district-wide action, with theWhangaroa Health Services Review providing the opportunity to“future-proof” local health services and funding.5

The NHSP uses a framework which examines population healthoutcomes; patient experience - clinical quality and safety; and costand productivity – value for money.The Whangaroa Health Services Review has looked forward forthe next 5-10 years to consider how best to deliver planned andunplanned care; support integrated care; ensure service quality andclinical and financial sustainability. There is a focus on improvinghealth outcomes, particularly for M ori.We need to do better for WhangaroaThe health service challenges are highlighted by the community’srelatively small size and distance from specialised services.The Review highlights Whangaroa has:• High rates of admissions to hospital that are potentiallypreventable through primary care interventions• Increasing prevalence of long-term conditions particularlydiabetes• Low immunisation rates• Increasing demand for primary and community services• High rates of smoking, obesity, dental decay, injuries, teenagepregnancy, and suicide.Who provides health services in Whangaroa?A number of different organisations provide health and socialservices in Whangaroa with varying levels of coordination (relyinglargely on personal relationships rather than organisational mandateand action). Community nursing services in particular have a widerange of providers including:6

• Northland DHB (district nursing; school-based public healthnursing; community mental health nursing)• Whangaroa Health Services Trust (mobile nursing; diabetesnursing)• Te Rununga O Whaingaroa (marae-based outreach services;rheumatic fever school-based services)• Plunket (well child nursing).The wide range of providers risks confusion for patients, duplicateduse of scarce resources, and poorer health outcomes. It alsomeans that local providers lack economies of scale and scope.WHST Kauri LodgeKauri Lodge is a 20-bed Aged Residential Care facility employing12.73 full time staff. It receives around $930,000 per annum toprovide rest home and hospital-level aged care services.Research and evidence indicates that the Kauri Lodge facilityis financially non-viable, and is dependent on significant crosssubsidisationfrom funding streams intended for primary healthcare. This means that many people miss out on primary healthservices due to the money supporting Kauri Lodge and its patientsand residents.There is a need to increase support for older people to remainin their own home (ageing-in-place) and provide mobile ‘healthservices’ to their home. This will reduce the requirement for resthome-level capacity in Whangaroa.WHST GP BedsWHST is funded for the provision of two inpatient ‘GP beds’ foracute primary care, with an on-duty registered nurse and on-callGP for 24/7 cover.7

Based on reported activity, these ‘GP beds’ have low overnight use(14% on average). Bed use increases slightly when day patients awaitingtransfer to more advanced services are included (17% on average).The price paid by Northland DHB for these inpatient services isestimated to be approximately $1 million per year, which equatesto around $20,000 per overnight patient stay. For comparisonpurposes, the cost of an overnight stay in a Northland DHB hospitalis approximately $1,000 a night.Future State Service Delivery ModelThe preferred model of care developed from key stakeholderinterviews, the Model of Care workshop, and research and analysis,builds a strong primary and community service foundation. Itis linked to the future development of the Whanau Ora Model inWhangaroa, particularly important given the area’s high Maoripopulation.The current after-hours use of the two GP beds suggests thatpatients who are sicker, are transferred to other centres providingmore complex care, rather than keeping them over night.Some stakeholders expressed concern about the safety of theovernight stay GP beds, given the travel distance of the on-call GPand sole nurse on duty covering the GP beds as well as the KauriLodge residents.The objective is to help people achieve the best health and qualityof life possible by preventing risk factors developing into longtermconditions such as diabetes and heart disease and stabilisingcurrent chronic conditions to prevent people from becoming sicker.8

The preferred future service delivery model has five key areas offocus:1. Shifting the balance of primary care services to plannedand preventive care, particularly in regard to long-termconditions and child healthTo improve planned and preventive care, changes to thecurrent services will include:• Developing models of care that match the level and type ofcare the person needs• More people with personalised, planned care supportedby a team of health workers (doctors, nurses, pharmacists,community health workers)• Improving health outcomes for more people• Helping people achieve the best health and quality of lifeby preventing the development of complications fromdiabetes and heart disease• Improving immunisation rates for children and preventingdiseases like rheumatic fever.The Primary Options Programme Northland (POPN), currentlyonly available in Whangarei, increases the range of servicesavailable to doctors through a service coordinator whoarranges a package of care with the aim of decreasing andavoiding admission to hospital.These services include:• Diagnostic procedures (eg, ultrasound; laboratory tests)• GP and practice nurse home visiting• Follow-up and return visits to general practice• Physiotherapy9

• Home nursing services, home help and equipment hire• Intravenous therapy• Transport to and from primary care locations• Overnight rest home care.POPN is not currently available in Whangaroa but would beextended to Whangaroa as part of the new model of care.2. Strengthening urgent, after-hours and acute careCurrently after-hours care is provided by a mix of the telephonetriage service and on-site assessment by nursing staff with theGPs available on-call.A refocused model of care should review health centre activityincluding:• When do patients call or present?• What are their needs?• When are peak times?• How do these match with staff resourcing?• Are 24/7 acute hospital settings (ie, Kaitaia, Bay of Islands,Whangarei) a safer option for patients sick enough to needovernight hospital care?We need to ensure that people have improved access to timely,responsive urgent and emergency care and design a model ofcare that achieves this.3. Shifting the emphasis of services for older people to‘ageing-in-place’, that is, supporting independent living inthe local community for as long as is possible10

Evidence shows that older people much prefer to stay in theirown home for as long as possible.More community support services that are better coordinatedwith Health Centre and community clinical services will supportageing-in-place and reflect the needs of the community as awhole.Currently, a range of health professionals and home-basedsupport workers from multiple organisations may be involved inthe ongoing care of an older person.Coordination and information sharing between providers is lessthan ideal, and results in delays in identifying and respondingto the changing needs of patients. This has adverse impacts onpatient care and health outcomes and results in inefficient useof resources.Timely and appropriate care can be improved through:• Services planned to meet level of health risk• Needs assessment• Care planning• Case management models• Multi-disciplinary team delivery.The proposed changes are not about the level of care beingprovided to the residents who live at Kauri Lodge. Theresidents have been receiving an excellent quality of care.We also acknowledge the emotional attachment felt for theresidents by the staff, especially those residents who have livedat Kauri Lodge for many years.11

Our role as the funder is to make sure we get value for moneyand to purchase what we think delivers the best health careservices for the greatest number of people.4. Integration of services provided in the communityAn important NHSP action for improving patient experienceis to better coordinate care across primary and communityproviders.• Recent initiatives to co-locate most of the nursing andcommunity-based workforce on the WHST campus, arean example of how to manage coordination and improveintegration across organisations and professional groups• The primary care response above includes the shift toplanned and preventive care based on population healthneeds, tailored care plans, improved assessment anddiagnosis and supports better integration of primary andcommunity care• The services for older people identify the opportunity forbetter linkages with home-based support services.5. Strengthening governance, leadership and management ofthe TrustStakeholder engagement including discussion at theWhangaroa Model of Care Workshop identified that:• There is a genuine desire to strengthen leadership,governance and management of Whangaroa healthservices• The community wants the Trust to be a leader and identifycommunity needs adequately• This requires the Northland DHB and the Trust to better12

align the strategic plan with the funding priorities, andagree on a model of care for the Whangaroa communitythat delivers improved access and outcomes withinavailable resources• Strengthening the Trust Board’s linkages with seniorclinical staff as a means of ensuring alignment of strategicand performance expectations, and reducing risk• Developing new community communication strategies tobuild health literacy, promote good health, and increaseengagement with the Trust and its business is required.Most significant features of the preferred new service deliverymodelThe most significant changes proposed for the Whangaroacommunity are:• Enhancement of local primary and preventive care services• Closure of the two acute ‘GP beds’ for after-hoursuse leading to earlier transfer of people requiring morespecialist assessment and treatment• New community support services for older people andexpansion of existing services• Reconfiguration of Kauri Lodge means closure of the agedcare residential service (10 rest home and 10 hospitallevelcare beds) which would mean a small proportion ofWhangaroa’s older residents accessing residential agedcare in neighbouring towns• A planned shift to the ageing-in-place model of care wouldinclude the potential of developing new supported housingoptions in Whangaroa including the potential to develop13

supported shared accommodation arrangements at KauriLodge, and additional supported housing on the HealthCentre campus (or elsewhere in Kaeo).The proposed new service delivery model• Redirects the funding to improve access to services thatare closer-to-home, mobile, led by nurses, supported bydoctors with a much safer after-hours clinical service• Improved access to local services for a greater numberof Whangaroa residents, striving for improved healthoutcomes for everyone• Nurses are more involved in leading and delivering care inyour community in a planned and coordinated way• There is a strengthened focus on health promotion andhealthy lifestyles, the things that need to be done to keeppeople well• By changing where and how we invest the money we candeliver better health services to the whole population.Key Messages• People of Whangaroa, your Trustees are doing their job.They have raised with us (Northland DHB) as the funder ofhealth services, the fact that they can no longer continueto deliver a sustainable aged care service• We believe that the proposed new service delivery modelof care will improve the primary health care service that issupporting slightly more than 3,000 people compared withthe significant amount of funding currently supporting just20 people.14

Options for feedback:The Preferred Model of Care document is available:• To be downloaded from the Northland DHB Websitewww.northlanddhb.org.nz• You can obtain a copy from Whangaroa Health ServicesTrust and Te Runanga O Whaingaroa• You can request a hard copy by contacting MichelleCrayton-Brown on (09) 4700000 Ext 3301 oremail michelle.crayton-brown@northlanddhb.org.nz• A limited number of copies will be available at theconsultation meetings• You can submit your feedback in writing via email or mail tothe following addresses:michelle.crayton-brown@northlanddhb.org.nzMichelle Crayton-BrownExecutive Assistant to GM Planning, M ori, Primary & Population HealthDHB Office, Ground Floor, Maunu HousePrivate Bag 9742, Whangarei 0148• Verbal feedback can be given at any of the locality meetingsscheduled for:Date Venue TimeMonday 24 June Totara North Hall 6-8pmTuesday 25 June Taupo Bay Camping Ground Lounge 6-8pmWednesday 26 June Whangaroa Community Hall 6-8pmThursday 27 June Kaeo Memorial Hall 6-8pmSunday 30 June Te Tapui Marae, Matauri Bay 2-4pmFurther information regarding specific Marae based consultationmeetings will be advised shortly.The deadline for feedback is Friday 19 July 2013.15

Notes:June 2013