Whangaroa Health Services Review Preferred Model of Care

Contents1. Background ................................................................................................................................................ 21.1 Northland Health Services Plan .......................................................................................................... 21.2 Review of Whangaroa Health Services .............................................................................................. 31.3 Review purpose, objectives and process ........................................................................................... 42. Trends in models of care for rural communities ......................................................................................... 43. Whangaroa population, funding and service profile ................................................................................... 63.1 Demographics, health needs, and secondary service utilisation ....................................................... 63.2 Services provided in the Whangaroa community ............................................................................... 73.3 Expenditure comparison ..................................................................................................................... 83.4 WHST financial performance .............................................................................................................. 94. Sustainable services for the Whangaroa community: a strategic response ............................................. 94.1 Options ............................................................................................................................................... 94.2 Preferred pathway ............................................................................................................................ 135. Shifting the balance to planned and preventive care ............................................................................... 146. Urgent, after-hours, and acute care ......................................................................................................... 176.1 Urgent access ................................................................................................................................... 176.2 ‘GP beds’ .......................................................................................................................................... 186.3 Access to diagnostics ....................................................................................................................... 186.4 Primary Options Programme Northland (POPN).............................................................................. 196.5 Summary .......................................................................................................................................... 197. Service integration .................................................................................................................................... 208. Services for older people.......................................................................................................................... 219. Leadership, governance and management.............................................................................................. 2310. Enabling actions ....................................................................................................................................... 2410.1 Workforce capacity and capability .................................................................................................... 2410.2 Information sharing and technology ................................................................................................. 2510.3 Clinical and management networks .................................................................................................. 2510.4 Partnership and community development ........................................................................................ 2510.5 Patient support to overcome access barriers ................................................................................... 2611. What the preferred model of care means for Whangaroa ....................................................................... 2612. Next steps ................................................................................................................................................ 27Appendices ...................................................................................................................................................... 281

1. Background1.1 Northland Health Services PlanIn 2012, Northland DHB (NDHB) developed the Northland Health Services Plan (NHSP). The NHSP is afive-year plan with a 20-year horizon. It defines the challenges faced by Northland health services, and howthe health system should respond. Specifically, it outlines the impending significant increase in demand forhealth services resulting from population ageing and increasing prevalence of long-term conditions within thecontext of constrained public funding increases. Under current DHB planning assumptions, in four yearstime, the DHB will go from financial breakeven to a $30 million deficit.Figure 1 - Demand and supply pressures impacting on clinical and financial sustainabilityIn responding to these challenges, the NHSP takes a ‘whole-of-system’ approach with a ‘Triple Aim’ focus ofimproving population health, and delivering high quality patient experience, while also ensuring costeffectivenessand productivity improvement (see Figure 2). This requires local as well as district-wide action,and the need to ‘future proof’ local health services and funding by: Considering different resource allocation patterns Ensuring equity of access Making better use of the available workforce Improving service performance (cost, quality, outcomes) Making better use of technology.2

Figure 2 -TheTriple Aim frameworkFollowing adoption of the NHSP, NDHB has embarked on a structured implementation plan. A key aspect ofthis is an ongoing programme of value-for-money improvements across the services the DHB provides andits service agreements with Non-Organisations (NGOs). As part of this programme, all NGO serviceagreements will undergo value-for-money review, with a small number prioritised for early focus.1.2 Review of Whangaroa Health ServicesWhangaroa health services have been prioritised as an early focus area for value-for-money review. TheWhangaroa Health Services Review encompasses all NDHB-funded services delivered locally to theWhangaroa population, including those contracted directly with the Whangaroa Health Services Trust(WHST), Te Tai Tokerau PHO (TTTPHO), Te Runanga O Whaingaroa (TROW), other NGOs, and the NDHBhospital provider.The prioritisation of Whangaroa health services for value-for-money review was prompted by: WHST’s concern that it cannot sustain the current configuration and level of services within the currentfunding provided by NDHB; and NDHB’s concern that the maintenance of the current configuration of WHST services may beunaffordable for the DHB in the future and that the level of funding for Whangaroa may be inequitable.Reflecting these shared concerns, the Review is being led by NDHB in partnership with WHST, TTTPHO,and TROW.Each partner is represented on a Review Steering Group, which provides oversight of the Review’s processand development of the preferred model of care option presented in this report.Health Partners has been commissioned by NDHB to undertake the Review.3

1.3 Review purpose, objectives and processThe purpose of the Review is to develop a plan for the future configuration of services in Whangaroa thatreflects contemporary models of care is cognisant of social, cultural and economic impacts; and maximiseshealth outcomes within available resources. In keeping with this, the plan to be developed through theReview is to be based on the following principles: Reflects New Zealand health policies and contemporary best practice; Responds to community and Māori health needs and priorities; Is practical, and clinically and financially sustainable; Engages the clinical community; and Is generally acceptable to the people of Whangaroa.The plan will take a five to 10-year view in considering how best to deliver planned and unplanned care,support integrated models of care, and ensure the quality and sustainability – both clinical and financial - ofservices. This is aligned with the NHSP’s Triple Aim focus.The objectives of the plan are to: Describe an integrated service delivery model that makes best use of available resources Focus on improving health outcomes, particularly for Māori, in line with the NHSP Reflect a level of funding for Whangaroa health services that is fair and equitable, and comparable withsimilar sized population groups with a similar demographic profile.The following actions have been undertaken to develop the model of care options and preferred modelpresented in this report:Completion of a population, funding, and service profile of services delivered in and for the people ofWhangaroa, to identify population health needs and resource allocation, and future service improvementprioritiesA literature review of contemporary models of care in small rural and remote communities to identify bestpractice trendsInterviews with key stakeholders to highlight Whangaroa health need and service delivery issues andpriorities for improvementStakeholder workshop to develop model of care options and identify a preferred model.The outcomes of these Review actions shape the options analysis and preferred model of care optionpresented in this report, which has been endorsed by the Review Steering Group.2. Trends in models of care for rural communitiesChanges are occurring in configuration of health services in response to challenges to their clinical andfinancial sustainability. Health systems – whether at locality, district, regional or national levels - are usingmedium to long-term planning to proactively address challenges, in order to avoid the need to respond at alater stage in a reactive, crisis driven manner. Major trends in health system responses to the challengesdescribed in Figure 1 include the following (see Figure 3):1. Increased emphasis on prevention, early intervention, self-management and home-based delivery2. Consolidation of primary care services into larger health centres, new organisational and professionalpartnerships, and multi-disciplinary teams3. Hospital clustering (‘networks’) and regional services4

4. Increase sub-specialisation, and consolidation into a smaller number of centres with outreach (‘hub andspokes’).Figure 3 - Trends in models of care 1These trends in service redesign and models of care are occurring in both urban and rural communities,affecting locally provided services and the connection of these services (and patients) with more specialisedservices provided elsewhere. However, the challenges to service sustainability facing health servicesgenerally are accentuated in rural communities by: Geographic distance, from both local primary care and more specialised services Low population density, and in many cases reducing populations Limited infrastructure Higher delivery costs Difficulty in attracting and retaining an appropriately skilled clinical workforce.Efforts to strengthen rural service sustainability tend to focus on improving access to local services. Fourcompeting factors must be balanced in this: quality; size; travel times; and cost. It is the balancing of thesefactors – and associated trade-offs - that determine which services are provided locally, and which areaccessed by patient travel. Factors determining local service availability include: Demand volume Workforce supply Funding Infrastructure.In determining what services are available locally, priority tends to be given to comprehensive and integratedprimary health care, with access to more specialised and/or capital-intensive services (such as inpatient andresidential care) requiring patient travel to a centralised location. Planning for rural services emphasisesdevelopment of a single point of access to a range of local primary health care services, and sufficientnumbers of health professionals to ensure mutual professional support, often with a common managementand governance structure. The emphasis is on maximising local economies of scale and efficiencies where1National Health Board (2010). Trends in Service Design and Models of Care.5

individual services are not sustainable, and strongly linking these services to support from a larger (nonlocal)centre. Mobile services, community support, health promotion and prevention, and intersectoralalignment are also features of many innovative rural models of care, particularly for high needs communities.Critical success factors for sustainable rural health services include: Local leadership and vision Strong relationships, and networks Locally available and engaged workforce Certainty of ongoing funding, and alignment with funder priorities Physical resources An engaged community that is ready for change.3. Whangaroa population, funding and service profile3.1 Demographics, health needs, and secondary service utilisationWhangaroa is a relatively remote rural area that is home to around 3,200 people 2 . Māori comprise anestimated 44% of the population. The population is more deprived than the Northland and New Zealandpopulations as a whole. The characteristics of Whangaroa suggest the health needs of the population arelikely to be greater than the Northland and national norms, meaning a higher demand for services andgreater challenge to lift health outcomes.The Whangaroa population is projected to remain relatively stable in size over the next 20 years. However,as with New Zealand as a whole, the population will experience a shift in age structure towards a higherproportion being aged 65 years and over. This implies an increase in the population’s demand for servicesgiven that age is strongly associated with increasing health needs.The number of Whangaroa residents reported as having diabetes and/or cardiovascular disease (CVD) ishigher than the estimated rate for the Northland population (11% vs 9.4%). The prevalence of diabetes/CVDcan be expected to increase as a result of population ageing, meaning that efficient and effective primaryhealth care services are essential to meet the needs of the population.In 2011/12, Whangaroa residents with diabetes/CVD had the second highest age standardised utilisationrate of NDHB inpatient and emergency department (ED) services in the Mid and Far North. This implies thatprimary health care services in Whangaroa have the opportunity for improved performance to better meetthe needs of residents with diabetes/CVD through locally-based delivery.Approximately one quarter of the attendances of Whangaroa residents at an ED result in hospital admission.Of these ED attendances, approximately 40% arise from GP referral, with self-referral (primarily toWhangarei Hospital) and ambulance referral comprising around 25% and 24% respectively. The rate of GPreferrals is slightly higher than other areas in the Mid and Far North 3 . Whangaroa residents are equally likelyto access emergency services at either Bay of Islands or Whangarei hospital EDs, but much less likely toaccess Kaitaia Hospital ED.2This is the Statistics Department population projection based on the 2006 Census. The Whangaroa Health Centre serves a slightly larger enrolledpopulation, with some patients from outside the area thought to be enrolling to access zero co-payment general practice, and some Whangaroaresidents enrolling with practices outside the area. The Whangaroa Health Centre’s enrolled population has a higher proportion of Māori patientsthan is shown by the Census projection.3Controlling for the Kaitaia ED attendance pattern of a very high rate of self-referral.6

Historically the Whangaroa area was designated as a ‘special medical area’. Although such areas have nowbeen phased out of the New Zealand health system, aspects of Whangaroa’s historic funding and servicemodel remain, including a NDHB targeted payment to WHST to support zero co-payments for generalpractice consultations.Today, NDHB, TTTPHO, central government agencies, WHST and TROW fund and provide a broad rangeof health and related social services that are delivered in the Whangaroa area. Whangaroa residents alsoaccess services provided by NDHB, TTTPHO and other government agencies for a wider Northlandpopulation.In 2010/11, NDHB spent between $10 and $11 million on health services for the people of Whangaroainclusive of Northland-wide services and funding for the then Whangaroa PHO. The largest share of thisspending (~33%) was for inpatient personal health services delivered in NDHB hospital settings.3.2 Services provided in the Whangaroa communityWhangaroa Health Services TrustWHST receives just under $4 million per year (2012/13 forecast $3.6m) to provide a broad suite of servicesincluding NDHB-funded primary health care, and aged residential care services.WHST receives $1.51 million from NDHB for the provision of enhanced rural primary health care services,which includes funding for GP acute inpatient care, physiotherapy services, radiography services, mobileclinics, and Māori health. The Trust is expected to prioritise this funding in accord with expected health andservice outcomes, and the needs of the Whangaroa community. Activity reporting by the Trust shows thatphysiotherapy, radiography, and mobile clinic service volumes are broadly in line with expected levels.However, although the pattern of admissions to inpatient care are consistent with what might be expected ina rural setting, the use and occupancy of local GP acute inpatient care appears to be significantly belowcost-efficient levels (average of 14% occupancy; and an average patient stay costing over $20,000 based onthe implied DHB-funded price).WHST receives a further approximately $1.1 million from NDHB (both directly and via TTTPHO) for theprovision of primary care services, which includes funding to maintain zero patient co-payments for GPservices. The Trust employs 8.7 full-time equivalent (FTE) staff to deliver these services, of which 3 FTE areGPs. The number of patients per GP appears to be slightly lower than the Far North average, and lowerthan Northland and New Zealand averages. The nurse to GP ratio is relatively high at 1.9 nurse FTEs to 1GP FTE. Overall, these staffing levels suggest that the Trust is relatively well-resourced to provide primarycare level services.Comparative rates of access to WHST primary care services show that Māori/Pacific residents in Whangaroareceive less service in total, and in total per capita terms, but from the middle to older ages receive a higherper capita level of service. When age standardised, the comparative utilisation rate for Māori/Pacific appearsto be commensurate for GP consultations and higher for nurse consultations. Comparative rates of accessalso appear to be broadly in line with other Mid and Far North areas with the exception of the Hokianga,which has a much higher utilisation rate than other areas. On the information received, WHST primary carenurse consultations appear significantly lower than most other areas (which is probably related to a reportinganomaly rather than actual activity).WHST generally performs well on the national PHO Performance Programme indicators relative to TTTPHOaverages, in particular in reaching high needs populations. However, it should be noted that whileTTTPHO’s performance is improving, it is variable across indicators and in aggregate places TTTPHO is inthe lowest quartile of PHOs across New Zealand.7

In addition to primary care services, WHST also provides aged residential care (ARC) for clients assessed asrequiring rest home and hospital-level care, excluding more specialised dementia and psychogeriatric care(which are available for Whangaroa residents in other areas of Northland). The Trust has a 20-bed ARCfacility (Kauri Lodge) and employs 12.73 FTEs to deliver ARC services. It receives around $930,000 from allsources to fund ARC, and is funded through the standard national service agreement. The occupancy rateof WHST’s ARC services (92%) is in line with expected levels. However, recent work undertaken by theaged care sector, DHBs, and the Ministry of Health suggests that smaller ARC facilities - particularly thosethat are not-for-profit - can struggle to provide viable services given their size and current service prices 4 .This national study suggested that facilities sized between 76 and 100 beds delivered the best financialperformance.Other providersOther providers also operate in the Whangaroa area, providing health or social services co-located at theWHST facility, other community facilities, or in client homes. Some of these services are close-in-kind toWHST services (eg, marae-based primary care nursing), or complementary (eg, community pharmacy;home-based support services; social work). In other instances, they are more specialised. Providers includeNDHB (specialist community mental health, district nursing and public health nursing services), He WhareAwhina (TROW’s social work and outreach nursing services), Plunket (well child nursing), and other nationaland local Non-Government Organisations (NGOs).Of particular note are NDHB-funded and provided district nursing services, and NDHB-funded home-basedsupport services for older people (HBSS):District nursing services are personal health services that are primarily intended to prevent hospitaladmissions and enable early discharge from hospitals. They are complementary, and in some casesclose-in-kind, to primary care services. In 2011/12, Whangaroa residents had the highest agestandardisedrate of district nursing services. Access rates between Māori and non-Māori were broadlysimilar, with Māori comprising 48% of clients.HBSS services support older people to remain living in the community. Providers of NDHB-fundedHBSS for Whangaroa resident older people are: Ngati Hine Trust (subcontracted to TROW); HomeSupport North Charitable Trust; and Healthlink North. These providers deliver both householdmanagement and personal care services, and eligible Whangaroa residents have choice of provider.Whangaroa residents receive fewer hours per person than other catchment populations in the Mid to FarNorth, which is primarily related to fewer hours for personal care services. In Whangaroa, Māoricomprise over 40% of HBSS clients. This is a higher percentage than their share of the older populationof Whangaroa. However, Māori clients receive fewer HBSS hours per client than non-Māori. This maybe related to the younger age profile of Māori HBSS clients.3.3 Expenditure comparisonAn expenditure and equity analysis of the funding allocation pattern by (former) PHO area undertaken byNDHB in 2010/11 suggests that Whangaroa residents receive the highest or second highest level of totalNDHB funding per head, which equates to a little less than $200 more per head than the Northland percapita average (see Table 1).4Grant Thornton Ltd (2010). Aged Residential Care Service Review.8

Table 1 - Funding allocation pattern by former PHO areas in 2010/11, showing a funding equity rankingMetricUsing PHO EnrolledPopulationHokiangaHealthKaiparaCareManaiaHealthTe TaiTokerauTihewaMaurioraWhangaroaCoasttoCoast3 5 4 6 1 2 7Using PHO Total Revenue 6 5 2 3 4 1 73.4 WHST financial performanceAs the most significant provider of health services in the Whangaroa community, WHST’s financial andservice performance and Whangaroa resident access to local services are inextricably linked. Over the pastfive financial years, WHST expenses have been growing faster than the revenue it receives and, as aconsequence, the organisation has been carrying an operating deficit for most of the period. The Trust’sworking capital position does not suggest it faces immediate financial sustainability issues. However, givenexpenses have been growing faster than revenue, in the medium-term it needs to restrain expendituregrowth, improve resource allocation and ensure that its service model is appropriately sized to match NDHBrevenue (both direct and via TTTPHO), together with pursuing any further revenue generation opportunities.4. Sustainable services for the Whangaroa community: a strategic response4.1 OptionsThe challenges confronting the Whangaroa community and its local health services are reflective of thosefacing Northland more broadly, accentuated by Whangaroa’s relatively small size and distance fromspecialised services.There are three broad strategic options for sustainable services in the Whangaroa community in the future:1. Maintain the status quo2. Maintain the current service configuration while continuing to trim costs to live within available funding3. Redesign services to deliver better value, through a refocused model of care that will deliver betteraccess and population health outcomes, at lower cost.Each of these options has strengths, weaknesses, opportunities, and threats as summarised in the followingoption analysis (Tables 2, 3, and 4).9

Table 2 - Option 1 - Maintain status quoStrengths:Continuity of the current service model, thatfeatures community governance; good primarycare performance; affordable access to primarycare; co-located primary and community staff;and locally based aged residential careWeaknesses:Expenditure has been increasing faster than revenue due tocurrent service configuration, which will impact on WHST’sability to deliver same level and quality of service. This meansmedium-term financial unsustainabilityPatients can wait significant time for access to primary levelcare, and make relatively high use of acute hospital EDsPoor coordination of services across multiple providers, meaningduplication of service overhead costs and inefficient deliveryAccess and health outcomes maintained at their current level,with no opportunity for improvementOpportunities:Threats:DHB funding may be constrained further, resulting in asignificant, abrupt, and unplanned change to WHST funding andhence servicesPatient safety and quality of care is compromised resulting inpoor patient outcomes and reputational effectsClinical professionals lose confidence in organisation withimpacts on workforce continuity and sustainabilityDeteriorating performance against measures such as PHOPerformance ProgrammeCommunity loses confidence in being able to access timely careresulting in patients going elsewhere for services, resulting inreduction of revenue for WHSTSocial and economic impacts on the Whangaroa community10

Table 3 - Option 2 - Maintain the current service configuration while continuing to trim costsStrengths:Continuity of current service model in the shorttermWeaknesses:Expenditure has been increasing faster than revenue due tocurrent service configuration, meaning need for cost reductionwill be ongoingPatients can wait significant time for access to primary levelcarePoor coordination of services across multiple providers,meaning duplication of service overhead costs and inefficientdeliveryAccess and health outcomes maintained at their current level,with no opportunity for improvementOpportunities:Threats:DHB funding may be constrained further resulting in significant,abrupt, and unplanned change to WHST funding and henceservicesCost savings are not sufficient to manage within availablefunding while meeting performance expectations, resulting inthe need for significant, abrupt and unplanned service changePatient safety and quality of care is compromised significantlyresulting in reputational effectsClinical professionals lose confidence in organisation withimpacts on workforce continuity and sustainabilityDeteriorating performance against measures such as PHOPerformance ProgrammeCommunity loses confidence in being able to access timelycare resulting in patients going elsewhere for services resultingin reduction of revenue for WHSTSocial and economic impacts on the Whangaroa community11

Table 4 - Option 3 - Redesign services to a better value model of careStrengths:Services are designed to better meet the prioritisedneeds of the Whangaroa communityWeaknesses:Significant change in locally available servicesServices are designed in line with national and NHSPpriorities and contemporary models of careIncreased confidence by WHST, the community andfunders that local models of care are sustainable andcost-effectiveOpportunities:Deliver the range and mix of services NDHB is willingto fund in the Whangaroa community, ensuring asustainable delivery systemDuplication in services and costs can be identified andaddressed to improve efficiencyThreats:Lack of community and/or clinical ‘buy-in’Community and clinical expectations may ratchet up costsSocial and economic impacts on the WhangaroacommunityGaps in service provision can be addressedAlign service model with NHSP and associatedperformance indicatorsImproved access to local services for a greater numberof Whangaroa residents, with improved outcomes12

4.2 Preferred pathwayThere was general consensus at the Whangaroa Model of Care Workshop held with key stakeholders on 28February 2013 that the preferred option is to redesign services provided in Whangaroa to a refocused andbetter value model of care, with improved access and population health outcomes, and lower costs – Option3 above. This reflects a growing recognition among key stakeholders that the current service model isfinancially unsustainable for WHST and NDHB, and that there are opportunities to improve access andoutcomes via a refocussed model, which can also contribute to productivity and cost improvements. Option3 is seen as offering gains in all three dimensions of the Triple Aim.Five areas of focus were agreed at the Workshop as important in service redesign:1. Shifting the balance of primary care services to planned and preventive care (particularly in regard tolong-term conditions and child health)2. Strengthening urgent, after-hours and acute care3. Shifting the emphasis of services for older people to ‘ageing-in-place’ (ie, supporting independent livingin the local community for as long as possible)4. Integration of services across professional and organisational boundaries, and in particular in relation tocommunity nursing services5. Strengthening governance, leadership, and management.(A sixth potential area was also discussed – increasing acute capacity in Whangaroa to reduce demand atBay of Islands and Whangarei hospitals. This option is not supported, in light of the analysis summarised inAppendix 1.)These five focus areas are discussed further below, and are interlinked and mutually reinforcing. In keepingwith the NHSP, they also provide the opportunity for a greater emphasis on reducing health inequalitiesbetween Māori and non-Māori in terms of access and health outcomes. It should be noted that the ReviewSteering Group considers these five focus areas and the initiatives for each described below as a ‘completepackage’, rather than a list from which items can be selected for implementation.Key components of the preferred pathway for the better value model of care include: Developing a patient-centred model that proactively addresses the immediate and longer-term healthand support needs of the Whangaroa community Strengthening the role of primary care services as the hub of the patient-centred model in Whangaroa Improving coordination between primary care, community health and home-based support services inWhangaroa by, inter alia:– Developing multidisciplinary teams and care planning– Nurse-led models of care including cost-effective models of mobile nursing– Strengthening and formalising information sharing across providers– Integrating health and support services where this contributes to efficiency and effectiveness,including consideration of shared governance and management options Ensuring administration costs are minimised.13

Figure 4 provides a graphic depiction of the preferred model of care, while Figure 5 shows in stylised formthe funding and resource allocation impacts of the preferred model of care option.Figure 4 - The preferred model of care for WhangaroaHealth literacy & self managementWhānau OralinkagesCommunity & mobile servicesWhangaroaHealth Centre servicesAged residential careservicesAcutehospitalservicesTertiarycarePaihia, KaikoheKerikeri, KaitaiaWhangareiKawakawaKaitaiaWhangareiAuckland5. Shifting the balance to planned and preventive careHealth systems were historically oriented to diagnosis and treatment of acute episodes of illness and injuryas a reactive response to patient needs. However, today increasing emphasis is being placed onanticipating and proactively addressing patient and population health needs, given the increasing demandarising from population ageing, and increased prevalence and complexity of long-term conditions. Thisincludes a focus on prevention of ill-health, early detection of risks and disease, and slowing the progressionof the disease through structured care. Long-term conditions generate much of the burden of disease inNew Zealand, and as a consequence, reduce the quality and quantity of life, while also increasing healthservice demand and expenditure.The NHSP recognises the significant demand and cost pressure that unplanned care (including urgentgeneral practice visits, ED attendances and acute hospitalisations) place on the Northland health system;pressures that are forecast to intensify as a result of population ageing and increasing prevalence of longtermconditions. In light of this, the NHSP has a headline target of reducing unplanned hospital admissionsfor Northlanders by 2,000 annually by 2017.In Whangaroa there is an opportunity to accelerate the shift to planned and structured care. This isimportant given forecast future demand growth (ageing; long-term conditions), and workforce and fundingconstraints. WHST has already started on this journey (through initiatives such as Care Plus, use of thePredict CVD tool, and mobile diabetes nursing), and is delivering good results on national indicators in areassuch as child immunisation, diabetes and CVD. The next stage could be planned and actioned across thelong term-conditions continuum (from health promotion to case management), building on what’s workingnow together with evidence of cost-effective interventions.14

Figure 5 - Stylised overview of funding and resource allocation under the preferred model of care optionThe following explanatory notes relate to the bracketed numbers in Figure 5:1. Includes TTTPHO funding to WHST for GP and practice nurse care with additional investment to supportshift to planned and preventive care, increased provision of mobile services where cost-effective, andintroduction of Primary Options Programme Northland (POPN) to assist with DHB acute demandmanagement. NDHB funding for zero co-payments also included in this funding.2. Reprioritisation of NDHB funding for the two GP inpatient beds to support other model of careenhancements.3. Reprioritise ARC rest home-level funding to support ageing-in-place including deepening and broadeningcommunity support services for older people. ARC hospital-level funding is maintained based on NASCassessment of Whangaroa resident needs, but services are provided by other facilities in Northland.4. Deepen and broaden community support services for older people including improving coordination withclinical services.5. District nursing service level to be maintained but better coordinated with other community nursing andsupport services.6. Enhance public health services in Whangaroa to support shift to planned and preventive care, with afocus on health promotion for child health and long-term conditions risk factors.7. Enhance allied health services (eg, physiotherapy; social work; clinical pharmacy) to support primary careand ageing-in-place.15

Figure 6 - Stylised risk stratification profile and associated intervention model. Note that the percentages of thepopulation ineach groupare not necessarily representative ofthe Whangaroa population, and are for illustrativepurposes onlyAn important component of shifting the balance to planned and preventive care is to develop acomprehensive understanding of the different levels of health need ofthe Whangaroa community, and inparticular, their health-risk profile. The use of risk profiling of the population enrolledwith primary care is animportant building blockfor plannedcare, allowing the design and application of care models to meet thevarying levels of health need. Figure 6 provides a stylised depiction of population risk stratification and thetypes of intervention that may effectively addresss the needs of different risk profile groups.Based on risk profiling of the Whangaroa community, care models for the different population segmentsscould be developed to match their level and type of need, and workforce capacity. A focus would be ondeveloping consistent, multidisciplinary approaches to needs assessment, careplanning and serviceedelivery. Care planswould be personalised to individual patients based on their health status,whanau/family support networks, and preferences, and thereby contribute to improved health outcomes andpatient experience of a responsive system.The care models wouldincrease inresource intensity as the level of risk increases. For people and theirwhanau with higher andmore complex needs, the care model could be intensified tocase management, andbroadened to include, for example, clinical pharmacy services, community mental health services, and socialservices.The objective would be to help people achieve the best health and quality of life possible by preventing riskfactors developing into long-term conditions, and stabilising current chronic conditions to prevent diseaseeprogression. Importantly, adoption of risk stratification supports a patient-centric approach to model of caredesign and resource allocation, and in turn supports better integrated service delivery.16

The overall goals of shifting to planned and preventive care include: Improved population health outcomes Reduced health inequalities between Māori and non-Māori Increased patient satisfaction Increased staff satisfaction Improved health literacy.Key early actions include: Identifying the most appropriate methodology for risk stratification, and ensuring baseline data is ofappropriate quality Factor into design of the model of care learning on what already works well in Whangaroa (eg, selfmanagementgroup sessions, home visits) Identify evidence-based models of care for different risk profiles and population groups (eg, frail elderly;children; adults with diabetes) Define the scope and mix of health professionals at each level of risk stratification and associatedmodels of care Identify varying methods of patient contact, including nurse-led models, home visits, mobile clinics, and‘virtual consults’ (eg, telephone), and the suitability for patient groups Undertake a task and activity analysis to identify appropriate clinical and support staff input to models ofcare, and identify where possible staff substitution opportunities to improve efficiency and free up timefor more specialised professionals to focus on more complex cases Size resource and utilisation intensity for different models of care to inform resource and fundingallocation Align with urgent, after-hours and acute care, services for older people and nursing integration initiativesdescribed below.6. Urgent, after-hours, and acute care6.1 Urgent accessThe NHSP places significant focus on ensuring that all Northlanders have good access to primary careservices. A key measure of the responsiveness of health services is the ability for patients to have timelyaccess to appropriate services when urgent health needs arise. There is a perception amongst some in theWhangaroa community that getting same-day access to primary care services can be difficult.Often the key drivers of access issues in primary care relate to how effectively the practice triages patientneeds, how it uses the available workforce, and how productive that workforce is enabled to be by thepractice’s systems and processes. Currently, the Whangaroa Health Centre uses nurse triage to determinewho should receive a same-day appointment, who should see the patient, and the duration of theappointment. Conflicting views were expressed by stakeholders on how well the triage process is working.It was also noted that triage is challenging given the low health literacy and high expectations of thecommunity.A refocussed model of care would include as an immediate priority a review of Centre activity including: When do patients call or present? What are their needs? When are peak times?17

How do these match with staff resourcing?Based on the above, what is the best mix of responses, including immediate advice and scheduledappointments (including face-to-face clinic or home visits, and ‘virtual’ telephone appointments), and ofstaff resourcing?Consideration of the HML after-hours service and of how other health centres are managing demand duringnormal business hours would also be part of this review. It should be noted that the Whangaroa HealthCentre is relatively well resourced in terms of GP:patient and nurse:GP ratios when compared to Northlandand New Zealand benchmarks. This suggests that the process review (which could use the ‘lean’methodology) may bring material benefits in patient access, including opportunities to free up staff time forincreased patient contact. Community education regarding when and how to access care should also beprioritised as part of the wider effort to build community and patient/whanau health literacy.6.2 ‘GP beds’WHST is funded for the provision of two inpatient beds for acute primary care, with an on-duty registerednurse and on-call GP for 24/7 cover. Based on reported activity, these ‘GP beds’ have a low over-nightutilisation (14% on average). Bed utilisation increases slightly when day patients awaiting transfer to moreadvanced services are included (17% on average). The price paid by NDHB for these inpatient services isestimated to be approximately $1 million per year, which equates to around $20k per over-night patient stay 5 .For comparison purposes, this is over four-times the standard national price for DHB secondary inpatientservices of $4,600 (2012/13).Some stakeholders also expressed concern about the safety of the over-night stay model of care inWhangaroa, given the distance of the on-call GP (Kerikeri), and a sole nurse on duty covering the GP bedsas well as the Kauri Lodge residents. It was thought that a 24/7 acute hospital setting (ie, Kaitaia, Bay ofIslands or Whangarei) is a safer option for patients sick enough to need over-night care, and that Whangaroashould offer GP observation and assessment capacity during Health Centre business hours only.In 2010, around 12% of the 58 patients admitted to the GP beds were day-stay with nearly all of thesepatients discharged home; in 2011 this increased to 60% of 107 patients, with 94% of these patientstransferred to an acute hospital; and in 2012 (part year) 63% of the 49 patients, with 97% of these patientstransferred to an acute hospital. For day-stay and over-night stays combined, the proportion of patientstransferred to an acute hospital has increased from 9% to 65% in the past three years. This suggests anincrease in the proportion of day-stay patients over the past three years and also an increase in theproportion of patients being assessed as requiring transfer to more specialised services. Given this, it is likelyto be more cost-effective to maintain observation and treatment capability during business hours in theHealth Centre itself, and not have dedicated inpatient beds for acute over-night stays – a configuration whichis the norm in most Mid and Far North (and nationwide) general practice facilities. This would be combinedwith robust emergency response and retrieval.6.3 Access to diagnosticsA further opportunity for lifting Health Centre performance exists with the available and emerging point-ofcare(PoC) diagnostic tests that enable GPs and nurses to make a definitive diagnosis and deliver effectivelocal treatment strategies without the delays that arise from a remote specimen analysis or requirement forreferral to more specialised services. A further early action should therefore be to identify which additionalPoC testing options 6 could support a refocused model of care, and the cost and benefit of these.5Note no attempt has been made to adjust for any cross-subsidisation of other WHST services or initiatives.6Note that the Whangaroa Health Centre already has diagnostic radiology capacity.18

6.4 Primary Options Programme Northland (POPN)Priority is given in the NHSP to reduction in unplanned acute hospital medical admissions through enhancedprimary care services. A wide range of actions is identified in the NHSP to support this. One of these isexpansion of the Primary Options Programme Northland (POPN), which aims to: Reduce GP referrals Support diversion of ED self-referrals Support early discharge and transition to a new model of integrated primary health care.POPN increases the range of service options available to GPs and ED doctors considering a hospital referralor admission; provides a service coordinator to arrange the package of care that will avoid the referral oradmission and establishes a funding source to access those services. POPN service options include: Diagnostic procedures (eg, ultrasound; laboratory tests) GP and practice nurse home visiting Follow-up and return visits to general practice Physiotherapy Home nursing services, home help and equipment hire Intravenous therapy Transport to and from primary care locations Overnight care.POPN is not currently available in Whangaroa, but would be extended to Whangaroa as part of the newmodel of care.6.5 SummaryGoals for urgent, after-hours, and emergency care include: Improved patient access to timely, responsive urgent and emergency care Improved community health literacy regarding when, where, and how to access services Cost-effective use of local primary care resources and technologies.Key actions include: Undertaking an assessment of the effectiveness of WHST triage processes Conducting a process mapping and resource use of WHST primary care services Identifying the most cost-effective approach to treatment, observation, and stabilisation of patientspresenting to WHST primary care services Introducing POPN in Whangaroa, including identifying what PoC testing technologies should beavailable through the programme.19

7. Service integrationAn important NHSP action for improving patient experience is to develop coordinated multidisciplinarymodels of care across primary and community providers (inclusive of Whanau Ora Collectives 7 ), and withspecialist services, with a focus on integrated, culturally competent care particularly for long-term conditions.As identified in the Funding and Service Profile, a number of different organisations provide health and socialservices in Whangaroa with varying levels of coordination (relying largely on personal relationships ratherthan organisational mandate and action). Community nursing services in particular have a wide range ofproviders including: NDHB (district nursing; school based public health nursing; community mental health nursing) WHST (mobile nursing; diabetes nursing) TROW (marae-based outreach nursing; rheumatic fever school-based nursing) Plunket (well-child nursing).The wide range of providers risks confusion for patients, duplicated use of scarce resources, and suboptimaloutcomes. It also means that local organisations lack economies of scale and scope.There has been some recent progress made towards better aligning services through co-location of most ofthe nursing workforce on the WHST campus. There is now an opportunity to take this further throughmanaged coordination, and moving towards integration. This can occur within and between organisationsand professional groups. The primary care response discussed above – including the shift to planned andpreventive care based on risk stratification and tailored models of care, and the review of triage andresponse - will enable identification of opportunities for integration of primary and community care. Inaddition, the services for older people section below identifies the opportunity for better linkage with homebasedsupport services.Goals in improving service integration include: Develop patient-centred and coordinated care Develop evidence-based pathways Avoid duplication of services Ensure no gaps in services Develop a locally-based multidisciplinary team with critical mass.Key actions include: Undertaking a comprehensive stocktake of existing services, their overlap, and any gaps Patient journey mapping Evidence-based pathway implementation for prioritised common conditions Introducing a shared care record for all health professionals, and as appropriate, community supportworkers Aligning local quality indicators with NHSP outcome measures.7TROW and WHST (together with Hokianga Health) are members of Te Pu O Te Wheke Whanau Ora Collective. The Collective has recently beenadvised of new TPK funding for four Whanau Ora navigators.20

In the immediate future, better integration of community nursing services provides the most significantopportunity to improve efficiency and effectiveness. Consideration should be given to: A single governance/management structure for community nursing services Defining core competencies aligned with planned careDefining a generic skill-set for community nurses and a pathway for implementation, including theinterface with specialist nurses.8. Services for older peopleThe NHSP has a key population health performance measure of increasing the proportion of older peoplereceiving home-based support services compared to aged residential care (ARC). This is aligned with thenational policy priority (and clear preference of older people) for supporting ‘ageing-in-place’ – that is, forolder people to live in their own homes or supported housing, rather than in residential care settings.Delivery of ageing-in-place requires availability of the necessary range and quantity of community-basedsupport services, and coordination of clinical and support services across the continuum of care for olderpeople.The ageing-in-place policy has prevailed since 2002, and evidence gathered to date suggests thatcommunity care may achieve better outcomes at lower costs than institutionalised care, and is preferred byolder people even when they are terminally ill (Parsons et al, 2012 8 ). Key service components to amelioratethe risk of older people being admitted to aged residential care include: Comprehensive needs assessment Case management Coordination of support and clinical services Multiple home follow-ups (Stuck et al, 2002 9 ).The Funding and Service Profile analysis and stakeholder engagement undertaken as part of the Reviewindicates that the Kauri Lodge facility operated by WHST is financially non-viable, and is dependent onsignificant cross-subsidisation from NDHB funding streams intended for other services. Demand for KauriLodge services is considered to be almost exclusively local – from Whangaroa residents, and relatives ofresidents. At its current capacity of 20 beds, the facility can provide service for 4.2% of the Whangaroacommunity’s population aged 65 years and over, at an average cost of approximately $59,000 per residentper year 10 . As noted earlier in this report, a recent joint national study by DHBs, the aged care sector, andMinistry of Health suggested that capacity of between 76 and 100 beds is required for strong financialviability.While Whangaroa’s population is ageing, it is unlikely that this will generate the level of future demand tosustain a financially viable ARC service such as is currently provided at Kauri Lodge 11 . Future demand isalso likely to be moderated by increased support for ageing-in-place, which has been shown to reduce therequirement for rest home level care (which is 50% of Kauri Lodge’s total capacity). It appears thatWhangaroa residents currently receive fewer hours of home-based support services than other Mid and Far8Parsons, M. et al (2012). ‘The Assessment of Services Promoting Independence and Recovery in Elders Trial (ASPIRE): a pre-planned metaanalysisof three independent randomised controlled trial evaluations of ageing-in-place initiatives in New Zealand,’ Age and Ageing, 41, pp. 722-728.9Stuck, A. et al (2002). ‘Home Visits to Prevent Nursing Home Admission and Functional Decline in Elderly People: Systematic review and MetaregressionAnalysis’, JAMA, 287(8), pp. 1022-1028.10ARC subsidised rates are $116.51 (excl GST) per bed day for rest home level care, and $204.29 (excl GST) for hospital level care.11A recent attempt by WHST to obtain bank support for investment in expanding ARC capacity to 34 beds was unsuccessful. The WHST Board isyet to determine whether it intends to maintain provision of ARC.21

North populations, have very limited local access to day care, and no local meals-on-wheels access. Afurther risk for WHST exists in the potential for future competition from other ARC providers 12 .WHST has historically used NDHB funding associated with the Rural Health Centre contract to crosssubsidisethe Kauri Lodge ARC service. This situation is clearly not sustainable from a NDHB funderperspective.Refocusing of Whangaroa health services on supporting ageing-in-place is likely to better reflect the needsof the community as a whole, and make better use of the available financial resources 13 . Shifting to a newmix of older people services would include broadening and deepening community support services, andbetter coordinating these with Health Centre and community clinical services. Hospital-level ARC serviceswould be provided at other facilities close to Whangaroa 14 .Supported independent living arrangements could be expanded from their currently very limited base. Kaeocurrently has five ‘Kaumatua flats’ in Turner St, developed by Abbeyfield and Housing New Zealand, andmanaged by TRW. The units are for those aged 55 years and over. Lunch and dinner are provided daily toresidents, but no other services are provided.There is no other supported housing for older people in Whangaroa. However, a planned shift to the ageingin-placemodel of care would include consideration of development of further support housing options inWhangaroa including the potential to develop supported shared living arrangements at Kauri Lodge, andadditional supported housing on the Health Centre campus (or elsewhere in Kaeo). Partnering arrangementswith Housing New Zealand, Far North District Council, TROW and NGO providers would be explored.Currently, a range of health professionals and home-based support workers from multiple organisations maybe involved in the ongoing care of an older person. Coordination and information-sharing between theseproviders will be less than ideal, and result in delays in identifying and responding to the changing needs ofpatients, with adverse impacts on their care and health outcomes, and on efficient resource use. Often, theworkers with the most regular contact with older people will be those least equipped to diagnose andrespond to their health needs. Timely and appropriate care can be improved through risk stratification,needs assessment, care planning, case management models, and multidisciplinary team delivery (seediscussion of planned care above).Goals for improving services for older people include: Implement an ageing-in-place strategy aligned with Government priorities and NHSP Make support services for older people available to a wider number of people in the Whangaroacommunity Align clinical and support services for older people.Key actions include: Develop a plan for scoping and introducing the ageing-in-place model of care commencing withdeveloping an understanding of current client and service issues, particularly in regard to coordinationbetween clinical and support services Scope opportunities to develop new supported housing options (eg, flatting; supported housing units; reuseof Kauri Lodge) in partnership with Far North District Council, TROW and Housing New Zealand12NDHB and WHST were both approached in 2012 by a provider considering establishment of a new ARC facility at Coopers Beach.13It should be noted that more resource intensive dimensions of the health of older people continuum of care (such as dementia andpsychogeriatric care) are already provided away from Whangaroa for reasons of critical mass.14Currently the nearest aged residential care facilities are at Kerikeri, Paihia, Kaikohe and Kaitaia.22

Scope the possibility for WHST to become an operational coordinator of home and community supportservice delivery for older people in Whangaroa, to support alignment with clinical servicesExplore opportunities to increase community voluntary services as per the NHSPAlign any proposed changes to the Whangaroa model of care for older people with other changesoccurring in NDHB’s Specialist Services for Health of Older People including workforce.9. Leadership, governance and managementA key theme of stakeholder engagement, including discussion at the Whangaroa Model of Care Workshop,has been the desire to strengthen leadership, governance and management in Whangaroa health services.Given its relative size and scale in the local Whangaroa health system and its community representativestructure, the role of WHST has received particular attention.Indeed, stakeholders believe that WHST must exercise strategic leadership in the community, as one of thefew local organisations that can make resource allocation decisions. In particular, the Trust has theopportunity to lead the local Whangaroa health system, in identifying community needs and either allocatingits own resources or promoting action from others. However, there is a perception amongst somestakeholders that the Trust has not grasped this opportunity, and has lost the confidence of some of itscommunity.The goal for strengthening leadership and governance is for WHST to function as the leader of the localhealth system, within the wider Whangaroa community development strategy.Key actions to deliver on this leadership potential include: Revisit the Trust’s strategic plan to ensure alignment with funder priorities, and description of a pathwayfor a model of care for the Whangaroa community that delivers improved access and outcomes withinavailable resources Connect this strategic plan more strongly with an action plan, and annual business plans Develop an orientation programme for new Trustees that provides for capability development,particularly in regard to financial management Where necessary, supplement the skills of elected trustees with co-opted members at Trust Board orCommittee level (eg, external financial and clinical governance expertise) Review reporting processes and content to the Trust Board, particularly in regard to financial and clinicaltargets and performance Strengthen the Trust Board’s linkages with senior clinical staff as a means of ensuring alignment ofstrategic and performance expectations, and reducing risk Develop new community communication strategies to build health literacy, promote good health, andincrease engagement with the Trust and its business.A revised strategic plan would build on the work undertaken within this Review by: Outlining a shared vision and mission for the organisation, cognisant of its community partners Developing and aligning medium to long-term strategic priorities (national, NDHB, TTTPHO, TROW,WHST) Identifying short-term actions including capacity (eg, workforce, facilities, IT) and financial ’enablers’, thatsupport the identified medium to long-term priorities Assigning management and clinical accountabilities for delivery of priorities and actions23

Implementing key performance measures at organisational, management, clinical, and service deliverylevels that enable the WHST Board and its committees to monitor achievement of priority actions.Revision of the strategic plan (and associated action plan) should be informed by input from WHST staff,from funders, and from partner organisations. A development process that also engages the Whangaroacommunity would address a number of the issues discussed above.There are stakeholder perceptions that management and administration infrastructure and costs at WHSTappear to be higher than would be reasonably expected of an organisation of its size, particularly given thatthe Trust has ceased to be a PHO (with those functions having been subsumed by TTTPHO).Administration costs have been increasing at a considerable rate at the Trust (131% over the past five years,or 18% a year), although they represent a small share of total expenses. The level of management costsand associated cost growth is less clear. An indication of estimated management costs for primary carelevel services is provided by management fees paid to PHOs by the Government, which for populationsunder 40,000 is $15.60 per person enrolled for each person up to 20,000. If this is applied to the Whangaroaregistered patient population, the implied management fee is $55,000.Given concerns raised by some stakeholders and the potential for more funding to be directed to frontlinecare, more detailed analysis of Trust administration, management, and other overhead costs relative torevenue could be commissioned by the Board, including benchmarking with like organisations.10. Enabling actionsAction in a number of important ‘enabler’ areas will support a refocussed model of care for the Whangaroacommunity including: Workforce capacity and capability Information sharing and technology Clinical and management networks Partnerships and community development Patient support to overcome access barriers.10.1 Workforce capacity and capabilityIt is vital that Whangaroa makes the best use of the available health and support workforce. This requiresinnovations aligned with moving towards coordinated and/or integrated multidisciplinary ways of working, inaccord with the direction of the NHSP.Assuming adoption of the preferred model of care described above, key actions related to workforce include: Ensuring the primary health care workforce (GPs, nurses, and allied health professionals) are workingeffectively together, developing their skills, working at the full scopes of their practice, and utilisingsupport roles effectively Establishing additional health care assistant and other support worker roles where these are costeffective Strengthening the primary health care multidisciplinary team, particularly in regard to the roles of clinicaland community pharmacy, community nursing, and home-based support services Developing the health of older people workforce to support ageing-in-place, including linkages withclinical services and support for voluntary services Strengthening the Māori health and support workforce.24

10.2 Information sharing and technologyAccess to timely, robust and relevant information is important for multidisciplinary patient-centred care,resource allocation, and quality improvement. As part of NHSP implementation, NDHB is pursuing a rangeof actions for improving information sharing and use of technology in Northland. Whangaroa needs toensure that it leverages off these improvements, and that NDHB actions reflect the priorities of ruralcommunities.A key early action is to establish what IT linkages are required to foster stronger linkages between providersin Whangaroa, and how this might be achieved cognisant of NDHB’s NHSP action planning. Better linkagebetween WHST’s primary care service and Kaeo’s community pharmacy has been identified as animmediate opportunity to support improved patient care.10.3 Clinical and management networksEffective formal and informal clinical and management networks support sustainable rural health care that ispatient-centred and cost-effective. For example, formal clinical networks can define care pathways toimprove timely access to services for patients in rural areas and reduce the need for multiple visits tosecondary and specialist care.The benefits of developing networks to support rural delivery of care have been identified as: Access to expert opinion to inform local clinical decision-making Peer group support, training and education Rotation for skills update and maintenance Development of shared protocols and pathways Transfer protocols Increased practitioner confidence and satisfaction Improved discharge planning and support (NHS Scotland, 2007) 15 .To realise these benefits, two types of network relationships are needed: Laterally, between local health professionals and support providers to collaborate on agreed standards,protocols, training and development, support and sharing of good practice; and Vertically, through working with specialists in a central location to ensure quality and sustainability oflocal services.10.4 Partnership and community developmentHealth needs are often multi-factorial in nature, with key determinants lying outside the health sector – forexample, in housing, education, or social services. Pooling expertise and resources across multipleorganisations and sectors, and aligning planning and action should provide greater leverage to address longstandingsocial determinants of health in Whangaroa.Examples of such partnership and community development are already evident in Whangaroa, and can befurther strengthened and broadened. The Government’s Whanau Ora policy provides a strong strategicfoundation for this.Improving communications between organisations and the community will also assist in better understandingneeds and preferences, and how these can be best met by collaborative action.15NHS Scotland (2007). Delivering for remote and rural healthcare: The final report of the remote and rural workstream.25

10.5 Patient support to overcome access barriersPatients and their whanau can face access barriers, resulting from transport issues, lack of telephoneconnections, poor understanding of how to use services, and poor responsiveness of services to their needs.In some instances, these barriers can be overcome through provision of mobile nursing and communitysupport workers. In other instances, it may be appropriate to provide other supports to patients and whanauto improve their access to services.The nature of these access barriers and what action to take to reduce them would be strengthened throughengagement of patients and whanau in the detailed planning to support refocussing of Whangaroa healthservices in the areas described above.11. What the preferred model of care means for WhangaroaThe proposed model aims to ensure the clinical and financial sustainability of locally based Whangaroahealth services. Key dimensions of sustainable services for Whangaroa are: Improved patient access and population health outcomes Increased capacity to manage increased demand Best use of the available workforce Acceptable safety and quality, with effective clinical governance and meeting external standards Linked effectively to the wider Northland health system Adaptable to changing circumstances Effectively governed and managed, with strong community engagement Affordable for NDHB as the major funder Efficient, in making best use of the available funding.The proposed model is strongly in line with the Government’s priorities 16 : Reduce pressure on hospital services Develop a more personalised primary health care system Provide services closer to home where possible Improve the status of the total population.It also builds a strong primary and community service foundation for future development of the Whanau Oramodel in Whangaroa – which is particularly important given the area’s high Māori population.The most significant features of the proposed new model for the Whangaroa community that depart from thestatus quo will be: Enhancement of local primary care services New community support services for older people, and expansion of existing services Reconfiguration of Kauri Lodge in the context of ageing-in-place, with the requirement for a small numberof Whangaroa residents to access aged residential care in neighbouring towns.The implications for Whangaroa patients are summarised in Table 5.16As presented in Towards Better Sooner More Convenient Primary Health Care26

Table 5 - Implications of the preferred model of care for Whangaroa residentsGroupImplicationsAll patients (and whanau) Additional health services delivered in community settings, such as aperson’s home, or in a school Increased use of telephone, email and web technologies to access careand advice from home, avoiding the need for a Health Centre visit More rapid response for people with urgent needs Better coordination of nursing care across the community, meaningsharing of patient information amongst nurses, and less waste ofresources Better linkage of pharmacy and Health Centre services, meaning saferprescribing and dispensing of medication Closer and more regular monitoring of health, and earlier interventionwhere a change of care is needed Design of care plans, and tailoring of services to match the varyinghealth needs of Whangaroa people Additional local health services to avoid the need for referral to a hospitalor specialist, such as improved access to diagnostic tests Stronger linkages of health and social services, and improved access tosocial work services No change to zero fees for Health Centre general practice services Health promotion activity tailored to the needs of the Whangaroacommunity, and linked with health education and support for self-careOlder people (and their whanau) A wider range of support services in the local community for anincreased number of older people, included supported housing, meals onwheels, and day programmes that will help people to live in the localcommunity for longer Better coordination of nursing services with home-based supportservices for older people The need for the small number of people needing aged residential careto move to a facility out of the local community (eg, in Kaitaia, Kerikeri,Paihia, Kaikohe or Whangarei)In addition to these impacts on access to and outcomes from health services in Whangaroa, the preferredmodel of care would also have social and economic impacts arising from the funding reallocation illustratedin Figure 5. During the detailed planning that would follow a NDHB decision to implement the new model ofcare, one area of focus would be the impact on Whangaroa’s health workforce, and opportunities forretraining and redeployment.(It should also be noted that the other model of care options considered – that is, options 1 and 2 in section4.1 – also would have social and economic impacts over time, but these would essentially be unplanned innature.)12. Next stepsIf the NDHB Board approves the preferred model of care described in this paper, the next step would be toproceed to a further round of stakeholder engagement, followed by consultation with the Whangaroacommunity and providers. This and other subsequent actions are outlined in Appendix 2.27

Appendix 1Should Whangaroa Health Centre inpatient capacity be increased?At the Model of Care Workshop in Whangaroa, the potential for increased acute inpatient capacity inWhangaroa was identified. Factors discussed included: Local provision may offer a lower-cost model than the larger acute hospitals for people with lower levelsof need Local inpatient capacity could support more locally based care, and complement local general practice inproviding alternatives to referral to a larger acute hospital Local inpatient capacity could assist retention of ARC by spreading the costs There could be potential also for sub-acute (step-up; step-down) beds.The Steering Group considered this option, but concluded it was not feasible given: The priority of maintaining critical mass at Bay of Islands and Whangarei hospitals means thatunbundling into multiple smaller local units could not occur Whangaroa’s small catchment population and proximity to acute hospitals Whangaroa is unlikely to attract and retain locally-based doctors who would provide the required 24/7cover, and volumes would be too low to maintain credentialing The cost of 24/7 medical, nursing and clinical support would be very high in relation to the small volumes Trade-offs are needed, and work to date with stakeholders in Whangaroa suggests that comprehensiveprimary care and ageing-in-place are prioritised over ARC and inpatient capacity for locally availableservices.28

Appendix 2Significant activities to be included in a work programme to further develop theproposed Whangaroa model of careService area Activities CommentsConsultationAgeing-in-placeServiceintegrationPlanned andpreventive careUrgent, afterhoursand acutecareGovernance,leadership andmanagementChangemanagement Preparation of consultation documents Planning of consultation Undertaking consultation Revision of plan as required, based onconsultation Explore and develop supportedaccommodation options Expand scope of other communitysupport services Define and implement transition path Complete stocktake of service deliveryresourcing and outputs Map current and improved patientjourneys and care pathways Develop detailed model of care forintegrated nursing Identify and establish infrastructure tosupport the model Define and implement transition path Develop detailed model of plannedand preventive care Identify and establish infrastructure tosupport the model Define and implement transition path Undertake ‘lean’ process review anddesign for Health Centre triage andresource deployment Assess impact of HML after-hoursservice, and fine-tune as appropriate Strengthen community educationabout how to access services, incontext of health literacy developmentand support for access Design and implement a POPNprogramme appropriate to Whangaroa WHST to review and update theirstrategic plan WHST, TROW, TTTPHO and NDHBto consider organisational structureoptions for future service delivery inWhangaroa Develop project plan and associatedproject governance and managementstructure Identify the provider entities for thenew service mix Negotiate new funding agreement(s) Within the scope of the current project Final plan would be brought back to the Board Following a Board decision, an implementationplan would be developed, including the workoutlined belowNeed to align with Northland-wide planning Need to engage NDHB and TTTPHO nursingleaders Engage the local nursing workforce Learn from Hokianga model, and others elsewherein NZ Infrastructure to include IT linkages; co-location;governance and management Need to align with Northland-wide planning Engage the local primary care team Infrastructure to include risk stratification tool; caremodels for each risk group; IT linkages; colocation;governance and managementNeed to align with Northland-wide after-hours andPOPN initiativesTo be considered in context of desire for more explicitstrategic direction, closer integration of local services,strengthening of governance skills and disciplines,building community engagement, and constrainingexpenditure on management and administrationOverall work programme will need effective: Linkages between the various workstreams Governance oversight and management resources NDHB, WHST, TROW and TTTPHO involvement Local workforce engagement and communication Local community engagement and communication Linkage with NHSP work programme Linkage with emerging Whanau Ora model29

Appendix 3Whangaroa Health Services Review Steering Group membersKim Tito (NDHB) – Steering Group ChairHelen Linssen (WHST)Jannye Freeman (WHST)Garry Ware (WHST)Rose Lightfoot (TTTPHO)Norm McKenzie (TROW)John Wigglesworth (Hokianga Health)Robert Paine (NDHB)30