This documentation includes the Taranaki DHB Annual Plan 2014/15 and
This documentation includes the Taranaki DHB Annual Plan 2014/15 and Te Matakite Māori Health Plan 2014/15 1 This document presents our Annual Plan 2014/15 (referred to as the Plan). The Plan is broken into a number of modules that can be extracted for different purposes including presentation of our Statement of Intent 2013/2016. Central to understanding this Plan, is our performance story which sets out our key outcomes (what we are trying to achieve), our impacts (our shorter term contribution to an outcome), our outputs (goods and services supplied), and our inputs (resources). This Plan should be read in conjunction with the Taranaki District Health Board Maori Health Plan and the Midland DHB Regional Services Plan. Published by Taranaki District Health Board Private Bag 2016, NEW PLYMOUTH 4342 This document is available on the Taranaki District Health Board website: www.tdhb.org.nz 2 TABLE OF CONTENTS TABLE OF CONTENTS ........................................................................................................................................ 3 EXECUTIVE SUMMARY ...................................................................................................................................... 7 MINISTER’S LETTER OF APPROVAL ................................................................................................................ 9 MODULE 1: INTRODUCTION AND STRATEGIC INTENTIONS ....................................................................... 14 1.1 CONTEXT ................................................................................................................................................. 14 1.2 PERFORMANCE STORY .......................................................................................................................... 15 1.3 NATIONAL OPERATING ENVIRONMENT .............................................................................................. 17 1.3.1 Treaty of Waitangi ........................................................................................................................ 17 1.3.2 Health Sector Challenges and Pressures .................................................................................. 17 1.4 REGIONAL OPERATING ENVIRONMENT .............................................................................................. 18 1.5 LOCAL OPERATING ENVIRONMENT ..................................................................................................... 18 1.5.1 Our Geography and Population ................................................................................................. 18 1.5.2 Health Profile ................................................................................................................................ 20 1.6 NATURE AND SCOPE OF FUNCTIONS ................................................................................................... 20 1.7 STRATEGIC INTENTIONS ....................................................................................................................... 21 1.7.1 Our Vision ...................................................................................................................................... 21 1.7.2 National Context ........................................................................................................................... 21 1.7.3 Regional Context........................................................................................................................... 24 1.7.4 Local Context ................................................................................................................................. 25 1.8 KEY RISKS AND OPPORTUNITIES ......................................................................................................... 26 1.8.1 Health Inequalities ....................................................................................................................... 26 1.8.2 Living Within Our Means ............................................................................................................ 27 1.8.3 Health System Workforce Shortages ........................................................................................ 27 1.8.4 System Integration ....................................................................................................................... 27 1.8.5 Regional Integration .................................................................................................................... 27 1.9 KEY MEASURES OF PERFORMANCE ..................................................................................................... 27 1.9.1 Outcome 1 – People are Supported to Take Greater Responsibility for their Health ..... 27 1.9.2 Outcome 2 - People Stay Well in Their Homes and Communities ....................................... 30 1.9.3 Outcome 3 - People Receive Timely and Appropriate Specialist Care ............................... 33 MODULE 2: DELIVERING ON PRIORITIES AND TARGETS ............................................................................ 38 2.1 HEALTH TARGETS .................................................................................................................................. 39 2.1.1 Shorter Stays in Emergency Departments ............................................................................... 39 2.1.2 Improved Access to Elective Services ....................................................................................... 41 2.1.3 Shorter Waits for Cancer Treatment / Transitioning to Faster Cancer Treatment......... 43 2.1.4 Increased Immunisation ............................................................................................................. 44 2.1.5 Better Help for Smokers to Quit ................................................................................................ 46 2.1.6 More Heart and Diabetes Checks .............................................................................................. 50 2.2 BETTER PUBLIC HEALTH SERVICES ..................................................................................................... 51 2.2.1 Reducing Rheumatic Fever ......................................................................................................... 51 2.2.2 Prime Minister’s Youth Mental Health Project ....................................................................... 52 2.2.3 Children’s Action Plan ................................................................................................................. 55 2.2.4 Whānau Ora ................................................................................................................................... 57 2.3 SYSTEM INTEGRATION .......................................................................................................................... 59 2.3.1 Long Term Conditions ................................................................................................................. 59 3 2.3.2 2.4.2 2.4.3 2.4.4 2.4.5 2.4.6 2.4.7 2.4.8 2.4.9 Stroke ............................................................................................................................................. 61 Acute Coronary Syndrome .......................................................................................................... 62 Improved Access to Diagnostics ................................................................................................ 64 Shorter Waits for Cancer Treatment/Faster Cancer Treatment ......................................... 65 Cardiac – Secondary Services ..................................................................................................... 68 Primary Care ................................................................................................................................. 69 Health of Older People ................................................................................................................ 71 Mental Health Service Development Plan ............................................................................... 74 Maternal and Child Health .......................................................................................................... 77 2.5 NATIONAL ENTITY INITIATIVES ........................................................................................................... 82 2.5.1 Our Approach ................................................................................................................................ 82 2.5.2 Linkages ......................................................................................................................................... 82 2.5.3 Action Plan ..................................................................................................................................... 82 2.6 IMPROVING QUALITY............................................................................................................................. 91 2.6.1 Our Approach ..................................................................................................................................... 91 2.6.2 Linkages .............................................................................................................................................. 92 2.6.3 Action Plan.......................................................................................................................................... 92 2.7 LIVING WITHIN OUR MEANS ................................................................................................................. 94 2.7.1 Our Approach ..................................................................................................................................... 94 2.7.2 Linkages .............................................................................................................................................. 95 2.7.3 Action Plan.......................................................................................................................................... 95 2.8 SUPPORTING DELIVERY OF REGIONAL PRIORITIES .......................................................................... 96 2.8.1 Our Approach ..................................................................................................................................... 96 2.8.2 Linkages .............................................................................................................................................. 96 2.8.3 Action Plan.......................................................................................................................................... 96 MODULE 3: STATEMENT OF PERFORMANCE EXPECTATIONS ................................................................. 100 3.1 OUTPUT CLASSES .................................................................................................................................100 3.2 GUIDE TO READING THE STATEMENT OF PERFORMANCE EXPECTATIONS ................................100 3.3 PEOPLE ARE SUPPORTED TO TAKE GREATER RESPONSIBILITY FOR THEIR HEALTH ..............101 3.3.1 Fewer People Smoke..................................................................................................................101 3.3.2 Reduction in Vaccine Preventable Diseases .........................................................................102 3.3.3 Improving Health Behaviours ..................................................................................................102 3.4 PEOPLE STAY WELL IN THEIR HOMES AND COMMUNITIES ...........................................................103 3.4.1 An Improvement in Childhood Oral Health ...........................................................................103 3.4.2 Long-Term Conditions are Detected Early and Managed Well ..........................................103 3.4.3 Fewer People are admitted to Hospital for Avoidable Conditions ...................................104 3.4.4 More People Maintain their Functional Independence ......................................................105 3.5 PEOPLE RECEIVE TIMELY AND APPROPRIATE CARE ......................................................................105 3.5.1 People Receive Prompt and Appropriate Acute and Arranged Care ................................105 3.5.2 People Have Appropriate Access to Elective Services .........................................................106 3.5.3 Improved Health Status for those with Severe Mental Illness and/or Addictions ........107 3.5.4 More People With End Stage Conditions are Supported Appropriately ..........................107 3.6 SUPPORT SERVICES ..............................................................................................................................108 MODULE 4: FINANCIAL PERFORMANCE ..................................................................................................... 110 4.1 KEY POINTS FROM THE BUDGETED FINANCIALS 2014-18.............................................................111 4.2 KEY RISKS ..............................................................................................................................................112 4.2.1 Taranaki DHB’s Funder Operations .......................................................................................112 4.2.2 Taranaki DHB’s Hospital Provider Operations ....................................................................113 4.3 KEY FINANCIAL ASSUMPTIONS ..........................................................................................................114 4.3.1 Application of New Zealand Equivalents to International Financial Reporting Standards (NZ IFRS) ....................................................................................................................................114 4 4.3.2 4.3.3 Equity and Borrowing ...............................................................................................................114 Operating Expenditure assumptions: ....................................................................................115 4.4 TDHB FUNDER – “RING FENCE PRINCIPLE” AND APPLICATION OF SURPLUS/DEFICITS ...........115 4.4.1 Mental Health Services ..............................................................................................................115 4.4.2 Interest Rates ..............................................................................................................................115 4.4.3 Asset Revaluation and its Impact ............................................................................................116 4.4.4 Depreciation ................................................................................................................................116 4.4.5 Capital Charge .............................................................................................................................116 4.4.6 Leasing..........................................................................................................................................116 4.4.7 Financial Covenants and Ratios ...............................................................................................117 4.4.8 Changes in Accounting Policies ...............................................................................................117 4.4.9 Capital Investment .....................................................................................................................117 4.4.10 Capital Divestment .....................................................................................................................118 4.4.11 Personnel .....................................................................................................................................118 4.5 CAPITAL EXPENDITURE 2014/15 (STRATEGIC) ..............................................................................119 4.5.1 Base Hospital Inpatient Facilities Development Programme ...........................................119 4.6 COST AND EFFICIENCY INITIATIVES ..................................................................................................120 4.7 DEBT AND EQUITY ...............................................................................................................................121 4.8 SENSITIVITY ANALYSIS: PLAN 2014/15 ............................................................................................122 4.9 STATEMENT OF COMPREHENSIVE INCOME ......................................................................................123 4.10 CONSOLIDATED STATEMENT OF FINANCIAL POSITION .................................................................125 4.11 CONSOLIDATED STATEMENT OF CASHFLOWS .................................................................................126 4.12 CONSOLIDATED STATEMENT OF MOVEMENT IN EQUITY ..............................................................127 MODULE 5: STEWARDSHIP.......................................................................................................................... 130 5.1 MANAGING OUR BUSINESS ..................................................................................................................130 5.1.1 Our People ...................................................................................................................................130 5.1.2 Organisational Performance Management ...........................................................................130 5.1.3 Funding and Financial Management ......................................................................................131 5.1.4 National Health Sector Agencies .............................................................................................132 5.1.5 Risk Management .......................................................................................................................132 5.1.6 Performance and Management of Assets...............................................................................132 5.1.7 Shared Decision-making ...........................................................................................................133 5.2 BUILDING CAPABILITY ........................................................................................................................134 5.2.1 HealthShare Limited ..................................................................................................................134 5.2.2 Information Communications Technology ............................................................................136 5.2.3 Integrated Contracting ..............................................................................................................136 5.2.4 Capital and Infrastructure Development ...............................................................................136 5.2.5 Collaboration ..............................................................................................................................137 5.2.6 Long Term Demand Forecasting .............................................................................................138 5.3 WORKFORCE .........................................................................................................................................139 5.3.1 Managing Our Workforce within Fiscal Restraints ...................................................................139 5.3.2 Strengthening Our Workforce .......................................................................................................139 5.3.3 Safe and Competent Workforce .....................................................................................................141 5.3.4 Child Protection Policies .................................................................................................................142 5.3.5 Children’s Worker Safety Checking ...............................................................................................142 5.4 ORGANISATIONAL HEALTH .................................................................................................................143 5.4.2 Providing Health and Disability Services ..............................................................................143 5.4.3 Planning and Funding Health and Disability Services ........................................................144 5.5 REPORTING AND CONSULTATION......................................................................................................145 5.5.1 Consultation with the Minister and the Ministry of Health ................................................145 5.5.2 External Reporting .....................................................................................................................146 5 MODULE 6: SERVICE CONFIGURATION ...................................................................................................... 148 6.1 SERVICE COVERAGE .............................................................................................................................148 6.2 SERVICE CHANGE ..................................................................................................................................148 6.3 SERVICE ISSUES ....................................................................................................................................148 MODULE 7: NON-FINANCIAL PERFORMANCE MEASURES ........................................................................ 152 MODULE 8: APPENDICES.............................................................................................................................. 158 8.1 GLOSSARY OF TERMS ...........................................................................................................................158 8.2 OUTPUT CLASS DEFINITIONS .............................................................................................................162 8.3 OUTPUT CLASS REVENUE AND EXPENDITURE .................................................................................168 8.4 OUTPUT MEASURE RATIONALE .........................................................................................................169 6 EXECUTIVE SUMMARY The Taranaki District Health Board is ready to meet the significant challenges of 2014/15 onwards. We remain focused upon improving performance, meeting national health targets, living within our means and ensuring access to high quality services for the people of Taranaki. Our plans and activities for 2014/15 concentrate on supporting service integration and achieving greater efficiency across all health care providers. Planning involves using a range of information, (demographic, long-term demand projections and epidemiological information) to help us determine the needs of our population over the three years and beyond, and to inform the planning and development of the services that will best meet those needs. DHBs rely heavily on census data to support the planning function, and so the timing of the release of this data (mid April 2014) has impacted on some of the information contained in this planning document and our ability to show the most up to date data at this point in time. A driving priority for Taranaki DHB is the health of Maori. We must improve health outcomes and reduce disparity by addressing priority needs first. We will continue to advance service integration between the services delivered by the DHB and services delivered by our key primary care partners the Te Kawau Maro Strategic Alliance and the Midland Health Network. Our PHO partners have jointly developed and agreed with all the relevant sections of this plan as it relates to their service delivery. The health environment is constantly changing. New technologies, changes in models of care, work practices, clinical practice, a changing demographic (particularly an ageing population) and increases in demand and community expectations require our health care system to be both adaptable and responsive. If we are to respond to change there will need to be developments in the way we support new models of service delivery, including information systems, embedding the benefits of recent facility redesign, and workforce capacity. Underpinning change these must always be a commitment to provision of quality in health care delivery, and of course to sustainability. To this end we support the New Zealand Triple Aim: A greater emphasis on care in the community will see more support for those with long term conditions, a greater emphasis on self-care, primary options to deliver short term acute care in the community, and better use of our valued health professionals who work within the community. 7 Already a new community pharmacy model has capitalised on the clinical expertise of our pharmacists in the area of medicines adherence for those with long term conditions. This Annual Plan is supported by a Maori Health Plan, in line with Te Kawau Maro (Taranaki Maori Health Strategy), developed together with the Maori Health Sector and Te Whare Punanga Korero, our Iwi relationship board. The Plan has been informed by the 2012 Whānau Ora Health Needs Assessment on Maori living in Taranaki. It sets challenging and practical steps to be taken in the years ahead to improve the health status of Taranaki Maori. All of this work will be done sensitively, with the benefit of working together with others as we treat people with trust, respect and compassion – as we continue to strive for Taranaki Together, a Healthy Community – Taranaki Whanui He Rohe Oranga. 8 MINISTER’S LETTER OF APPROVAL 9 10 11 12 13 MODULE 1: INTRODUCTION AND STRATEGIC INTENTIONS 1.1 CONTEXT Taranaki DHB was established on 1 January 2001 by the New Zealand Public Health and Disability Act 2000 (NZPHD) and is one of 20 DHBs in New Zealand. DHBs were established as vehicles for the public funding and provision of personal health services, public health services and disability support services for a geographically defined population. Each DHB is a Crown Entity and is accountable to the Minister of Health. This Plan sets out the activities we will undertake in terms of national, regional and local priorities. It describes to Parliament and to the New Zealand public what we intend to achieve in 2014/15, to improve the health of the Taranaki DHB population and to reduce or eliminate health inequalities. We are part of the Midland DHB region, and have worked together to improve regional consistency across our plans. This collaboration is reflected throughout this Plan. We receive funding from Government to undertake our role. The amount of funding is determined by the size of our population, as well as the population’s age, gender, ethnicity and socio-economic status characteristics. We are both a funder and provider of health services. In 2014/15 the Funder has a planned expenditure of $309,753,347 in order to pay for services to improve the health of our community. This includes most personal health (services to improve the health of individuals), mental health and addictions, Maori health and health of older people services for the Taranaki DHB population. The Hospital and Specialist Services, our Provider division (which includes Governance costs), will receive approximately $161,686,344 (52.2%) of this funding with $111,523,999 (36.0%) being utilised to fund services including those provided by non-government organisations (NGOs), primary care, pharmacy and laboratories. The remaining $36,518,532 (11.8%) is allocated to fund services that are provided by other DHBs on behalf of Taranaki (inter-District Flows). The Ministry of Health and National Health Board also have a role in the planning and funding of some services. Some services are funded and contracted nationally, for example public health services, breast and cervical screening as well as the provision of disability support services for people aged less than 65 years. We are socially responsible and uphold the ethical and quality standards commonly expected of providers of services and public sector organisations. We are responsible for monitoring and evaluating service delivery, including audits of the services we fund. The costs of providing services to people living outside of our district are met by the DHB of the patient and are referred to as ‘inter-district’ services or Inter-District Flows (IDFs). Likewise, where we do not provide the service, we have funding arrangements in place enabling our district residents to travel outside the district. We also deliver against service delivery contracts with external funders, such as the Accident Compensation Commission (ACC). We closely monitor IDFs and ACC volumes to ensure our ability to provide for our own population is not adversely affected by demand from outside the district. In order to achieve the planned outputs, impacts and outcomes as outlined in this Annual Plan, we may, pursuant to section 25 of the New Zealand Public Health and Disability Act 2000, negotiate and enter into, or vary any current agreement for the provision or procurement of any health and disability support service. These agreements (or variations) may contain any terms or conditions acceptable to the DHB. 14 1.2 PERFORMANCE STORY The diagrams presented on the following pages provide a high level summary of our performance story and demonstrate the link between our outcomes and our stewardship areas. The right hand column of the diagram indicates the relevant module of this Plan for further details. The outputs section of the service performance diagram contains examples of measures contained in Module Three. Diagram: Our Performance Story All New Zealanders lead longer, healthier and more independent lives The health system is cost effective and supports a productive economy Module 1 Overarching Health & Health Sector Disability Goals System Outcomes National Performance Story Better, Sooner, More Convenient Health Services for all New Zealanders Regional Midland Strategic Outcomes Objectives All residents of Midland District Health Boards lead longer, healthier and more independent lives To improve the health of our population To build the workforce Systems integration across the continuum of care Module 1 Midland Vision Midland DHBs’ Regional Performance Story To reduce or eliminate health inequalities To improve quality access across agreed regional services To improve clinical information systems To improve Maori health outcomes By focusing on these objectives we will be able to drive change that enables us to live within our means 15 Our Outcomes To improve the health of our population Health Targets To reduce or eliminate health inequalities Maori Health/Disparities greater responsibility for their Health of Older People Primary Health People stay well in their homes People receive timely and and communities appropriate care health An improvement in Intermediate Impacts Fewer people smoke Reduction in vaccine preventable diseases Improving health arranged care detected early and managed well behaviours People have appropriate access to elective services Improved health status for Fewer people are people with a severe admitted to hospital for mental health illness avoidable conditions More people maintain their and/or addiction functional independence More people with endstage conditions are appropriately supported are seen by a health dental services practitioner in public hospitals are offered brief enrolled with a PHO Percentage of rest home advice and support to quit residents receiving vitamin smoking D supplement from their Percentage of eight GP months olds who will have Percentage of population Percentage of older their primary course of people receiving long-term immunisation on time home support who have Number of people referred had a comprehensive to the Green Prescription clinical assessment and a programmes completed care plan in the Acute re-admission rate Elective and arranged day surgery rate Improving the percentage of long-term clients with up Module 2 Percentage of children (04) enrolled in DHB funded Percentage of hospitalised patients who smoke and Outputs Long-term conditions are People receive prompt and appropriate acute and childhood oral health Wellness/Chronic Conditions Module 1 People are supported to take Long Term Impacts Our Strategic Priorities Vision: Taranaki Together, a healthy Community – Taranaki Whanui He Rohe Oranga Mission: Improving Promoting, Protecting and caring for the health and wellbeing of the people of Taranaki Module 1 Our Vision and Mission Taranaki DHBs Performance Story to date relapse prevention/treatment plans last 12 months 16 Output Classes Intensive treatment and Rehabilitation and support Services management services assessment services Workforce 1.3 Performance Management Collaboration/Partnerships Information Module 5 Stewardship Early detection and Module 3 Prevention NATIONAL OPERATING ENVIRONMENT The Minister of Health with Cabinet and the Government develops policy for the health and disability sector. The Minister is supported by the Ministry of Health and its business units, advised by the Ministry, the National Health Board, Health Workforce New Zealand, the National Health Committee and other Ministerial Advisory Committees. Accident services are funded by the Accident Compensation Corporation (ACC). Health and Disability Services in New Zealand are delivered by a complex network of organisations and people. Each has their role in working with others across the system to achieve better, sooner, more convenient services for all New Zealanders. The network of organisations is linked through a series of funding and accountability arrangements to ensure performance and service delivery across the health and disability system. 1.3.1 Treaty of Waitangi The Treaty of Waitangi (Te Tiriti o Waitangi) is New Zealand’s founding constitutional document and is often referred to in overarching strategies and plans throughout all sectors. Taranaki DHB values the importance of the Treaty. Central to the Treaty relationship and implementation of Treaty principles is a shared understanding that health is a ‘taonga’ (treasure). 1.3.2 Health Sector Challenges and Pressures Major, long-term systematic pressures are shaping the way health services will be delivered in the future. These pressures not only impact on New Zealand, but on a majority of health systems across the world, with: A changing population – urban growth, rural decline, increasing diversity, an ageing population and evolving family structure An increasing burden of chronic conditions A reducing rate of funding growth Substantial inequalities in health status persisting Workforce shortages are worsening Multiple new technologies being developed Public expectations rising 17 1.4 REGIONAL OPERATING ENVIRONMENT Taranaki DHB is one of five DHBs that make up the Midland Region. In 2014/15 all five Midland DHBs will continue to progress activities towards regional cooperation in a planned manner. Our region has worked together to develop a Midland DHB Regional Services Plan (RSP) which is available from: www.healthshare.health.nz By actively participating in planning across the Midland DHB Region, we will: 1.5 Reduce duplication of effort Enable the Midland DHBs to collectively develop more sustainable solutions Identify efficiencies Ensure that specialist skills, services and input remain available at a local level LOCAL OPERATING ENVIRONMENT We are responsible for the provision (or funding the provision) of the majority of health services in our district. These services in our district include: 1.5.1 Two hospital sites One mental health inpatient facility Five community bases Six community mental health residential facilities 29 aged related residential care facilities (rest homes) 25 pharmacies 36 GP practices One preferred Maori provider Two primary health organisations Our Geography and Population Our DHB serves a population of 109,608 (from the 2013 Census) and covers a geographic area of 723,610 hectares. It stretches from Mokau River in the north to Waitotara River in the south. Our district takes in the major population centres of New Plymouth and Hawera. A detailed breakdown of our population is presented in the following table 1. Ethnic group (grouped total responses) 1 Taranaki Region usually resident population count- 2013 Census European Māori Pacific Peoples Asian Middle Eastern/Latin American/African 2 Other Ethnicity 3 89,802 18,150 1,701 3,594 447 2,112 86.2% 17.4% 1.6% 3.5% 0.4% 2.0% Source: Statistics New Zealand 1 Includes all people who stated each ethnic group, whether as their only ethnic group or as one of several. Where a person reported more than one ethnic group, they were counted in each applicable group. 2 Middle Eastern, Latin American, and African was introduced as a new category for the 2006 Census. 3 Previously Middle Eastern, Latin American, and African responses were allocated to the 'other ethnicity' category. 18 Table: Taranaki DHB population by age and ethnicity – 2013 Census Age Group Ethnicity Maori Other Total 00 – 24 9,450 26,610 36,060 25 – 44 4,422 22,167 26,589 45 – 64 3,273 25,878 29,151 65 – 74 672 8,925 9,597 75+ 333 7,872 8,205 18,150 91,458 109,608 Total Taranaki DHB Map 19 A large proportion of our population live outside the main urban areas. Our large rural population presents diverse challenges in service delivery and ensuring access to health services. The two main population centres are New Plymouth and Hawera. There are a large number of more rural towns and settlements including Urenui, Waitara, Inglewood, Stratford, Eltham, Opunake, Manaia, Patea and Waverley. Taranaki District Health Board areas reach from Mokau in the north to Waitotara in the south. The geographic boundaries of Taranaki District Health Board cover the council areas of Taranaki Regional Council, New Plymouth District Council, Stratford District Council and South Taranaki District Council. 1.5.2 Health Profile Understanding our health profile plays an important part in our decision making processes. This information helps us focus on where we can make the greatest gains in terms of our strategic outcomes, as well as for planning and prioritisation of programmes at an operational level. Key points of interest in terms of the health profile of the population are: Around 60% of Taranaki population live in NZDEP2006 Decile 6, 7, and 8 compared to 30% nationally. Non-Maori are over-represented in the wealthiest socio-economic deciles and Maori are over-represented in the lowest socio-economic deciles. Within Taranaki, 28% of Maori live in the most deprived 20% of areas compared to 10% of nonMaori. In contrast, 4.2 % of Maori live in 20% of the most affluent areas compared to 12.2% of non-Maori. Maori in Taranaki experience a shorter life expectancy than non-Maori. Based on the 2011/12 HNA1, Maori females have a life expectancy of 75.5 years compared to 82.5 years for nonMaori, a difference of 6.9 years. Based on the 2011/12 HNA Maori males have a life expectancy of 72.4 years compared to 79.0 years for non-Maori, a difference of 6.6 years. This difference is less than that for the general New Zealand population at 7.7 years for females and 7.9 years for males. The leading causes of avoidable mortality in Taranaki DHB for non-Maori are ischaemic heart disease, cerebro-vascular disease and chronic obstructive pulmonary disease (COPD) and lung cancer. For Maori in the Taranaki District, the leading causes of avoidable mortality are ischaemic heart disease, lung cancer, diabetes and chronic obstructive pulmonary disease (COPD). In 2011/12 Taranaki DHB completed a Whānau Ora Health Needs Assessment on the Maori Population in the Taranaki Areas. The following areas were identified as priorities in terms of protective and risk factors and preventative care: smoking, alcohol and drug issues, breastfeeding, immunisation, breast screening and cervical screening. Priority health conditions identified were; diabetes, cardiovascular disease, lung cancer, breast cancer, respiratory disease (i.e. COPD and asthma), oral health, mental health and disability. 1.6 NATURE AND SCOPE OF FUNCTIONS As a DHB we will: Plan in partnership with key stakeholders, the strategic direction for health and disability services Plan regional and national work in collaboration with the National Health Board and other DHBs 1 Taranaki DHB’s Whānau Ora Health Needs Assessment† (Ratima and Jenkins, 2012) 20 Fund the provision of the majority of the public health and disability services in our district, through the agreements we have with providers Provide hospital and specialist services primarily for our population and also for people referred from other DHBs Promote, protect and improve our population’s health and wellbeing through health promotion, health protection, health education and the provision of evidence-based public health initiatives 1.7 STRATEGIC INTENTIONS 1.7.1 Our Vision Our Shared Vision - Te Matakite Taranaki Together, A Healthy Community Taranaki Whanui He Rohe Oranga Our Mission – Te Kaupapa Improving, promoting, protecting and caring for the health and wellbeing of the people of Taranaki Our Aims To promote healthy lifestyles and self-responsibility To have the people and infrastructure to meet changing health needs To have people as healthy as they can be through promotion, prevention, early intervention and rehabilitation To have services that are people-centred and accessible where the health sector works as one To have a multi-agency approach to health To improve the health of Maori and groups with poor health status To lead and support the health and disability sector and provide stability throughout change To make the best use of the resources available Our Values How We Work Together With Others – Ngā Tikanga The actions and behaviours described below are how we aim to contribute to all our relationships including those with our patients, clients, Whānau, funded agencies, staff and members of the public. Therefore, we will work together by: Treating people with trust, respect and compassion Communicating openly, honestly and acting with integrity Enabling professional and organisational standards to be met Supporting achievement and acknowledging successes Creating healthy and safe environments Welcoming new ideas 1.7.2 National Context There are two identified health system outcomes for New Zealand2 as detailed in our performance story diagram. Further detail relating to these outcomes can be found in the Ministry of Health Statement of Intent 2013 to 2016. The outcomes are: 1. New Zealanders live longer, healthier, more independent lives 2. The health system is cost effective and supports a productive economy 2 Sourced from: Statement of Intent 2013 to 2016 – Ministry of Health 21 The Ministry of Health and DHBs are charged with giving effect to the overarching goal for the health sector of Better, Sooner, More Convenient Health Services for all New Zealanders. 1.7.2.1 Minister’s Letter of Expectations The Minister of Health has outlined his expectations for the 2014/15 year, which enables us to plan and prioritise activity for the year. The expectations reinforce the Government’s commitment to a public health system that delivers better, sooner, more convenient health services to all New Zealanders within constrained funding increases. The areas of priority focus are: Better Public Services: Results for New Zealanders Of the Prime Minister’s 10 whole-of-government key result areas, DHBs are expected to actively engage and invest in increased infant immunisation, reduced incidence of rheumatic fever, and reduced assaults on children. National Health Targets We acknowledge the national health targets have proven very successful at driving major improvements for patients: more elective surgery, faster access to emergency and cancer care, and better prevention. How we will continue to achieve national health targets is a focus in this Annual Plan. The Minister expects that we will undertake particular work to achieve the three preventive targets, demonstrating appropriate performance management arrangements for PHOs. We will help patients by meeting our objectives of shorter waiting times for surgery, diagnostics, cardiac and cancer care as per the Minister’s expectations. Care Closer to Home Taranaki DHB will focus on clinical integration – providing joined-up care across primary and secondary services to ensure patients get their care sooner and closer to home. We will continue to focus strongly on service integration across the health system, primary care direct referral for diagnostics, clinical pathways (Map of Medicine) and will look at ways to promote the sharing of patient controlled health records. Health of Older People Our DHB will continue working with primary and community care to deliver integrated services for older people to support their continued safe, independent living at home. Avoiding a hospital admission and care after a hospital discharge are key focus areas. Regional and National Collaboration Progress will continue to implement Regional Service Plans including workforce, IT and capital objectives. We acknowledge and support the implementation of the key Health Benefits Ltd savings programmes. Further gains in quality, efficiency and cost control will also come from our work with Pharmac, Health Workforce NZ and the Health Quality and Safety Commission. Strong clinical leadership and engagement is important and remains essential. Living within Our Means The Minister expects that to support New Zealand’s recovery, Taranaki DHB must keep to budget. We must have detailed and effective plans to improve financial performance year on year. Equity and capital remain constrained. As agents of the Crown Taranaki DHB supported by its Board must have in place the appropriate clinical and executive leadership to deliver on the Government’s objectives. Our Board will monitor and hold our CE accountable against these expectations. 22 1.7.2.2 Nation-Wide Health Targets Improving performance across the sector is fundamental to the goal of Better, Sooner, More Convenient Health Services for all New Zealanders. One of the mechanisms used to monitor our performance is the nation-wide health targets. The following table outlines our target levels for each of the six health targets. Table: Taranaki DHB Health Targets 2014/15 Health Target Long Term Target Taranaki DHB Target 95 per cent of patients will be admitted, discharged, or transferred from an Emergency Department (ED) within six hours. 95 per cent The volume of elective surgery will be increased nationally by at least 4,000 discharges per year. 4,369 total elective surgical All patients ready for treatment, wait less than four weeks for radiotherapy or chemotherapy. 100 per cent discharges The 62-day Faster Cancer Treatment (FCT) indicator will become the next cancer Health target during 2014/15. 85 percent of patients referred with a high suspicion of cancer wait 62 days or less to receive their first treatment (or other management) to be achieved by July 2016) 95 per cent of eight months olds will have their primary course of immunisation (six weeks, three months and five months immunisation events) on time. Total 95 per cent 95 per cent of patients who smoke and are seen by a health practitioner in public hospitals and Total 95 per cent 90 per cent of enrolled patients who smoke and are seen by a health practitioner in primary care are offered brief advice and support to quit smoking. Total 90 per cent Total 90 per cent Within the target a specialised identified group will include: Progress towards 90 percent of pregnant women who identify as smokers at the time of confirmation of pregnancy in general practice or booking with Lead Maternity Carer are offered advice and support to quit. 90 percent of the eligible population will have had their cardiovascular risk assessed in the last five years. 23 1.7.2.3 Better Public Services (including Social Sector Trials) New Zealand's State Sector, (which includes DHBs), faces increasing expectations for better public services in the context of prolonged financial constraints compounded by the global financial crisis. The key to doing more with less lies in productivity, innovation, and increased agility to provide services. Agencies need to change, develop new business models, work more closely with others and harness new technologies in order to meet emerging challenges. The area that health is taking a major role in is the results around supporting vulnerable children3, which are: Result 2: Result 3: Result 4: Increase participation in early childhood education Increase infant immunisation rates and reduce the incidence of rheumatic fever Reduce the number of assaults on children The Social Sector Trials (SSTs) involve Education, Health, Justice and Social Development, and the New Zealand Police working together to change the way that social services are delivered4. They test what happens when a local organisation or individual directs cross-agency resources, as well as local organisations and government agencies to deliver collaborative social services. There is one SST in our district in South Taranaki. The Social Sector Trial in South Taranaki covers five distinct community areas, Hawera, Patea, Manaia, Eltham and Opunake all with quite different needs. Health, Justice, Ministry of Social Development, Education and Police are collectively working together in the region to: Reduce offending Reduce truancy Reduce young people’s use of alcohol and other drugs Increase the number of young people in education, training and employment; and Support co-ordination and collaboration and community. Taranaki DHB will continue to offer workforce development and training opportunities to our agency partner’s which provides consistency in tools being used in the community. Health is also working closely with the schools in South Taranaki and in 2014/15 in schools we will provide additional clinical psychology support and Alcohol and Drug group work and one on one intervention. Health will also be an active part of the truancy forums and actively working with the five communities and iwi be more responsive to specific needs of the distinct communities. 1.7.2.4 Non-financial Monitoring Framework Another mechanism used to monitor performance is the DHB non-financial monitoring framework. It is a key tool to provide assurance that DHBs deliver5 in terms of the legislative requirements, and in terms of Government priorities. A summary of the monitoring framework, including our targets (where appropriate) has been included in Module 7 of the Annual Plan. 1.7.3 Regional Context The Midland DHBs have produced an RSP, which describes the strategic intent for the Midland DHB Region. The strategic outcomes and objectives for the region are outlined in our performance story diagram (see section 1.2) and further information is provided in the Midland DHBs Regional Services Plan 2014/15. 3 4 5 For further information please see http://www.ssc.govt.nz/bps-supporting-vulnerable-children For further information please see http://www.msd.govt.nz/about-msd-and-our-work/work-programmes/initiatives/social-sector-trials/ “to the extent they are reasonably achievable within the funds provided” (NZPH&D Act 2000 S3(2) 24 Our DHB is committed to being an active participant in our regional planning process. This is evidenced by both clinical and management representatives from our DHB being part of the various forums and networks that have been established to guide RSP implementation activities as well as directly funding regional work and positions. HealthShare6 is tasked with co-ordinating the delivery of regional planning and implementation on behalf of the Midland DHB region. 1.7.4 Local Context To contribute to achieving the outcomes at a national and regional level, we have identified our local strategic intent for 2014/15. Our strategic intent represents a continuation from previous years, as the challenges we face are not short term issues easily resolved within a 12 month period. Our local strategic outcomes listed below align directly to the regional strategic outcomes outlined in the Regional services Plan (RSP). 1. To improve the health of the Taranaki DHB population 2. To reduce or eliminate health inequalities Strategic Priority Maori Health/Disparities Description Improving Maori health and enabling a Whānau Ora approach to the health and welling being of Maori living in Taranaki, are priorities for the Taranaki DHB. Understanding of the implications of the Whānau Ora Health Needs Assessment was considered necessary in order to determine the priority areas for service planning for Maori. This in turn will lead to improved health outcomes and reduced inequalities in health. Meeting and maintaining Health Taranaki DHB is committed to meeting the Health Targets. Targets Improving our performance requires a ‘whole of system’ approach with a combination of focused attention, clinical leadership and system integration. Financial Performance Ensuring delivery on agreed financial forecasts and the ability to live within our means, while delivering national, regional and local initiatives. Mama Pepi Tamariki This is a focus on all children having the best start in life. Delivering on the Children’s Action Plan, Health Beginnings and the Well Child Tamariki Ora Quality Improvement Framework are a priority for Taranaki DHB. The approach involves working closely with our agency partners, recognising the important contribution and accountability all agencies have in improving outcomes for all Taranaki children. Youth We will continue to implement the Taranaki Taiohi Health Strategy, Prime Ministers Youth Mental Health Project objectives and use the Social Sector Trial site as the platform to do things differently for Taranaki Taiohi. Health of Older Persons We will continue working with primary and community care to deliver integrated services for older people to support their continued safe, independent living at home. Particularly important are avoiding hospital admission and care after a hospital discharge. 6 Further detail on HealthShare is presented in Section 5.2 25 We are also working with the Ministry to implement our commitment to improving home care, stroke services and dementia care pathways. Mental Health We will continue with the redesign of the Mental Health and Addictions Services with an emphasis on achieving and aligning to align to the objectives of the Service Development Plan, Rising to the Challenge. The sector recognises the importance of robust early intervention strategies to maintain wellness for those experiencing Mental Health and Addictions issues. Service development takes into consideration a whole of life and whole of system approach. We also see our Primary Care partners as important for service integration. Work in this area will focus on Perinatal, Infant and children. Service Integration and redesign This will involve many stakeholders working together to of non-acute services redesign the Taranaki Integrated Health System. A key to this will be the collective effort of local providers and communities, together with lessons from elsewhere developing new ways and potentially new locations for services to be delivered within the resources available. The local priorities have been included in our overall performance story to ensure items important to us that are not explicitly covered in the regional strategic intent are included within this Annual Plan. 1.8 KEY RISKS AND OPPORTUNITIES By its nature, the health sector is complex and challenging. We have identified the following risks and opportunities as being particularly relevant for 2014/15. 1.8.1 Health Inequalities We are committed to reducing or eliminating the effects of health disparities through, firstly, identifying them and, secondly, through funding and providing universal programmes which include a focus on reducing disparities as well as specific programmes that target disparities and improve access to services. It should be noted that long term conditions, particularly those that are exacerbated by tobacco use, and maternal smoking (particularly in the third trimester) are significant contributors to health disparity. A challenge for DHBs in this region is to configure health service delivery in a way that takes account of the complex relationships between the key social determinants of health inequalities (e.g. housing quality and employment), while recognising that a number of public and private agencies influence health outcomes. The approach we intend to take includes: Implementing Te Matakite 2014/15 (our Māori Health Plan) Promoting screening services to hard to reach groups to increase early detection of disease Implementing services that target communities with identified health inequalities Setting targets by ethnicity or by high needs Supporting kaupapa Māori services where appropriate Increasing the capability of the Māori and Pacific workforce across our district Using an equity lens as part of decision-making processes Engaging with our Disability Support Advisory Committee to provide advice and inform decision making Engaging with Iwi Governance bodies to provide advice and inform decision making Engaging with community health forums and expert advisory groups to provide and receive advice – this will include alliance mechanisms and Service Level Alliance Teams (ALTs) representing community/primary/DHB perspectives. 26 1.8.2 Living Within Our Means The ongoing pressure of the financial environment is driving a need to improve efficiency, reduce waste and improve healthcare. This, together with the Government’s goal of returning to surplus in 2014/15 has created a strong focus on improving fiscal management. 1.8.3 Health System Workforce Shortages Workforce shortages, particularly in rural and provincial areas, are a key threat to the health system’s ability to provide a full range of accessible, high-quality health services. Between 2001 and 2021 there is a projected to be a 47 percent increase in demand for registered health professionals in New Zealand; over the same period it is anticipated that there will be a 12 percent projected increase in supply7. We will work to strengthen the Taranaki health workforce through collaboration with: Health Workforce New Zealand Midland Regional Training Network Local partners, e.g. Western Institute of Technology, the Whakatipuranga Rima Rau Trust and other Government agencies 1.8.4 System Integration A growing commitment to the achievement of more effective system integration in partnership with primary care and other appropriate stakeholders is fundamental to strengthening our healthcare system. We will use clinical leadership to drive improved system integration and Better Public Services. Evidence shows that integrating primary care with other parts of the health system is vital for better management of long term conditions, responding to the pressure of an ageing population and in managing acute demand. Hospital demand is growing at a rapid rate, and as more hospital admissions occur due to preventable causes, we need to examine what could be improved in regard to how we deliver our services. Alliance Leadership Teams and Service Level Alliance Teams have a key role to play in the development of the 2014/15 DHB Annual Plans for Primary Care (including Rural Health) and Youth Health. 1.8.5 Regional Integration Integration between regional DHBs is important for both financial and clinical reasons. Clinical Networks provide a platform from which to deliver clinically-led innovation and best practice approaches, and these are supported by integration initiatives in other areas (pharmacy, home-based support services, information systems and so on). The over-arching driver for such developments is improved service quality, and ultimately better health outcomes. The Midlands DHBs have also articulated the services and activities intended to be addressed through the Regional Services Plan (RSP). 1.9 KEY MEASURES OF PERFORMANCE The following outcomes and impacts described below set out what we expect to see occurring in response to the outputs we deliver over time. Local actions in relation to our services are recorded, along with deliverables and timing, in Module 1 (Strategic Intentions - priorities and targets), Module 3 (Statement of Performance Expectations) and Module 5 (Stewardship) of this Plan. 1.9.1 Outcome 1 – People are Supported to Take Greater Responsibility for their Health Expectation Population health and prevention programmes ensure people are better protected from harm, more informed of the signs and symptoms of ill health and supported to reduce risk behaviours and modify lifestyles in order to maintain good health. These programmes create health-promoting physical and social environments which support people to take more responsibility for their own health and make healthier choices. 7 Source: Trends in Service Design and New Models of Care: A Review, Ministry of Health 2010 27 Why is this outcome a priority? New Zealand is experiencing a growing prevalence of long-term conditions such as diabetes and cardiovascular disease, which are major causes of poor health and account for a significant number of presentations in primary care and admissions to hospital and specialist services. We are more likely to develop long-term conditions as we age, and with an ageing population, the burden of long-term conditions will increase. The World Health Organisation (WHO) estimates more than 70 percent of all health funding is spent on long-term conditions. Figure 1 - Percentage of Year 10 high school students how have indicated they have never smoked, not even a puff in the annual ASH survey. ASH New Zealand 2013. Report for the Ministry of Health, Health Sponsorship Council and Action on Smoking and Health: Auckland, New Zealand. Tobacco smoking, inactivity, poor nutrition and rising obesity rates are major and common contributors to a number of the most prevalent long-term conditions. These are avoidable risk factors, preventable through a supportive environment, improved awareness and personal responsibility for health and wellbeing. Supporting people to make healthy choices will enable our population to attain a higher quality of life and to avoid, delay or reduce the impact of long-term conditions. 1.9.1.1 Fewer People Smoke Why is this important? Smoking is a major contributor to preventable illness and long term conditions, such as cancer, respiratory disease, heart disease and strokes. Cancer is the leading cause of death in New Zealand (29.8 percent), and is a major cause of hospitalisation and driver of cost. Cancer also highlights continuing inequalities, with Maori experiencing a higher incidence (20 percent +), higher mortality and higher stage at presentation. In some communities, a sizeable portion of household income is spent on tobacco, resulting in less money being available for necessities such as nutrition, education and health. Supporting our population to say “no” to tobacco smoking is our foremost opportunity to target improvements in the health of our population and to reduce health inequalities for Maori. Key findings from the 2009 NZ Tobacco Use Survey identify that one in five adults aged 15-64 years (21 percent) and around one in five (18 percent) youth aged 15-19 years are current smokers. While nationally, we are seeing a decline in smoking rates, we want to reduce the incidence even further. Notably, 80 percent of current smokers aged 15-64 years said “they would not smoke if they had their life over again”. How will we know we are succeeding? In order to have the greatest impact, we will prevent people from taking up smoking in the first place (Year 10 students), working our way through the continuum from prevention, to detection (identifying adults who smoke and offering them cessation advice – see Health Targets), and ultimately reducing the number of people who smoke. Fewer People Smoke Percentage of Year 10 Students who have never smoked Actual Target Target Target 2013 2014 2015 2016 73.1% >73.1% Improve 28 1.9.1.2 Reduction in Vaccine Preventable Diseases Why is this important? Immunisation can prevent a number of diseases and is a very cost-effective health intervention. Immunisation provides protection not only for individuals, but for the whole population by reducing the incidence of diseases and preventing them from spreading to vulnerable people or population groups. Population benefits only arise with high immunisation rates, and New Zealand’s current rates are low by international standards and insufficient to prevent or reduce the impact of preventable diseases such as measles or pertussis (whooping cough). These diseases are entirely preventable. See Health Targets. Figure 2 - 3 Year average Crude Rate per 100,000 of vaccine preventable diseases in hospitalised 0-14 year old How will we know we are succeeding? We will know we have succeeded by reducing our admissions for vaccine preventable diseases. Reduction in vaccine preventable diseases Actual Target Target Target 10/11 to 12/13 12/13 to 14/15 13/14 to 15/16 14/15 to 16/17 7.36 <7.36 3 Year average Crude Rate per 100,000 of vaccine preventable diseases in hospitalised 0-14 year old Decrease 1.9.1.3 Improving Health Behaviours Why is this important? Good nutrition is fundamental to health and to the prevention of disease and disability. Nutrition-related risk factors (such as high cholesterol, high blood pressure and obesity) jointly contribute to two out of every five deaths in New Zealand each year. How will we know we are succeeding? By seeing a reduction in obesity, a proxy measure of successful health promotion and engagement and a change in the social and environmental factors that influence people to make healthier choices. Improving health behaviours Figure 3 - 2011/12 New Zealand Health Survey. Note - Obesity is defined as a body mass index (BMI) of 30 or more (calculated by dividing a person’s weight in kilograms by the square of their height in metres). Survey interviewers measured respondents’ height and weight, from which BMI could be calculated. Actual Target % Obese of New Zealand 5 -14 years population 11/12 10.7 2016/17 reduce rate of increase % Obese of New Zealand 15+ years population 27.8 reduce rate of increase 29 1.9.2 Outcome 2 - People Stay Well in Their Homes and Communities Expectation Primary and community services support people to stay well by providing earlier intervention, diagnostics and treatment and better managing their illness or long-term conditions. These services assist people to detect health conditions and risk factors earlier, making treatment and interventions easier and reducing the complications of injury and illness. They also support people to regain their functionality after illness and to remain healthy and independent. Why is this outcome a priority? For most people, their general practice team is their first point of contact with health services. Primary care can deliver services sooner and closer to home and prevent disease through education, screening, early detection and timely provision of treatment. Primary care is also vital as a point of continuity and effective coordination across the continuum of care, particularly in improving the management of care for people with long-term conditions. Supporting primary care are a range of other health professionals including midwives, community nurses, social workers, aged residential care providers, personal health providers and pharmacists. These providers have prevention and early intervention perspectives that link people with other health and social services and support them to stay well. Studies show countries with strong primary and community care systems have lower rates of death from heart disease, cancer and stroke, and achieve better health outcomes for lower cost than countries with systems that focus on specialist level care. With an ageing population, the Midland Region will require a strong base of primary care and community support, including residential care, respite and home-based support. If long-term conditions are managed effectively, crises and deterioration can be reduced and health outcomes improved. Even where returning to full health is not possible, access to responsive, needs-based services helps people to maximise function with the least restriction and dependence. If people are well they need fewer hospital-level or long-stay interventions and, those who do, have a greater chance of returning to a state of good health or slowing the progression of disease. This is not only a better health outcome for our population, but it reduces the rate of acute and unplanned hospital admissions and frees up health resources. 1.9.2.1 Children and Adolescents Have Better Oral Health Why is this important? Good oral health demonstrates early contact with health promotion and prevention services and reduced risk factors, such as poor diet, which has lasting benefits in terms of improved nutrition and healthier body weights. Oral health is also an integral component of lifelong health and impacts a person’s comfort in eating (and ability to maintain good nutrition in old age), selfesteem and quality of life. Maori children are three times more likely to have decayed, missing or filled teeth, and improved oral health is a proxy measure of equity of access and the effectiveness of mainstream services in targeting those most in need. Figure 4 – Diseased, Missing and Filled Teeth (DMFT) for year 8 students in Taranaki DHB, Midland Region and New Zealand. Data Source PLANNING FOR 2013/14 DISTRICT HEALTH BOARDS' ORAL HEALTH PERFORMANCE MEASURES 30 How will we know we are succeeding? With the continued decrease in the DMFT score of year 8 children. Mean Diseased, Missing or Filled Teeth (DMFT) for permanent teeth. DMFT is a count of Diseased, Missing or Filled Teeth in permanent dentition (permanent teeth) in a person’s mouth. By Year 8, children’s teeth should be their permanent teeth and any damage at this stage is life long, so the lower a child’s DMFT, the more likely that their teeth will last a life time. Children and adolescents have better oral health Mean DFMT Year 8 Actual Target Target Target 2012 2014 2015 2016 0.96 <0.96 reduce 1.9.2.2 Long-Term Conditions are Detected Early and Managed Well Why is this important? If we are to empower people to take greater responsibility for their health, to improve the health of our population and if we are to “contain costs” we have a significant opportunity by detecting conditions early. Early detection will lead to either successful treatment, or delaying or reducing the need for secondary and specialist care, enabling more people to stay well in their homes and communities for longer. Our greatest Figure 5 - Female Cervical Cancer mortality in New Zealand 1948 opportunity to do this is to manage to 2010. Ministry of Health. 2013. Cardiovascular Disease (CVD or heart disease). It is one of the largest causes of death in New Zealand, and disproportionately higher for Maori. Often by the time heart problems are detected, the underlying cause of atherosclerosis (arterial disease) is usually well advanced. Our aim is to either prevent the disease by modifying risk factors such as healthy eating, exercise and avoiding smoking, or early detection and management. See also Health Targets. How will we know we are succeeding? Screening is one of the most effective methods to reduce the incidence and impact of some cancers. By catching cancers when they are small screening programmes offer the best chance of success. Also by increasing the proportion of people with well managed diabetes, we will reduce avoidable complications that require hospital-level intervention, such as amputation, kidney failure and blindness, and will improve people’s quality of life, allowing more people to stay well in their homes and communities for longer. Cervical Cancer mortality in New Zealand Aged Standardised rate for NZ Actual Target Target Target 2010 2014 2015 2016 1.7 Decrease 31 1.9.2.3 Fewer People are Admitted to Hospital for Avoidable Conditions Why is this important? There are a number of admissions to hospital for conditions which are seen as avoidable through appropriate early intervention and a reduction in risk factors. As such, these admissions provide an indication of the effectiveness of screening, early intervention and community-based care. A reduction in these admissions will reflect better management and treatment of people across the whole system, will free up hospital resources for more complex and urgent cases and deliver on the Government’s priority of “better, sooner, more convenient” healthcare. Figure 6 – Rate of Ambulatory Sensitive Hospitalisations, Ministry of Health, Ash summary by DHB, Q1 2014 The key factor in reducing avoidable hospital admissions is an improved interface between primary and secondary services. Improving people’s access to, and the effectiveness of, primary care will facilitate early interventions, particularly among Maori and Pacific people, which supports improving our population’s health outcomes and reducing health inequalities for Maori. How will we know we are succeeding? When we reduce the ratio of actual to expected avoidable hospital admissions for our population (Total and Maori)? Fewer people are admitted to hospital for avoidable conditions Taranaki DHB 0-74 year olds Actual Target 2013 2014 1,688 <1,688 Target 2015 Target 2016 decrease 1.9.2.4 People Maintain Functional Independence Why is this important? If we are to deliver on our twin goals of improving health outcomes, and reducing or eliminating health inequalities, for our older population, we aim to support people to maintain functional independence. With an increasing and ageing population, as this cohort increases, so does demand on our constrained funding. Aged Residential Care (ARC) is a specialist, high cost, and scarce resource. We are looking to manage the expected growth in demand, through an ageing population, by improved models of care that support people to remain independent for as long as possible. Figure 7 – Average age at entry to residential care facilities in each of the last 4 years for people under the Health of Older People funding stream. Data sourced from Client Claims Processing System (CCPS). 32 How will we know we are succeeding? Ideally, we would like to promote a model of care that reduces the proportional length of time an older person requires ARC. As we do not currently capture this information, our best proxy indicator is to increase the average age at which an older person enters ARC. Average Age of Entry to Aged Related Residential Care Actual Target Target Target 12/13 14/15 15/16 16/17 Rest Home 84.04 Increase Dementia 82.50 Increase Hospital 84.07 Increase 1.9.3 Outcome 3 - People Receive Timely and Appropriate Specialist Care Expectation Secondary-level hospital and specialist services meet people’s complex health needs, are responsive to episodic events and support community-based care providers. By providing appropriate and timely access to high quality complex services, people’s health outcomes and quality of life can be improved. Why is this outcome a priority? Clinicians, in cooperation with patients and their families, make decisions with regards to complex treatment and care. Not all decisions result in interventions to prolong life, but may focus on patient care such as pain management or palliative services to improve the quality of life. For those who do need a higher level of intervention, timely access to high quality complex care improves health outcomes by restoring functionality, slowing the progression of illness and disease and improving the quality of life. The timeliness and availability of complex treatment and care is crucial in supporting people to recover from illness and/or maximise their quality of life. Shorter waiting lists and wait times are also indicative of a well-functioning system that matches capacity with demand by managing the flow of patients through services and reducing demand by moving the point of intervention earlier in the path of illness. As providers of hospital and specialist services, DHBs are operating under increasing demand and workforce pressures, and Government is concerned that patients wait too long for diagnostic tests, cancer treatment and elective surgery. The expectations around reducing waiting times, coupled with the current fiscal situation, mean DHBs need to develop innovative ways of treating more people and reducing waiting times with limited resources. This goal reflects the importance of ensuring that hospital and specialist services are sustainable and that the Midland Region has the capacity to provide for the complex needs of its population now and into the future. 1.9.3.1 People Receive Prompt Appropriate Acute Care and Why is this important? Long stays in Emergency Departments (EDs) are linked to overcrowding of the ED, negative clinical outcomes and compromised standards of privacy and dignity for patients. Less time spent waiting and receiving treatment in an ED improves the health services DHBs are able to provide. 33 The duration of stay in ED is influenced by services provided in the community to reduce inappropriate ED presentations, the effectiveness of services provided in ED and the hospital and community services provided following exit from ED. Reduced waiting time in ED is indicative of a coordinated ‘whole of system’ response to the urgent needs of the population. Figure 8 – Emergency Department Waiting times How will we know we are succeeding? When we see an increase in the percentage of people who visit our ED are admitted, discharged or transferred within six hours. Improved performance against this measure will not only improve outcomes for our population, but will improve the public’s confidence in being able to access services when they need to. Percentage of patients admitted, discharged or transferred from emergency departments within 6 hours Actual Target Target Target 12/13 14/15 15/16 16/17 95% >95% >95% >95% 1.9.3.2 People Have Appropriate Access to Elective Services Why is this important? Elective services are an important part of the health system, as they improve a patient’s quality of life by reducing pain or discomfort and improving independence and wellbeing. The Government wants more New Zealanders to have access to elective surgical services (see Health Targets). Improved performance against this measure is also indicative of improved hospital productivity to ensure the most effective use of resources so that wait times can be minimised and year-on-year growth is achieved. How will we know we are succeeding? To meet the appropriate level of access, we want to ensure that our Standard Intervention Rates (SIRs) meet national expectations for elective procedures. Figure 9 – Ministry of Health Year Ended June 2013 Standardised Discharge Rates per 10,000 for Publicly Funded Cardiac Surgery Discharges for patients with 95% Confidence Intervals Actual DHB performance (12/13) Elective service standardised intervention rates (per 10,000) Target 14/15 Target 15/16 Target 16/17 Major joint replacement 20.2 21 Maintain Maintain Cataract procedures 31.4 27 Maintain Maintain Cardiac surgery 7.94 6.5 Maintain Maintain Percutaneous revascularisation 7.82 12.5 Maintain Maintain Coronary angiography services 45.33 34.7 Maintain Maintain 34 1.9.3.3 Improved Access to Mental Health Services Why is this important? It is estimated that at any one time, 20 percent of the New Zealand population will have a mental illness or addiction, and 3 percent are severely affected by mental illness. With high suicide rates in some of our communities, we are working to reduce this rate and support our communities with Whanau Ora initiatives (see Module 3). There is also a high prevalence of depression with the economic downturn and other pressures. The World Health Organisation (WHO) predicts that depression will be the second leading cause of disability by 2020. We have an ageing population, which places increased demand from people over 65 for mental health services appropriate to their life stage. The prevalence of mental illness in the population increases with age, and older people have different patterns of mental illness, often accompanied by loneliness, frailty or physical illness. Figure 10 – Data from PRIMHD showing the percentage of mental health patient admissions who are readmitted to hospital within 28 days of a previous discharge How will we know we are succeeding? Access is the key to improving health status for people with a severe mental illness. Our goal is to build on our existing, and well established intersectoral cooperation between primary / community and secondary services, by offering programmes to individuals and groups from a broad range of ages – children and youth, adults and older people. If we improve access, and providing we provide services to people at the right time, and in the right place, and can expect to see a reduction in our 28 day readmission rate. This will, in turn, assist in reducing pressure on our hospital services. 35 28 day acute re-admission rates Actual Target Target Target 12/13 14/15 15/16 16/17 14% ≤15 % Decrease 1.9.3.4 More People with End-Stage Conditions are Appropriately Supported Why is this important? For people in our population who have end stage conditions, it is important that they, their family and whanau are supported to cope with the situation. Our focus is on ensuring that the patient is able to live comfortably, without undue pain or suffering. Early identification and recognition of end-of-life choices heavily influence the quality of life an individual experiences during the dying process. Rehabilitation and Support Services contribute to this impact. Programmes include palliative care, aged residential care, respite care and home based support services. How will we know we are succeeding? Palliative care is being accessed, but we want to target those with greatest need. The Palliative Care Council has identified inequalities of access to palliative care based on diagnosis (evidence of underutilisation by those with non-malignant conditions), with a lack of suitable service provision for children and young people. We would like to see an increase in palliative support for this group. The Palliative Care Council in its 2010 position statement identified a lack of data on the need for palliative care for New Zealand and monitoring on the implementation New Zealand Palliative Care Strategy. Over the next 12 months we hope to work towards identifying and reporting on an impact measure. 36 37 MODULE 2: DELIVERING ON PRIORITIES AND TARGETS This module presents the actions we are planning to deliver in 2014/15. Implementation of the actions outlined in this plan is expected to enable us to positively contribute to local, regional and national outcomes as well as the goal of Better, Sooner, More Convenient Health Services for all New Zealanders. The actions and measures presented in this module show: How we are implementing Government priorities How we are contributing to the activities in the Midland Region Service Plan How we plan to improve performance in terms of our local priorities Sections of this module have been developed in collaboration with key stakeholders both internal to the health sector and external. This helps us to ensure service planning is not done in silos. The methods we utilise include: An alliancing approach to service planning with our primary care partners Active engagement of clinical leaders / champions Working with other DHBs from the Midland region A collaborative cross-sector approach to working with vulnerable children and their families where information, services, resources are coordinated and shared to improve outcomes Working with NGOs with a view to including them in alliance arrangements in the future Utilising the expertise of community clinicians working across the service continuum with an educative and capacity building focus Expanding implementation of clinical pathways via Map of Medicine across the region to promote regional clinical collaboration and consistency Participating in the social sector trials work streams with cross agency partners The narrative and tables in this module are clustered into the following topics: Health Targets - Shorter Stays in Emergency Departments - Improved Access to Elective Surgery - Shorter Waits for Cancer Treatment (transitioning to Faster Cancer Treatment) - Increased Immunisation - Better Help for Smokers to Quit - More Heart and Diabetes Checks Better Public Health Services (including Social Sector Trials) - Reducing Rheumatic Fever - Prime Minister’s Youth Mental Health Project - Children’s Action Plan - Whānau Ora System Integration - Diabetes and Long Term Conditions - Stroke - Acute Coronary Syndrome - Improved Access to Diagnostics - Faster Cancer Treatment - Cardiac – Secondary Services - Primary Care - Health of Older People - Mental Health Service Development Plan - Maternal and Child Health 38 National Entity Priority Initiatives Improving Quality Actions to Support Regional Delivery of Regional Priorities Living Within Our Means 2.1 HEALTH TARGETS 2.1.1 Shorter Stays in Emergency Departments 2.1.1.1 Our Approach Better Sooner More Convenient Health Services for New Zealanders in relation to Emergency Departments means all New Zealanders can easily access the best services, in a timely way to improve overall health outcomes. A health system that functions well for people with acute care needs is one that: • Delivers and coordinates acute care services in the hospital and community • Improves the public’s confidence in being able to access services when they need to • Sees less time spent waiting and receiving treatment in the ED • Moves patients efficiently between phase of care • Makes the best use of available resources In a constrained system with limited capacity, our approach to managing patient flow becomes even more important. If we are to continue to deliver care, we will need to ensure that our capacity is matched to demand and the right care is delivered rapidly and responsively to reduce the risk of Emergency Department attendance and avoidable hospital admission. Increasing Emergency Department presentations and unplanned (acute) admissions to our hospitals consume resources and place pressure on clinical care, diminishing the effectiveness of hospital activity. Activities that will contribute to achieving our target include: Working with primary care services to reduce demand for unplanned care Integrated and improved long term health conditions care and management across the health system An effective functioning Emergency Department Ensuring hospital flow, reducing gridlock and improving community based discharge services and rehabilitation Also the Midland Regional Trauma System is a clinical programme outlined in our RSP, as a regional activity that links multiple services across the region with a common goal: to provide the best care leading to the best outcomes for trauma patients and their families. 2.1.1.2 Linkages Minister’s Letter of Expectations Health Target – Shorter stays in Emergency Departments Midland DHBs Regional Services Plan 2014/15 Our Performance Story Impact: People receive timely and appropriate specialist care 2.1.1.3 Action Plan Objective Shorter Stays in Emergency Departments: Actions to Deliver Improved Performance Diagnostic/analysis work to identify the main factors impacting on ED length of stay Measure 95% of patients will be admitted, discharged, or transferred from an Emergency Department within six hours. Reporting Quarterly 39 Objective Support the education campaign with Midlands Regional Health Network Charitable Trust (MHN) to ensure only those who need E.D. care present there, and that General Practices and others offer care as appropriate that enables patients to avoid the need to attend ED. Sustainable Services for Unplanned and Acute Care Actions to Deliver Improved Performance TDHB ED will align its quality activities to the ED Quality Framework Measure All mandatory measures will be audited and reported as per guidelines Non-mandatory measures will be included where relevant 95% of patients will be admitted, discharged, or transferred from an Emergency Department within six hours. Senior clinicians and managers continue working in partnership to enhance pathways through the ED Whole of organisation focus, with demonstrable support from senior managers and clinicians. ED Quality framework is utilised to monitor and support ED activity Key activities include: Ongoing diagnostic/analysis of patients with extended length of stay to ensure service development continues. Work collaboratively with MHN to develop across sector processes to manage growth in the ED Focus on non-urgent ED presentations including analysis of why patients are attending the ED for non-emergency reasons Embed the ED CNS service at Taranaki Base Hospital and Hawera Hospital Appropriate resources placed on the most significant bottlenecks and constraints identified in the diagnostic analysis work Actions spanning the whole system – pre ED, within the ED, and post-ED Whole of organisation focus, with demonstrable support from senior managers and clinicians Funding has been allocated to enhance access to GP service for under sixes after hours Quality measures established and reported against as per the ED Quality Framework Reduced rate of admissions Number of patients seen and discharged by ED CNS Service – create baseline PHOs to report annual utilisation of services provided to under sixes after hours to measure effectiveness in reducing demand for ED services Implemented by 1 December 2014 Quarterly Reports showing a reduction in Primary Health Care ED presentations in both Hawera and New Plymouth Midlands Health Network and the Taranaki DHB will implement a programme to manage overflow at ED across Taranaki. This will include implementation of Primary Options in Taranaki Reporting Quarterly Performance against the health target Quarterly Performance against the health target Quarterly reporting re progress on specific actions Quarterly Quarterly 40 2.1.2 Improved Access to Elective Services Better Sooner More Convenient Health Services in relation to electives means improved and timelier access to elective services for our population. There is an increasing demand for elective services. It is important for wellbeing of our population that we meet as much of this elective demand as possible, ensure our population receives equitable access to services and minimises the demand for unplanned (acute) care. 2.1.2.1 Our Approach Managing patient length of stay is important to sustaining our elective service in terms of capacity. It is also important for good patient health outcomes; high length of stay is a quality issue and usually linked to high surgical infection rates. Reducing length of stay is critical to providing an efficient optimal use of our health budget. We are working regionally with other Midland DHBs and moving towards greater integration of each DHBs elective services. Purchasing appropriate regional volumes will allow sustainable service improvement. Service improvement will be supported by regional referral pathways, clinical networks and consistently applied access criteria. 2.1.2.2 Linkages Minister’s Letter of Expectation Health Target – Improved Access to Elective Services Midland DHBs Regional Services Plan 2014/15 Our Performance Story Impact: People receive timely and appropriate specialist care 2.1.2.3 Action Plan Objective Improved Access Elective Surgery to Actions to Deliver Improved Performance Delivery against TDHB agreed volume schedule, including elective surgical discharges, to deliver the Electives Health Target Electives funding will be allocated to support increased levels of elective surgery, specialist assessment, diagnostics, and alternative models of care Standardised intervention rates and/or other mechanisms (such as demand analysis) will be used to assess areas of need for improved equity of access Patient flow management will be improved to achieve further reductions in waiting times for electives. No patient will wait longer than five months during 2014, and waiting times are reduced to a maximum of four months by the end of December 2014 Measure Reporting Delivery against agreed volume schedule, including a minimum of 4,369 elective surgical discharges in 2014/15 towards the Electives Health Target (will be provided in electives funding advice) Quarterly reporting Reported against non-financial reporting to MoH (Please see SI4): Elective services standardised intervention rates Quarterly reporting Elective Services Patient Flow Indicators expectations are met, and all patients wait four months or less for first specialist assessment and treatment from January 2015 Quarterly reporting 41 Objective Actions to Deliver Improved Performance Implementation of the National Patient Flow Project, Phase One completed December 2014 Actions to support improvements in electives access, quality of care, patient flow management, or that maximise available capacity and resources: o Design of Enhanced Recovery (ERAS) Pathway for orthopaedic patients admitted with fracture Neck Of Femurs (NOF) o Maintenance, development and audit of standards with existing ERAS pathways for elective orthopaedic hip and knee joint replacement patients and for patients having colorectal surgery o Development of a perioperative anaemia pathway o Design and implementation of demand and capacity management tools for planning of patient bookings o Production plans in place for all surgical specialties Participate in regional planning with regard to Elective Surgery delivery ensuring equity of access across the region Patients will be prioritised for treatment using national, or nationally recognised, tools, and treatment will be in accordance with assigned priority and waiting time Regional Alignment: TDHB will participate in regional activities that support the delivery of elective services across the Midlands region. The three regional focus areas for elective services are: Chronic Pain, Increasing endoscopy and Ophthalmology Measure Patient level data for referrals for FSA are reporting into new collection See Non-financial reporting framework - Ownership Dimension performance measures for Inpatient Length of Stay (OS3) Reporting Quarterly reporting Average time to theatre for appropriate orthopaedic patients with fracture NOF will be less than 36 hours by January 2015 Average length of stay for elective hip and knee procedures will be reduced to four days by January 2015 Reduced transfusion rates for patients who would have previously had them for anaemia management – baseline to be established Tools in place by December 2014 In place by December 2014 Increased uptake of latest national CPAC tools to improve consistency in prioritisation decisions Quarterly reporting Implementation of National Scoring tool for ORL by December 2014 Implementation of National Scoring Tool for Gynaecology by December 2014 Increase endoscopy capacity to reduce waiting times as per Ministry of Health guidelines by June 2015. Continue with introduction of GRS tools to enhance productivity and quality measures Quarterly reporting Quarterly reporting 42 2.1.3 Shorter Waits for Cancer Treatment / Transitioning to Faster Cancer Treatment Better Sooner More Convenient Health Services for New Zealanders in relation to cancer means all New Zealanders can easily access the best services, in a timely way to improve overall cancer outcomes. Cancer is the country’s leading cause of death (29 per cent) and a major cause of hospitalisation. Most New Zealanders will have some experience of cancer, either personally or through a relative or friend. The incidence of cancer is 20 percent higher for Maori than for non-Maori, but cancer mortality is nearly 80 percent higher for Maori. Maori are also more likely than non-Maori to have their cancer detected at a later stage of disease spread. Residents of more socioeconomically deprived areas are more likely to develop cancer, less likely to have their cancer detected early, and have poorer survival than residents of less deprived areas. While the overall risk of developing cancer in New Zealand is decreasing, New Zealand has an increasing number of people who are developing cancer, mainly because of population growth and ageing. The total number of cancer registrations is projected to increase by approximately 21 percent from 2006 to 2016. In addition, once people are diagnosed with cancer they are now less likely to die from it. This means that people are surviving longer, and being treated for longer periods of time, with different treatments. 2.1.3.1 Our Approach Taranaki DHB maintains a clinical relationship with the Central Cancer Network for care and treatment of our cancer clients. The Central Cancer Network area includes Capital and Coast, Hutt Valley, Wairarapa, MidCentral, Whanganui, Hawkes Bay and Taranaki DHBs. Cancer is an area of high need which can only be effectively met through regional and inter-regional collaboration and cooperation. In the Central Region there are strong clinical networks which provide for essential collegial support in the provision of cancer services to mitigate the risks to a potentially vulnerable service. A health system that functions well for cancer is one that ensures all: People get timely services across the whole cancer pathway (screening, detection, diagnosis, treatment and management, palliative care) People have access to services that maintain good health and independence People receive excellent services wherever they are Services make the best use of available resources Health system success is measured by five year survival rates, cancer incidence and cancer mortality data. The focus of the regional work programme covers the following areas: 2.1.3.2 Continuing to ensure timely and improved access to radiotherapy and chemotherapy services Building knowledge and capacity to ensure timely and improved access to diagnosis and cancer treatment services via the Faster Cancer Treatment programme of work Improving colonoscopy wait times and quality of services Improving system integration and service collaboration Linkages Minister’s Letter of Expectations National Cancer Programme Work Programme Midland DHBs Regional Services Plan 2014/15 Central Cancer Network Strategic Plan Taranaki Palliative Care Plan 2013-16 Hei Pā Harakeke Action Plan 43 Health Target – Shorter Waits for Cancer Treatment Our Performance Story Impact: People receive timely and appropriate specialist care 2.1.3.3 Action Plan Objective Shorter Waits for Cancer Treatment 2.1.4 Actions to Deliver Improved Performance Maintain performance against the radiotherapy and chemotherapy wait time targets by investing in workforce and capacity as required Report against the shorter waits for cancer treatment target on a monthly basis Work with CCN to implement priority areas for the year identified in the regional radiation oncology capital and service plans (plan to be developed by June 2014) Work with CCN to continue implementation of the priority areas for each year identified in the National Medical Oncology Models of Care Implementation Plan 2012/13, including: o Support the implementation of e-prescribing into both cancer centres ensuring process appropriate for TDHB site o Implement SMO workforce priorities as identified by the national plan To work with CCN to submit a joint proposal for service improvement initiatives along the patient cancer pathway that support achievement of the 62 day DCT indicator and/or implementation of the provisional tumour standards. The new Health target to be achieved by July 2016 is 85 percent of patients referred with a high suspicion of cancer wait 62 days or less to receive their first treatment (or other management) Measure Reporting 100% of patients, ready for treatment, wait less than four weeks for radiotherapy or chemotherapy Monthly reports submitted Monthly Implementation priorities identified by July 2014. Priorities completed by June 2015 Quarterly Implementation priorities identified by July 2014. Priorities completed by June 2015 Quarterly Joint proposal developed and submitted Quarterly Increased Immunisation 2.1.4.1 Our Approach During 2014/15 we will continue our focus on increasing immunisation in our district. There are many stakeholders from across the sector whose individual work forms part of the ‘greater whole’ in terms of the approach to supporting children in this district. The results against the target and initiatives planned for our district will reflect the combined effort of all these stakeholders. We will be working with our primary care partners to make progress against this priority. 44 2.1.4.2 Linkages Our Performance Story Impact: People take greater responsibility for their health Better Public Services: Supporting vulnerable children 2.1.4.3 Action Plan Objective Increased Infant Immunisation Actions to Deliver Improved Performance Support and strengthen relationships between immunisation stakeholders and other relevant agencies by: 1. Maintaining the Taranaki Immunisation Steering Group (TISG) that includes all the relevant stakeholders for the DHB’s immunisation services including the Public Health Unit 2. Participation in regional and national forums as required 3. The TISG will meet quarterly to review, monitor and implement actions as identified through the Taranaki Immunisation Action Plan 4. Support activities for Immunisation Week 5. Through the TISG identify and develop relationships with other relevant agencies. Including actions that support the increase immunisation rates Actively monitor and evaluate immunisation coverage at DHB, PHO and practice, and Outreach Immunisation level. 1. Targeting of specific populations groups where gaps in immunisation are identified 2. Monitoring of the DHB Monthly dashboard and follow-up on indicators where gaps are identified 3. Ensure effective Outreach Immunisation Services 4. That the immunisation status of all patients receiving care is checked on or soon after admission and the number of opportunistic immunisations increases as a result of this 5. Maintain process between NIR and ED for children presenting Department who Measure National Health Target – 95% of 8 months children vaccinated Reporting against DHB Quarterly Reporting through to MoH Evidence of Immunisation Week activities through Narrative report on DHB and interagency activities to promote immunisation week (April 2015) Increase the number opportunistic immunisations as a result of Paediatric Ward admissions Increase the % of Outreach Immunisations referrals that have completed immunisation Reporting Quarterly Quarterly 45 Objective Actions to Deliver Improved Performance are due or over-due for immunisation. Ensuring follow-up with OIS where appropriate Work with primary care partners to monitor to increase immunisation rates 1. Through the Taranaki WCTO QIF – Access Indicator 1 – New-born’s are enrolled with a PHO by two weeks of age. Work towards 100% enrolment 2. In collaboration with primary care stakeholders monitor systems for seamless handover of mother and child as they move from: maternity care services to general practice and WCTO services 3. Primary Care will monitor the performance of their immunisation rates through Best Practice Intelligence Tools Measure Reporting Quarterly Increase new-born enrolments from 66% to 88% by December 2014 at 2 weeks of age Maintaining the current handover to WCTO and Primary Care of 99% PHO Quarterly reporting activities and monitoring on 2.1.5 Better Help for Smokers to Quit Better Sooner More Convenient Health Services for New Zealanders in relation to tobacco means more smokers make more quit attempts, leading to more successful quit attempts and a reduction in smoking prevalence. A renewed impetus is required in order to achieve the Government’s aspirational goal of a Smokefree New Zealand by 2025. Increased integration into all other aspects of health is critical to achieving Smokefree Aotearoa 2025. Supporting smokers to quit needs to be integrated into all primary, secondary and maternity health services and DHBs have a leading role. 2.1.5.1 Our Approach Our children and tamariki need to grow up free of the risk of becoming addicted to tobacco and the effects of second-hand smoke. We recognise that actions we take at a regional and local level will link with the actions driven at a national level to contribute to the achievement of the goal of a Smokefree New Zealand by 2025. A renewed impetus is required in order to achieve the Government’s aspirational goal of a Smokefree New Zealand by 2025. Increased integration into all other aspects of health is critical to achieving Smokefree Aotearoa 2025. Supporting smokers to quit needs to be integrated into all primary, secondary and maternity health services and DHBs have a leading role. We are active participants in the regional smokefree network and will be implementing the actions from our current Tobacco Control Plan. This plan has a focus on achieving the national health targets. We will continue to engage regularly with our primary care partners and share information about the health target as well as monitoring actual performance against planned performance. Our focus on smoking during pregnancy is part of our Maternity Quality and Safety (MQSP) programme. 46 We will be working with our primary care partners to make progress against the primary care portion of this priority. 2.1.5.2 Linkages Minister’s Letter of Expectations Health Target – Better Help for Smokers to Quit Parts of this section have been developed and agreed with our primary care partners Our Performance Story Impact: People stay well in their homes and communities Our Performance Story Impact: People receive timely and appropriate specialist care 2.1.5.3 Action Plan Objective Better Support for Smokers to Quit in Secondary Care Actions to Deliver Improved Performance TDHB is committed to sustain performance against the secondary Care target o Current unit procedures support ongoing process to ensure all patients who smoke are asked about their smoking status, given brief advice to stop smoking and are offered/given effective smoking cessation support for hospital based services To promote and monitor the use and access of Nicotine Replacement Therapy and Smoking Cessation medicines within the hospital o Determine a baseline by 31 September 2014 To improve and monitor the number of patients/clients to the Quitline and Specialist Smoking Cessation Providers o Determine a baseline by 31 September 2014 Continue to strengthen systems and linkages between Secondary and Primary Care To implement the National Smokefree Mental Health Project within the hospital Measure Maintain 95% of hospitalised patients who smoke and are seen by a health practitioner are offered brief advice and support to quit smoking Maintain 95% of hospitalised Maori patients who smoke are seen by a health practitioner are offered brief advice and support to quit smoking Quarterly Increase percentage of hospitalised smokers receiving pharmacotherapy medicine by June 2015 Quarterly Increase of direct referral numbers to Quitline and specialist smoking cessation providers by June 2015 Quarterly On-going work Implementation of National Smokefree Mental Health guidelines and resources within the hospital by June 2015 Smokefree Aotearoa 2025 logo and messages included across Smokefree projects, communication and resources Quarterly 90% of patients who smoke aged 15 years and over and are seen in General Practice by a health practitioner are offered brief advice and support to quit smoking Quarterly Better Support to Quit in Primary Care (PHOs) General Practice Reporting To promote and raise the awareness and knowledge of a Smokefree Aotearoa 2025 goal Continue to fund the Primary Care Midland Regional Health Network to deliver agreed local activities to support the achievement of the Tobacco Health Target 47 Objective Actions to Deliver Improved Performance Ensure all patients who smoke are asked about their smoking status, given brief advice to stop smoking and are offered/given effective smoking cessation support o MHN Network Liaison Team to provide quarterly reports to all practices on their performance against the Annual Quality Plan targets for Smoking o Network Liaison team when required to support practices to implement their smoking cessation plans to ensure a patient centred practice based on ABC service model o To provide a MHN centralised practice support approach for identified practices that require support for those smokers not contacted in 12 months o MHN will monitor utilisation of Patient Prompt and BPI reporting tools to record and report on smoking status and feedback to practices via the quarterly Network Liaison Team visits o Better Support for Pregnant Women to Quit PHO exploring additional, linkages, pathways and feedback loops for referrals to NGO’s for specialised cessation support Explore options for a range of dedicated smoking cessation support in the Primary Care Setting Ensure all patients who smoke are asked about their smoking status, given brief advice to stop smoking and are offered/given effective smoking cessation support for hospital based maternity services o To communicate Taranaki DHB quarterly results from Ministry of Health to local Midwifes and LMCs To monitor the use and access of Nicotine Replacement Therapy and Smoking Cessation medicines within hospital based Measure Reporting Make progress toward 90% of pregnant women who identify as smokers at the time of confirmation of pregnant in general practice are offered advice and support to quit Quarterly Increase of direct referral numbers to Quitline and specialist smoking cessation providers by June 2015 Quarterly Agree with MRHN a evidence based model to best support General Practice by 30 September 2014 Progress towards 90% of pregnant women who identify as smokers at the time of confirmation of pregnancy in General Practice or booking with Lead Maternity Carer are offered advice and support to quit. Quarterly Increase percentage of hospitalised Pregnant smokers receiving pharmacotherapy medicine by June 2015 48 Objective Actions to Deliver Improved Performance maternity services o Determine a baseline by 31 September 2014 To monitor the number of pregnant smokers to Mana Wahine Hapu and Specialist Smoking Cessation services o Determine a baseline by 31 September 2014 TDHB Hospital Service to work with Te Kawau Maro (Smoking in Pregnancy Services) and PHOs to inform ways in which the Hospital Services can improve its cessation advice and referral service for pregnant women Actions refer to Section 2.4.9 Maternal & Child Health Professional Mana Wahine Hapu community champions to deliver promotional sessions to health and community professionals Five Mana Wahine Hapu Whanau Champion trainers to recruit and provide training support packages Whanau champions to deliver Smokefree pregnancy conversations Provide smoking cessation / behavioural support group interventions to pregnant women and their partners/Whanau Measure Increase of direct referral numbers to Mana Wahine Hapu and specialist smoking cessation providers by June 2015 Measures refer to Section 2.4.9 Maternal & Child Health Quarterly To deliver Mana Wahine Hapu promotional sessions reaching 250 health and community professionals by 31 March 2015 Quarterly 40 whanau champions recruited and trained by 31 March 2015 Quarterly 400 smokefree pregnancy conversations recorded by 31 March 2015 125 women received three facilitated group support sessions (partners included based on ration 85% women 15% partners) by 31 March 2015 100 pregnant women enrolled in SmokeChange telephone support by 31 March 2015 Taranaki Tobacco Action Plan 2014-16 completed by 30 September 2014 Smokefree/Auahi Kore logo and messages included across all projects, communications and resources Quarterly Regional Collaboration – Implement the 2014-15 Actions in the Midland Smokefree 2025 Five Year Programme of Action 2010-15 Develop a Taranaki Tobacco Action Plan 2014-16 To align and implement agreed local actions and priority groups from Regional and National Smokefree Aotearoa 2025 Action Plans To promote and raise the awareness and knowledge of a Smokefree Aotearoa 2025 goal Representation on the Smokefree Midlands and Maori Caucus Advisory Group Reporting Quarterly Annually by June 2015 Ongoing attendance at Regional meetings 49 2.1.6 More Heart and Diabetes Checks 2.1.6.1 Our Approach We will continue to work with our primary care partners to reduce the impact of long term conditions like cardiovascular disease. We provide funding to our primary care partners to enable implementation of their respective long term conditions programmes (which include a focus on the More Heart and Diabetes Checks Health Target). Our primary care partners use the allocated funding to support and incentivise performance of their practices. This approach is intended to contribute to the achievement of our outcomes of improving the health status of our population and reducing or eliminating health inequalities. We are part of a sub-regional8 approach (overseen by an Alliance Leadership Team) to the funding allocation of our primary care partners, the Midlands Health Network. This approach focuses on enabling implementation of their Long Term Conditions programme using funding from an agreed flexible funding pool to support and incentivise practices. This funding is allocated to practices through a funding allocation model which covers inputs, outputs and outcomes: 2.1.6.2 Capacity funding - calculated in year one based on high needs; year 2 based on numbers in stratified risk categories with different categories buying different levels of intervention Coverage funding - as practices achieve agreed coverage targets in three bands in year one and then active care plans for year two; then the funding is adjusted to reflect that the harder to reach are being actively managed. Quality funding - year one coverage targets and some outcome; year two moving to less coverage and greater outcome Linkages Minister’s Letter of Expectation Health Target – More Heart and Diabetes Checks Section developed and agreed with our primary care partners Our Performance Story Impact: People stay well in their homes and communities 2.1.6.3 Action Plan Objective More Heart and Diabetes Checks 8 Actions to Deliver Improved Performance Using PHO resource, identify and target missed opportunities by: o Enhancing current reporting capability to provide more specific and timely analysis on network, locality and practice performance o Providing analysis to network liaison team to actively manage general practices where performance needs to be improved o Systematically reviewing performance at a network, locality and general practice level to ensure each practice is using the tools and reports to review Measure Quarter Reporting Minimum Percentage Coverage to be achieved in the Taranaki DHB district by the end of Quarter (expressed as a percentage of the Eligible Population) Maori Pacific Other Total Jul-Sep 2014 90% 90% 90% 90% Oct-Dec 2014 90% 90% 90% 90% Jan-Mar 2015 90% 90% 90% 90% Apr-Jun 2015 90% 90% 90% 90% Jul-Sep 2015 90% 90% 90% 90% Sub-region in this case refers to the geographic areas covered by Lakes DHB, Tairawhiti District Health, Taranaki DHB and Waikato DHB 50 Objective 2.2 Actions to Deliver Improved Performance missed opportunities and initiate active follow up o Providing an incentive for general practices to achieve their targets Using NGO resource, identify and target missed opportunities by implementing systems to capture activity undertaken outside of the general practice environment Fully integrate catch up and coordination services for key health targets including the utilisation of telephone catch up services Measure Reporting BETTER PUBLIC HEALTH SERVICES 2.2.1 Reducing Rheumatic Fever Rheumatic Fever left untreated can damage the heart leading to life-long heart problems. Working to reduce and eliminate rheumatic fever can reduce the incidence of heart disease and/or related complications. 2.2.1.1 Our Approach During 2013/14 we developed our Rheumatic Fever Prevention Plan. While the incidence of Rheumatic Fever is low in Taranaki (less than 1 per 100,000 population) we expect to reduce both the incidence and impact of Rheumatic Fever across our district. Our plan includes sections on: 2.2.1.2 Overarching actions to reduce the incidence of Rheumatic Fever Investment in reducing Rheumatic Fever Actions preventing the transmission of Group A Streptococcal throat infections Actions to treat Group A Streptococcal throat infections quickly and effectively Actions facilitating the effective follow-up of identified Rheumatic Fever cases Linkages Our Performance Story Impact: Fewer people admitted to hospital for avoidable conditions Better Public Services: Supporting vulnerable children Rheumatic Fever Prevention Plan 2013-2017 2.2.1.3 Action Plan Objective Reduce the Incidence of Rheumatic Fever Actions to Deliver Improved Performance Implement the Rheumatic Fever Prevention Plan appropriate to the level of intervention required Measure 2014/15 Rheumatic Fever target – number and rate reductions, 40% below 3-year average (by ethnicity) Reporting Quarterly 51 Objective Actions to Deliver Improved Performance Ensuring that primary care providers and other health professionals likely to see high risk children follow the National Heart Foundation Sore Throat Management Guidelines Ensuring people with Group A streptococcal infections are treated appropriately within 7 days of developing symptoms Ensuring that all cases of acute rheumatic fever are notified to the Medical Officer of Health within 7 days of hospital admission Reviewing all cases of Rheumatic Fever to identify any identifiable risk factors and system failure points Ensuring patients with a past history of Rheumatic Fever receive monthly antibiotics not more than 5 days after due date Undertake a root cause analysis of every Rheumatic Fever case and identify systems failures Measure Reporting The Taranaki DHB Rheumatic Fever Prevention Plan has been operational since the start of October 2013 Quarterly There was only one case notified in 2013 – a 10 year old Maori child in June. This gives a notification rate of 0.9 per 100,000 The activities in “What we are planning to do to achieve it” are reviewed annually An intersectoral project team then reviews the annual report and epidemiology of Rheumatic Fever in Taranaki over the previous year and decides on actions which are consistent with the level of need Quarterly Quarterly Provide a report on the lessons learned and actions taken following the root cause analysis to the Ministry each quarter 2.2.2 Prime Minister’s Youth Mental Health Project The Department of the Prime Minister and Cabinet developed a cross agency project looking at improving services for young people with, or at risk of, mild to moderate mental health disorders. The 52 project is designed to build on existing successful interventions and to trial new initiatives for young people aged 12-19 years (inclusive) in settings in which young people live their lives: schools, the health system, their families and community, and online. 2.2.2.1 Our Approach We will be working with our primary care partners to make progress against this priority. Our activities in this priority area are expected to mean young people will be able to access the services they require before their condition escalates to being a severe mental health disorder. 2.2.2.2 Linkages Minister’s Letter of Expectation PP25 - Delivery of the Prime Minister’s youth mental health initiative Our Performance Story Impact – People stay well in their homes and communities 2.2.2.3 Action Plan Objective Prime Minister’s Youth Mental Health Project Actions to Deliver Improved Performance Development of Taranaki Youth Health Teams (YHT’s) as per Taranaki Taiohi Health Strategy 2013-2016. 1. Identification of key agencies/organisations to partner with for the development of YHT’s 2. Establishment of Service Level Alliance Team with key agencies/stakeholders for the purpose of designing the teams 3. Undertake a service design process for YHT’s Improving access and service options for youth. 1. Roll out of (C)HEADSSS assessment tool to school counsellors, and other professionals working with youth 2. 3. 4. Expanding the use of standing orders and prescribing by Public Health Nurses in schools, alternative education and similar environments. Enabling Nurses to manage patients promptly and efficiently PHN pathway for linking youth with General Practice documented Embed the Primary Mental Health Initiative for Youth voucher access through General Practice, School Counsellors, Public Health Nurses and Social Sector Trial Measure Reporting Monthly progress updates to Taranaki DHB Board Monthly By December 2014, establishment of the Service Level Alliance Team Quarterly By June 2015 the service design process and action plan completed Quarterly By July 2014 60 professional working with youth would have undertaken the training (PMHI Reporting) Number of (C)HEADSSS assessments completed Quarterly Increase numbers prescribing and orders in clinics Quarterly By December 2014, documentation completed Quarterly Increase in the numbers of Youth accessing Primary Mental Health Initiative (PMHI Reporting) Quarterly of PHN standing 53 Objective Actions to Deliver Improved Performance Implementation of the 2014/15 workforce development and training, PMHI and PHO. 1. Delivery of workshops aimed to build skills/capacity and confidence in working with young people in supporting and understanding of interventions for youth experiencing poor mental health 2. Enhance electronic tools/resources available to general practice to include care planning and selfmanagement 3. Workforce education and training to support the utilisation of stepped care model is available 3.1 Access to increased specialist services for advice/training. 3.2 Launch policy as part of annual education. 4. Identify Map of Medicine pathways to better support treatment processes and improve access 5. Introduction of a Child protection policy and Family Violence policy for general practice and identify education opportunities Explore group programmes for working with youth 12-19 years Review and improve the follow-up care for those discharged from CAMHS and Youth AOD services: Consistently follow process of completing care plans in letters to GP to be sent within 7 days of discharge Measure Reporting 75% of General Practices have participated in the training by June 2015 (PMHI Reporting). Quarterly Information relating to electronic tools/ resources are included in quarterly narrative reporting. Monitoring via PHO quarterly reporting Quarterly Framework to be agreed by September 2014 Deliverables agreed by September 2014 Reporting through PHO Quarterly reporting Quarterly Reporting through Quarterly reporting PHO Reporting through Quarterly reporting PHO The percentage of care plans will increase The percentage of care plans included in discharge summaries to GPs from CAMHS & Youth AoD will increase to 75% by June 2015 An internal audit of the current status will be done in July as a baseline and to inform our confirmed target Improve follow-up in primary care of youth aged 12-19 years discharged from secondary mental health and addiction services by providing follow-up care plans to primary care providers. The follow-up care plans should be provided with the expectation that they are activated by the primary care 54 Objective Actions to Deliver Improved Performance provider within three weeks of discharge Measure Reporting Consistently follow process of completing care plans in letters to GP to be sent within seven days of discharge Ensure services are culturallycompetent and provided to meet the health needs of Māori and Pacific populations TDHB will ensure services are culturally-competent and provided to meet the health needs of Māori and Pacific populations through offering a range of services and training staff Improve access to CAMHS and Youth AOD services through wait times targets and integrated case management: Implement agreed action to meet the waiting time targets that by 2015 will enable: 80% of youth to access services within three weeks; 955 to access services within eight weeks TDHB will change the model of service through role redesign in order to complete initial assessments within three weeks of referrals All new staff will attend TDHB’s Tikanga Best Practice Training Existing staff will attend refreshers as required Delivery against target Measured through PP-8 being the MOH Measurement of MH&A waiting times. Targets being to achieve by June 2015 80% of service users to be seen within three weeks of referral and 95% within eight weeks 2.2.3 Children’s Action Plan Supporting vulnerable children contributes to the Government’s overall priorities by improving services and reducing avoidable expenditure in the justice, health and welfare systems – helping to deliver better public services within financial constraints and helping to build more competitive and productive economy. 2.2.3.1 Our Approach National Child Health Information Programme (NCHIP). Initially Catch 18 was a programme instigated by the Midlands Health Network who sought a partnership with the four Midland DHBs, Waikato, Lakes, Taranaki and Tairawhiti. These DHBs contributed $400,000 over a two year period to fund the programme that would establish a pathway for a regional and ultimately a national solution for child and youth health. Subsequently the Ministry of Health and the National IT Board joined the team as the owner of the national programme, (renamed NCHIP) the goal of which was to develop as proof of concept, a child and youth health platform and coordination service. The programme will create greater visibility of child health information and improve collaboration and standardisation in the delivery of health services of child health providers. It will also assist in the achievement of DHB health targets for immunisation, B4 Schools and obesity reduction. Registrations 55 of Interest were sought from appropriate IT vendors via a closed tender process. Following the selection of a preferred vendor, pricing discussions and modelling of national roll out costs have occurred. Good progress is being made on the project which now includes Bay of Plenty and Auckland DHBs. 2.2.3.2 Linkages Minister’s Letter of Expectation Health Target – Increased Immunisation Better Public Services: Result 2: Increase participation in quality early childhood education Better Public Services: Results 3: Increase infant immunisation rates and reduce the incidence of Rheumatic Fever Better Public Services: Result 4: Reduce the number of assaults on children Our Performance Story Impact: People take greater responsibility for their health 2.2.3.3 Action Plan Objective Implementation of the White Paper for Vulnerable Children – Establishment of Children’s Teams Reducing the Number of Assaults on Children Actions to Deliver Improved Performance Describe DHB actions to support establishment of Children’s Teams including: Participation in regional Children’s Team governance and leadership involvement by DHB and non-DHB employed health professionals Collaboration with other agencies to plan, test and monitor assessment processes to support early response systems, assessment processes and delivery of coordinated services for vulnerable children Work to develop effective referral pathways to/from Children’s Teams and primary and secondary health services Enabling health professionals to attend necessary training to support Children’s Teams DHBs to develop and evaluate VIP programmes MHN introduction of a Child protection policy and Family Violence policy for general practice and identify education opportunities Measure Reporting • DHBs support establishment of multi-disciplinary Children’s Teams • All DHBs achieve audit scores of 70/100 for each of the child and partner abuse components of their VIP programmes • All DHBs implement NCPAS by 30 June 2015 DHB has internal governance/engagement arrangements within the DHB and with primary and community partners to provide services for: Vulnerable children and their families/whānau Pregnant women with complex needs Children referred to Gateway All DHBs achieve audit scores of 70/100 for each of the child and partner abuse components of their VIP programmes Policy will be launched as part of the annual education plan and will be reported via quarterly narrative report Progress update In Q1 report Progress update in Q2 report Progress update in Q3 and 4 reports. Establish key steps to be included in the 2014/15 planning Quarterly Quarterly 56 Objective 2.2.4 Actions to Deliver Improved Performance TDHB will increase Family Violence screening of women over 16 years of age who receive any TDHB service for FV, to enable measuring of this within the DHB TDHB will code and audit screening results and continue with appropriate care plan implementation for women who have a positive screening Actions taken to plan, implement and/or maintain their National Child Protection Alerts System To ensure that interagency collaboration continues and that internal processes support the National Child Alert systems being maintained DHBs to confirm provision of Ministry-accredited training for health professionals to recognise signs of abuse and maltreatment in designated services To continue the FVIP training, increasing the numbers of staff in all areas who have attended Measure Reporting To increase the numbers of patients who are screened whilst being patients at TDHB – establish baseline and aim to increase screening rate to 50% by end June 2015 Audit scores of 70/100 for each child and partner abuse component of the VIP programme To increase the numbers of patients who are screened whilst being patients at TDHB – establish baseline and aim to increase screening rate to 50% by end June 2015 Audit positive screenings and associated care plans – aim for 100% by end June 2015 Implement NCPAS by 30 June 2015 Quarterly FVIP training to be rolled out to all areas and numbers of staff attending to be monitored and increased Quarterly Quarterly Quarterly Whānau Ora 2.2.4.1 Our Approach The vision for Taranaki Maori is “Whānau Ora – whānau supported to achieve their maximum health and wellbeing”. The Whānau Ora philosophy articulated by the Whānau Ora Taskforce, as it relates to health, provides the philosophical base for the TDHBs approach to Whānau Ora. The characteristics of the philosophy that give Whānau Ora definition and distinctiveness are as follows: Recognises a collective entity (whānau). Whānau Ora is not simply about the sum total of collective measures, but is primarily concerned with the ways in which the group functions as a whole to achieve health and wellbeing for its people. 57 Endorses a group capacity for self-management and self-determination. Whānau Ora activities will transfer knowledge and skills to whānau so that the group develops critical awareness and are best able to manage their own health and wellbeing. Has an intergenerational dynamic. That is, Whānau Ora is about ongoing intergenerational transfers towards the goal of increasing sustainability of improved health outcomes. For example, in managing diabetes health services may immediately treat the problems but will also support knowledge transfer and prevention activities among the next generation in order to avoid the development of diabetes among descendants. Is built on a Māori cultural foundation. Wellbeing is closely linked to Māori cultural identity and the expression of Māori values. Asserts a positive role for whānau within society. Health institutions should have the capacity to respond positively to whānau, and whānau should be able to negotiate freely with these institutions to achieve the best results. Can be applied across a wide range of social and economic sectors. Whānau Ora is equally concerned with socio-economic wellbeing, and cultural and environmental integrity. Therefore, the Health and Disability Sector should actively participate, and in some instances lead in intersectoral activities that contribute to Whānau Ora. The implication for Taranaki DHB is that every service offered should contribute to the generation of self-management knowledge and skills that are owned by whānau. The philosophical underpinning described above is supported by He Korowai Oranga, National Maori Health Strategy, as a framework for Whānau Ora implementation. Within this framework and at the core of the Taranaki DHB’s approach is to support whānau ownership over their own development. The transfer of knowledge and skills to enable this to happen is a key function of Whānau Ora health service provision. The Taranaki DHB is committed to taking a whānau-centred approach by aligning activities to the whānau context described above. 2.2.4.2 Linkages Minister’s Letter of Expectations Our Performance Story Impact: People stay well in their homes and communities 2.2.4.3 Action Plan Objective Whānau Ora Being Outcomes Focused Actions to Deliver Improved Performance Building capacity and capability: build on the investment Te Puni Kōkiri (TPK) has made to strengthen both the capacity and capability of the provider collectives across the governance, management and service delivery levels Continue implementation and refinement of integrated contracting processes, focused on outcomes; and to work with the Ministry to support GP providers, who are part of Whānau Ora provider collectives, to use their practice management systems to report on Whānau outcomes Measure Reporting Work with the Taranaki Ora Collective to identify and agree areas where the DHB can support capacity and capability building of the collective Annually Q2 Work with the relevant parts of the Taranaki Ora collective (Tui Ora Ltd) to support alignment of its GP client management systems to be able to satisfy MOH requirements for reporting on Whānau outcomes Six-monthly Q2 & Q4 58 Objective Implementing Programmes of Action Supporting Strategic Change Changes to the Future Direction of Whānau Ora 2.3 Actions to Deliver Improved Performance Support the provider collectives in the planned activities for implementation in 2014/15; and substantive engagement with provider collectives Strategic planning with the DHB includes participation of the Whānau Ora provider collectives; building and maintaining relationships with agencies implementing Whānau Ora; and support for Whānau Ora across all levels of the DHB, including at Board and Planning and Funding level Minister Turia announced changes on the future direction of Whānau Ora in July. A key feature of the announcement is the establishment of three NGO Commissioning Agencies. It is not yet clear what the commissioning agencies will look like and what will be required of DHBs. Te Puni Kōkiri aim to complete the procurement process and be in a position to announce the selected agencies by the end of this year Measure Reporting Establish processes to facilitate access by the Taranaki Ora collective, to the skills and services offered by the Taranaki DHB Taranaki Ora collective participates in at least one TDHB strategic planning forum TDHB participates / leads / facilitates at least one strategic funder forum involving local agencies involved in implementing Whānau Ora Six-monthly Q2 & Q4 Develop and implement a programme across all levels of the TDHB to socialise Whānau Ora and whānau-centred practice as an approach Six-monthly Q2 & Q4 Annually Q2 SYSTEM INTEGRATION 2.3.1 Long Term Conditions Long term conditions account for a significant number of potentially preventable presentations at emergency department and admissions to hospital. With an ageing population this burden will increase. Improving care for people with long term conditions can best be achieved through whole of the health system approach. 2.3.1.1 Our Approach We will continue to work with our primary care partners to reduce the impact of long term conditions. There will be a focus on ensuring the care of people with long term conditions takes place in the most appropriate setting (particularly community and primary settings), with primary care nurses and allied health professionals taking wider responsibility for helping people manage their ongoing health needs. 2.3.1.2 Linkages Midland DHBs Regional Services Plan 2014/15 Our Performance Story Impact: People stay well in their homes and communities Our Performance Story Impact: People receive timely and appropriate specialist care 59 2.3.1.3 Action Plan Objective Diabetes Long-term Conditions and Actions to Deliver Improved Performance Taranaki DHB, in collaboration with our primary care alliance partners, have identified actions to reduce the impact of long terms conditions that are driving demand upwards in our district Measure Linkage with Ambulatory Sensitive Admissions to Hospital (ASH) rates Measurement of improved diabetes outcomes using a set of clinical indicators to be developed 100% of MHN general practices have access to eligible population list via the risk stratification process Information pertaining to resources is demonstrated via quarterly reporting narrative Quarterly 90% of the diabetic eligible population (total and high need) have personal health assessment and planning available by 30 June 2015 Quarterly 10% of the diabetic eligible population (total and high need) have accessed personal health assessment and planning 30 June 2015 Volumes – 210 face-to-face contacts (Clinical Pharmacist); 2525 face-to-face contacts (Dietician/Social Worker) Information pertaining to resources is demonstrated via quarterly reporting narrative Education calendar for 14/15 still being finalised Information pertaining to funding strategy is demonstrated via quarterly reporting narrative Each practice has access to a list of their diabetic eligible population Further resources developed within the LTCMP website ‘tool kit’ so General Practice can best utilise their funding and resources Enhance and extend the electronic tools and systems to provide standardised assessment, care planning and clinical reviews using the MHN Personal health assessment and planning process Increased use of MDT for diabetes and CVD Enhance the electronic tools/resources available to general practice to include selfmanagement Workforce education and training in the delivery of LTCMP Enhancement of existing funding strategy to further encourage general practices to deliver quality care and management and to best target resources Via the MHN quality programme, a set of indicators and targets for the LTCMP including progress toward Smokefree by 2025 Continuation of the LTCMP evaluation and monitoring framework Reporting Quarterly Quarterly Quarterly Quality indicators and targets still being finalised – IPIF and MOH diabetes clinical indicator dependant Quarterly Information pertaining to evaluation and monitoring framework is demonstrated via quarterly reporting narrative Quarterly 60 Objective 2.3.2 Actions to Deliver Improved Performance TDHB ensures complex LTC inpatients are managed by specialist interdisciplinary teams. o Evaluation of current pathway Q1 o Recommendations for enhancements Q2 Q1 - Evaluation of the pathway from inpatients to primary care is evaluated and enhancements made to ensure support of complex patients back to primary care post discharge Measure Reporting Quarterly Quarterly Stroke 2.3.2.1 Our Approach Stroke Services are identified as a priority area in our Regional Services Plan (RSP) (see Integration across continuums of care – 2014/15 RSP). HealthShare through the Midland Stroke Action Group are leading the development and implementation of regional actions. 2.3.2.2 Linkages Midland DHBs Regional Services Plan 2014/15 Our Performance Story Impact: People stay well in their homes and communities Our Performance Story Impact: People receive timely and appropriate specialist care 2.3.2.3 Action Plan Objective Stroke Services Actions to Deliver Improved Performance Stroke thrombolysis quality assurance procedures will be developed, including processes for staff training and audit Workforce training to support thrombolysis, care pathways developed for thrombolysis, workforce allocation to support all DHBs in region having access to thrombolysis, for those DHBs not able to provide thrombolysis transport options to regional provider in place Continue to provide workforce training to support the delivery of thrombolysis - 80 % of staff involved in stroke care will attend a credentialling Study Day Planned (Nursing and Allied health Staff. This will be held x2 per year. Day to include general overview of Measure 6% of potentially eligible stroke patients thrombolysed 80% of stroke patients admitted to a stroke unit or organised stroke service with demonstrated stroke pathway Annual Refresher Education regarding stroke pathway presented at Nursing Annual Clinical Refresher Three educations sessions per year by the stroke CNS to include Stroke pathway, Stroke Care/ inclusive of thrombolysis management Quarterly Attendance at Midland Stroke Network meeting by lead stroke clinician and Stroke CNS Reporting Quarterly 61 Objective Actions to Deliver Improved Performance Stroke, swallow, positioning, thrombolysis, assessing cognition, Dietary, Physical assessment and monitoring - On commencement into the Stroke Unit, new staff will be required to undertake the Stroke Self Learning Package- This will be coordinated by the Stroke Clinical Nurse Specialist - Monthly in-service stroke education held in the stroke unit- Coordinated by the Stroke Clinical Nurse Specialist - Embedding of the FIM Assessment tool to be used on all stroke patients- 100% of staff already trained in FIM use to be recertified - 100 % - Acute Stroke team required to present a topic at monthly in-service Continue to utilise care pathways for thrombolysis Provide dedicated stroke units or areas for management of people with stroke, thrombolysis, and transient ischaemic attack services supported by ongoing education and training for interdisciplinary teams Maintenance of dedicated stroke unit for management of people with stroke, thrombolysis and TIA Participation in national and regional clinical stroke networks to support implementation and maintenance of stroke and thrombolysis services Support national and regional clinical stroke networks to implement actions to improve stroke services Measure Reporting Quarterly Quarterly Quarterly Quarterly 2.4.2 Acute Coronary Syndrome Cardiac services are a national priority service area in our RSP. Disparate access issues and workforce vulnerabilities exist, but an opportunity exists to make a difference to population health outcomes and inequalities through a cardiology pathway that is strongly entrenched across the continuum of care from prevention through to specialist care, and cardiac rehabilitation. The affordability of ever62 emerging new technologies will require focused attention to prioritisation in the future. Development of the acute coronary syndrome (ACS) pilot is a major focus area for the network. 2.4.2.1 Our Approach HealthShare through the Midland Action Group are leading the development and implementation of regional actions. In 2014/15 we will be continuing the work around the acute coronary syndrome (ACS) project, which is a major focus for our region. We will continue to engage with our primary care partners in the planning and implementation activities that occur in this area. 2.4.2.2 Linkages Minister’s Letter of Expectations Midland DHBs Regional Services Plan 2014/15 Our Performance Story Impact: People receive timely and appropriate specialist care 2.4.2.3 Action Plan Objective Acute Coronary Syndrome Actions to Deliver Improved Performance The Cardiac ANZACS-QI register enables reporting measures of ACS risk stratification and time to appropriate intervention Implement the Cardiac Surgical register that in conjunction with the ANZACS-QI register will give full reporting measures to intervention Develop processes, protocols and systems to enable local risk stratification and timely transfer of appropriate high risk ACS patients. Risk stratification enables angiography to be completed locally where clinically appropriate Active participation in regional cardiac networks to develop processes, protocols and systems across the region ensuring timely access to assessment and intervention. The regional network will develop and implement an agreed acute chest pain pathway Measure Reporting 70% of high-risk patients will receive an angiogram within three days of admission. (‘Day of Admission’ being ‘Day 0’) Reporting measures will be available that track through to intervention Quarterly Over 95% of patients presenting with ACS who undergo coronary angiography have completion of ANZACS-QI ACS and Cath/PCI registry data collection within 30 days Quarterly 70% of high risk patients will receive an angiogram within three days of admission. (‘Day of Admission’ being ‘Day 0’) Quarterly Quarterly 63 2.4.3 Improved Access to Diagnostics 2.4.3.1 Our Approach Diagnostics are a vital step in the pathway to access appropriate treatment. Improving waiting times for diagnostics can reduce delays to a patient’s episode of care and improve DHB demand and capacity management. We have a number of initiatives underway in terms of diagnostic services. It is planned that these initiatives will enable an improvement in waiting times. 2.4.3.2 Linkages Our Performance Story Impact: People receive timely and appropriate care Improved Access to Elective Services 2.4.3.3 Action Plan Objective Improved Access Diagnostics to Actions to Deliver Improved Performance Improving diagnostic waiting times has been identified a policy priority area for 2014/15. As a consequence, diagnostic waiting time indicators are shifting from a developmental status to full DHB accountability measures in 2014/15. This means formal performance targets will be set against the indicators for 2014/15 Measure We will work to achieve identified waiting time targets by more efficient use of existing resources; making improvements to referral management and patient pathways; and investing in workforce and capacity as required Participate in activity relating to development and implementation of the National Patient Flow (NPF) system, including adapting data Coronary angiography – 90% of accepted referrals for elective coronary angiography will receive their procedure within 3 months (90 days) CT and MRI – 90% of accepted referrals for CT scans, and 80% of accepted referrals for MRI scans will receive their scan within six weeks (42 days) Diagnostic colonoscopy – 75% of people accepted for an urgent diagnostic colonoscopy will receive their procedure within two weeks (14 days); and 60% of people accepted for a diagnostic colonoscopy will receive their procedure within six weeks (42 days) Surveillance colonoscopy – 60% of people waiting for a surveillance or follow-up colonoscopy will wait no longer than 12 weeks (84 days) beyond the planned date Reporting Quarterly Quarterly Quarterly 64 Objective 2.4.4 Actions to Deliver Improved Performance collection and submission to allow reporting to the NPF as required Work with regional and national clinical groups to contribute to development of improvement programmes Work with the Midland Regional Radiology Group to: o Scope and implement ereferrals and orders o Utilise regional benchmarking for performance improvement Measure Reporting Quarterly Above indicators are expected for all DHBs for CT, MRI and colonoscopy. For coronary angiography, indicators are expected where those services are locally provided Representation, attendance and participation in national and regional clinical group activities Agreed system changes are implemented Quarterly Quarterly Monitor and improve on the MOH CT and MRI waiting time indicators Implement the Global Rating Scale for Endoscopy with the support of the National Endoscopy team Quarterly Shorter Waits for Cancer Treatment/Faster Cancer Treatment 2.4.4.1 Our Approach There is a large amount of work underway around the faster cancer treatment targets including the appointment of additional nursing staff to co-ordinate the patient journey. A comprehensive database designed to monitor the timelines of each patient’s care, access to each of the multiple services involved in cancer care has been created. General Practitioners now flag all referrals for patients with a high suspicion of cancer and the patients are actively followed up wherever they are in their journey through the hospital system. The Multidisciplinary Care Coordinators help facilitate this journey for patients. 2.4.4.2 Linkages Minister’s Letter of Expectations National Cancer Programme Work Programme Midland DHBs Regional Services Plan 2014/15 Central Cancer Network Strategic Plan Health Target – Shorter Waits for Cancer Treatment Our Performance Story Impact: People receive timely and appropriate specialist care 2.4.4.3 Action Plan Objective Faster Cancer Treatment Actions to Deliver Improved Performance FCT Indicators Work with CCN to ensure a coordinated approach to identifying Measure % of patients (by DHB and ethnicity) referred urgently with a high suspicion of cancer who receive their first cancer Reporting Quarterly 65 Objective Actions to Deliver Improved Performance and implementing actions to improve faster cancer treatment data-collection systems, including: DHB FCT IT project implemented FCT trackers identify and implement processes to make FCT data collection systems/processes part of Business as Usual MDM Development Complete phased implementation of the regional Multidisciplinary Meeting (MDM) Implementation Plan within allocated funds. Priority activities: Review current MDMs against the National MDM Standards Review MDM access criteria against nationally developed criteria and adjust as required Tumour Standards Work with CCN to undertake the following actions to support use of the tumour standards: Analyse the DHBs review of three tumour standards (different tumour types to the review undertaken in 2013-14) to inform regional service improvement initiatives Implement the regional service improvement initiatives that were identified by the review of the tumour standards in 2013-14 Work with CCN to develop a coordinated approach to cancer pathway development via Map of Medicine / Health Pathways projects Care Coordination Support implementation of cancer nurse coordinators’ professional development plan, including attendance at national and regional training and mentoring forums Continue to work with CCN to support active patient tracking Measure Reporting treatments (or other management) within 62 days Baseline - At 30 June 2013 62% for the CCN region Target – 85% % of patients referred urgently with a high suspicion of cancer who have their first specialist assessment within 14 days % of patients with a confirmed diagnosis of cancer who receive their first cancer treatment (or other management) within 31 days Quarterly Reviews completed by June 2015 (Baseline – 2013/14 data) (PP24) No. of patients accessing MDMs for the most common tumour streams (Baseline - 2013/14 data) – PP24 Target – to be defined by National Tumour Standards Groups by May 2014 Identification of the three prioritised tumour standards for review by Aug 2014 Reviews completed by June 2015 Implementation priorities identified by August 2014 Priorities completed by June 2015 Reviews updated quarterly Approach developed by Aug 2014 Cancer Nurse Coordinator to attend National Forum by June Quarterly Quarterly 66 Objective Improved Waiting Times for Diagnostic Services (Colonoscopy) Improving Palliative Care Actions to Deliver Improved Performance aligned to CRISP and national patient flow Primary Care Work with CCN to coordinate a focus on the front end of the process in primary care identification of high suspicion of cancer (HSC), including: Implementing nationally developed e-referral criteria for referral of patients with HSC from primary care as enabled by CRISP 3.0 TDHB will take a coordinated approach to identifying actions to improve waiting times and quality of endoscopy / colonoscopy services, including: Implementing the Endoscopy Quality Improvement (EQI) programme identifying and implementing improvements to colonoscopy services Monitoring waiting times for diagnostic and surveillance/follow up colonoscopy Undertaking a regionally coordinated approach to implementing Provation (endoscopy reporting system) Undertaking a regionally coordinated approach to implementing Provation (endoscopy reporting system) Implementation of the Taranaki Palliative Care Plan (2013-16): Implementation of a formal partnership model with Midlands Health Network (MHN) to support the provision of primary palliative care to patients living in the community TDHB to formally contract the in-reach Palliative Care Services provided by Hospice Taranaki to Taranaki Base Hospital, and extend to Hawera Hospital, in alignment with the Draft Specialist Palliative Care Service Specifications Review the current model of specialist assessment and care Measure Reporting 2015 Number of patients referred to Cancer Nurse Coordinator per quarter Quarterly E-referral processes in place by June 2015 ProVation implemented by Jun 2015 Diagnostic colonoscopy: 75% of people accepted for an urgent colonoscopy will receive their procedure within two weeks (14 days) (PP29) Quarterly 60% of people accepted for a diagnostic colonoscopy will receive their procedure within six weeks (42 days) (PP29) Quarterly % of MHN GPs engaged in MHN Palliative Care Scheme (establish baseline in 2014/15)) % of MHN GPs who have completed specialist palliative care training by Hospice Taranaki (establish baseline in 2014/15) Formal partnership document between Taranaki DHB and Hospice Taranaki is agreed and signed by 30 December 2014 Quarterly Review undertaken and completed by 30 December Quarterly Quarterly 67 Objective 2.4.5 Actions to Deliver Improved Performance coordination for patients with complex needs who receive nursing services from District Nursing Services in Inglewood and Mokau Undertake a Taranaki wide needs assessment for palliative care training and develop a training plan for generalist palliative care providers Develop a directory of services available to those with palliative care needs (exploring potential opportunities to utilize the existing CCN Cancer Directory in the first instance) Measure Reporting 2014 Needs assessment undertaken and completed by 30 Dec 2014 Palliative Care Training Plan developed by 31 March 2015 Quarterly Service Directory developed by 30 June 2014 Quarterly Cardiac – Secondary Services HealthShare through the Midland Cardiac Network are leading the development and implementation of regional actions. Disparate access issues and workforce vulnerabilities exist, but an opportunity exists to make a difference to population health outcomes and inequalities through a cardiology pathway that is strongly entrenched across the continuum of care from prevention through to specialist care, and cardiac rehabilitation. The affordability of ever-emerging new technologies will require focused attention to prioritisation in the future. Development of the acute coronary syndrome (ACS) pilot is a major focus area for the network. 2.4.5.1 Our Approach In 2014/15 we will be continuing the work around the acute coronary syndrome (ACS) project, which is a major focus for our region. We will continue to engage with our primary care partners in the planning and implementation activities that occur in this area. 2.4.5.2 Linkages Our Performance Story Impact: People receive timely and appropriate specialist care Midland District Health Boards Regional Services Plan 2014/15 2.4.5.3 Action Plan Objective Cardiac Services Actions to Deliver Improved Performance Intervention rate for cardiac surgery is set in conjunction with the National Cardiac Surgery Clinical Network, to improve equity of access Improve access to cardiac diagnostics to facilitate appropriate treatment referrals, including angiography, echocardiograms, exercise tolerance tests, etc Manage waiting times for cardiac services, so that no patient waits longer than five months for first specialist assessment or treatment. Measure Reporting Agreement to and provision of a minimum of 84 total cardiac surgery discharges for local population in 2014/15 Quarterly Refer PP29: Improved access to diagnostics. 90% of people will receive elective coronary angiograms within 90 days Quarterly Elective Services Patient Flow Indicators: all patients wait four months or less for first specialist assessment and treatment from January 2014 Monthly 68 Objective Acute Coronary Syndrome 2.4.6 Actions to Deliver Improved Performance Reduce waiting times to a maximum of four months by the end of December 2014 Undertake initiatives locally to ensure population access to cardiac services is not significantly below the agreed rates. This includes cardiac surgery, percutaneous revascularisation and coronary angiography Participation in regional cardiology network activities Implementation of local cardiology project recommendations Taranaki DHB will Implement the Cardiac ANZACS-QI and Cardiac Surgical registers to enable reporting measures of ACS risk stratification and time to appropriate intervention Taranaki DHB will develop processes, protocols and systems to enable local risk stratification and transfer of appropriate high risk ACS patients Taranaki DHB will work with the midland region, to improve outcomes for high risk ACS patients Embed processes to increase number of acute angiograms completed locally TDHB cardiologists continue to meet with regional group to develop regional guidelines Measure Reporting Refer SI4: Standardised Intervention Rates Cardiac surgery: 6.5 per 10,000 of population Percutaneous revascularisation: 12.5 per 10,000 of population Coronary angiography: 34.7 per 10,000 of population Quarterly Indicator 1. >70% of high risk Acute Coronary Syndrome patients accepted for coronary angiography having it within 3 days of admission (Day of admission=Day 0) (TDHB baseline currently 60%.) Indicator 2 >95% of patients presenting with Acute Coronary Syndrome who undergo coronary angiography have completion of ANZACS Q1 ACS and Cath/PCI registry data collection within 30 days Performance reported against health target Performance reported against health target Performance reported against health target Performance reported against health target Performance reported against health target Primary Care 2.4.6.1 Our Approach We will work with our primary care partners. In addition, DHBs are expected to use their Alliance Leadership Team and any Service Level Alliance Teams to jointly develop 2014/15 DHB Annual Plans for the following in 2014/15: 69 2.4.6.2 Primary Care (including Rural Health) , and Prime Minister’s Youth Mental Health Project – Youth Services. Linkages Performance Story Impact: People stay well in their homes and communities Prime Minister’s Youth Mental Health Project – Youth Services. Strong linkages exist to other primary care focused services such as: o Shorter Stays in ED o Increased Immunisations o Better Help for smokers to quit o More Heart and Diabetes checks o Long Term conditions o Improved Access to Diagnostics o Maternal and Child Health 2.4.6.3 Action Plan Objective Primary Care Actions to Deliver Improved Performance Work programme as agreed by the Taranaki Alliance Leadership Team Measure Work programme agreed by 30 June 2014 Taranaki Primary Options programme available in Taranaki from 1 July 2014. Estimated volume 750 30 localised pathways published by 30 June 2015 Implementation of Options programme Primary Continuation of the localisation of the Map of Medicine programme Supporting the advancement of the Taranaki Health – Integrated System programme Working with general practice to introduce an improved primary care overflow and out of hours service Rural Service Level Alliance Team established and a plan for distribution of the Rural Primary Care funding developed and implemented Primary access services Care to TDHB continues to introduce locally agreed clinical pathways through the Map of Medicine to support improved access to services for primary care. Including maintenance of direct GP access to: 1. gastroscopy 2. minor operations list Work programme to be agreed by the Taranaki Alliance Leadership Team by 30 July 2014 100% of Taranaki general practices using the shared electronic health record provide an after-hours summary to ED by 30 September 2014 Option selected from 13/14 development work implemented by 30 September 2014 8% decrease in primary care presentation in hours to ED department Team established and plan completed by 30 September 2014 Active Specialist services pathways reported Reporting Quarterly 70 Objective 2.4.7 Actions to Deliver Improved Performance TDHB will maintain and support specialist advice services for GPs in their management of patients in the primary care environment. These services are Mental Health and Paediatrics. Resources for increased access to community radiology was provided for last financial year and TDHB commits to the maintenance of that funding level into the 2014/15 year with an expectation of an additional 3250 RVUs of general radiology being delivered above the baseline delivery as identified in 2012/13. Measure Reporting Specialist services pathways implemented by Quarter 2, 2014. Quarterly Primary access to radiology increased by 3250 RVU’s above 2012/13 baseline of 31,897 RVUs Quarterly Health of Older People 2.4.7.1 Our Approach During 2014/15 we will continue to work with our primary care partners and regional DHBs to develop and refine integrated services that will address the needs of older people - from those with basic needs to those whose needs have a greater complexity, working towards a restorative outcome wherever possible. During 2014/15 we will continue our focus on establishing a regional approach to the delivery of Home and Community Support Services. The Midland DHB region will participate in the development of the national Health of Older People Steering Group’s national framework and on the cost implications of quality care. Where applicable we will use the framework to inform decision-making about the implementation of a Midland DHB regional approach. 2.4.7.2 Linkages Our Performance Story Impact: People receive timely and appropriate specialist care Midland District Health Boards Regional Services Plan 2014/15 Midlands Health of Older People Clinical Action Network Action Plan 2.4.7.3 Action Plan Objective Health of Older People Actions to Deliver Improved Performance Rapid response and discharge management services (wrap around services) (PP23) Measure Reporting Quarterly TDHB will implement an ED Rapid Response Service aimed at identifying elderly with complex comorbidities and optimising their management to maintain functional independence and reduce avoidable readmission to Appointment of 1.0FTE Clinical Nurse Specialist by 1 July 2014 Number of over 65’s who undergo initial assessment by the Clinical Nurse Specialist (establish baseline in 2014/15) Reduction in over 75s ASH rates 71 Objective Actions to Deliver Improved Performance ED and hospital through the appointment of 1FTE Clinical Nurse Specialist who proactively identifies cases presenting in ED Home and Community Support Services for Older People (PP23) TDHB will appoint an additional 1FTE Care Manager (an increase from 7FTE to 8FTE) to work with older people identified as having high and complex needs to ensure timely and effective assessment using InterRAI Home Care TDHB will use the quality measures for HCSS as identified by the DHB HOP Steering Group Use of Budget 2013 funding for home and community support services Use of quality measures for Home and Community Support Services identified by the DHB HOP Steering Group Dementia Care Pathways (PP23) Measure Reduced ED re-presentation for over 75s Appointment of 1 FTE Care Manager by 1 July 2014 An additional 2500 hours/visits per year of HCSS will be delivered above 2013-14 baseline (actual hours delivered in 2013/14) Evidence of DHB using interRAI quality measure to progress and compare performance with other DHBs (to be finalised by HOP Steering Group) Reporting Quarterly Quarterly Local Dementia Pathway initiatives: Continued development and implementation of the Taranaki dementia care pathway Deliver Living Well Groups aimed at people recently diagnosed with dementia and their carers Ongoing education to the primary care sector on use of the dementia care pathway Continued development and implementation of Taranaki dementia care pathway Local Dementia Pathway initiatives: Regional Dementia Pathway initiatives Work with Midland DHBs to implement region-wide Primary Dementia Education Programme including dementia workshop, education and resource development to support use of the Map of Medicine dementia pathway across the Midlands Region Regional Dementia Pathway initiatives): Map of Medicine hits per GP practice Map of Medicine hits per GP Referrals to Alzheimers New Zealand Dementia care pathway in place 1 July 2014 2 Living Well Groups by end June 2015 10 GP practices have dementia care pathway packs in place and have received education 72 Objective Actions to Deliver Improved Performance Fracture Liaison Service (PP23) TDHB will recruit 0.5 FTE Fracture Nurse Coordinator to establish and manage the fracture liaison service from 1 July 2014 Full operation of a fracture liaison service Measure Quarterly 0.5FTE Fracture Nurse Coordinator is appointed by 1 July 2014 Number of over 65s identified as having fragility fractures referred for assessment by the fracture liaison nurse coordinator (establish baseline in 2014/15) Number of over 65s assessed by the Fracture Liaison Nurse and referred for bone density scans (establish baseline in 2014/15) Number of over 65s assessed by the Fracture Liaison Nurse and treated with appropriate medication in line with pathway (establish baseline in 2014/15) Reduction in current number of fractures NOF for over 65s as measured against 12-13 baseline data (currently 102 in 2013/14) Comprehensive Clinical Assessment in Residential Care (interRAI) (PP23) TDHB will provide ongoing support to the InterRAI long term care facility training programme through the provision of TDHB training facilities and support from the TDHB lead practitioner as required TDHB will continue to actively support aged care facilities to take up InterRAI training Facilities trained or engaged in training in the use of interRAI DHBs supporting the uptake of interRAI training Quarterly All aged residential facilities in DHB area using, or training their nurses to use, the interRAI LTCF assessment tool Evidence of how the DHB has supported the uptake of interRAI training (e.g. provision of training facilities at no cost, provision of support through TDHB Lead Practitioners) 100% of aged residential care facilities in TDHB area are using the InterRAI LTCF assessment tool by June 2015 Narrative report outlining actions TDHB has taken to support update of InterRAI LTCF training HOP Specialists (PP23) Proactive use of DHB specialist Health of Older People Services (geriatricians, gerontology nurse specialists) to advise and train health professionals in primary care and aged residential care TDHB will continue the proactive use of DHB specialist HOP Reporting Quarterly The DHB has increased the number of hours that specialist HOP services consult with health professionals in primary care and aged residential care (‘maintain’ rather than increase if already at an optimal level) or used another relevant measure to show an increase or 73 Objective Actions to Deliver Improved Performance services (Geriatricians, Gerontology Nurse Specialist) to advise and train Health Professionals in primary care and aged residential care TDHB has reviewed the role of the current Aged Care Nurse Consultant. This role will now be expanded to become a Gerontology Nurse Specialist role that provides practical, hands on clinical support and advice to aged residential care facilities caring for residents with high and complex needs with the aim of reducing avoidable ED and hospital admissions. Referrals will come via ED and following hospital discharge, or via TDHB Care Managers/Geriatricians following reassessment within an aged residential care facility Regional Alignment: 2.4.8 Continue to engage with Midland DHBs in development of the new service model and funding model for restorative home support Measure Reporting maintenance at optimal level (eg using FTEs rather than hours) Maintain the number of hours that specialist HOP services consult with health professionals in primary care and aged residential care at 250 hours per quarter Employment of 1 FTE Gerontology Nurse Specialist to work with complex clients in aged residential care Number of clients care managed by Gerontology Nurse Specialist – establish baseline Reduction in presentation rates to ED from aged residential care Quarterly New service and funding model implemented 30 June 2015. TBC at regional level Mental Health Service Development Plan 2.4.8.1 Our Approach A number of the planned actions in this area have been developed in association with the other four DHBs in our region. 2.4.8.2 Linkages Our Performance Story Impact: People receive timely and appropriate specialist care Midland District Health Boards Regional Services Plan 2014/15 Mental Health and Addiction Service Development Plan 2.4.8.3 Action Plan Objective Mental Health Service Development Plan Actions to Deliver Improved Performance 1. Make better use of resources/value for money Continued participation in Adult and Child and Youth Key Performance Indicator Forum – The adult KPI forum will focus on the agreed national KPIs for improvement. KPI data used to improve performance Measure See Module 7 – non-financial performance measures. Measures no: PP6, PP7,PP8 ,PP26 & OS10 Improving the health status of people with severe mental illness PP6 Reporting Quarterly 74 Objective Actions to Deliver Improved Performance Measure December 2014 – Provider Arm, NGO partners will attend KPI forums and implement at least 1 quality improvement activity Expand access and decrease waiting times Increasing number of patients with relapse plans in place through review of current plans and completion of new plans (excludes addictions) 60% of patients have relapse plans by June 2015. Milestone of 50% at end December 2014 Service redesign of adult intake processes to decrease waiting times and improve flow for newly referred patients Waiting time for adult outpatient services is reduced to achieve the targets in PP8 by June 2015. Milestone of 80% being seen <= 3 weeks and 95% being seen <= 8 weeks to be achieved by end December 2014 Continue to monitor the existing discharge delay codes within the inpatient unit to better understand reasons for delayed transfers of care 2. Improve integration between primary and specialist services Type and number of discharges recorded to establish baseline Quarterly Implementation of project outcomes from 2013-2014 Midland Health Network and Specialist Mental Health and Addictions Services Primary Secondary Integration – shared care etc Develop a project scope for management of non-complex Clozapine in primary care Project scope completed by September 2014. Aim for initial patients to be managed in primary care by June 2015 Provide education and training for GPs on management of patients with addiction through day training event with open invitation 3. Cementing and building on gains in resilience and recovery with for people with low-prevalence conditions and/or high needs Training content decided by September 2014 and training completed end June 2015 By July 2014 final reconfiguration for Residential services implemented By December 2014 models of care for redesign of nonresidential services complete Implementation of new models of care for residential services – increasing the options of services to enhance active intensive rehabilitation and recovery and ensuring resources Reporting 75 Objective Actions to Deliver Improved Performance are flexible and able to transition with tangata whaiora through their recovery journey Measure By June 2015 implementation of service re-design for nonresidential services complete TDHB will facilitate people’s access to parenting support programmes through improved data collection and embedded referral pathways. The data will be collected through initial assessment and development of management plans 4. Deliver increased access for all age groups Audit of initial assessment for data collection and audit of management plans – baseline to be established by December 2014 with aim of 50% appropriate management plans by June 2015 To reduce DNA rates through range of activities including exploring options for using the ‘Text To Remind’ system to send a text message to service users reminding them of their appointment, surveying patients to ask them why they do not attend and looking at DNA rates across teams Review service entry and exit criteria for community service users against current client base – review service users with subclinical HONOS scores for potential discharge from service Quarterly Current DNA rate 8.75%. Aim to reduce to 8.5% by December 2014 and less than 8% by June 2015 Current sub-clinical HONOSCa = 9%. Current sub-clinical HONOS = 8.5%. Aim to utilise HONOS sub-clinical data routinely to assist MDTs in decision making regarding entry and exit. Assess utility via internal audit and report acceptance of new referrals & discharges across all services monthly Outcomes Champions Group to establish agreed sub-clinical reduction targets by December 2014 based on good clinical practice in combination with outcomes data such as HONOS Implementation of the New Zealand Suicide Prevention Strategy 20062016 and the New Zealand Suicide Prevention Action Plan 2013-2016. Submission of District Suicide Prevention and Postvention Plans for review in the second quarter reporting Annual ASIST training offered to Primary Care, School Counsellors and other health and non-health professionals working with young people Establishment of a local interagency collective with other lead agencies to implement the Action Plan TDHB’s Plans to be finalised to include training health workers to identify and support etc Reporting Quarter 2 Number of training sessions offered. Numbers and types of professionals taking up training – reporting in accordance to the PMHI quarterly reporting Six monthly reporting from agencies against milestones in the plan Plans in place December 2014 76 Objective Drivers of Crime and Welfare Reforms 2.4.9 Actions to Deliver Improved Performance Established working group with the following local agencies who are part of the Suicide Prevention Action Plan – MSD (CYF), MYD, MOE, MOJ, Corrections Mental Health and Addiction Service provision ring-fence will be maintained as per MoH expectations of 2013/14 Funder expenditure plus CCP of 0.61%. Continued delivery of the actions and outcomes from the South Taranaki Social Sector Trial. Also refer Youth Mental Health Section Improving maternity and early parenting support. Also refer sections for Maternal and Child Health and Children’s Action Plan o Implementation of identified actions from the Phase II, Perinatal and Infant Mental Health Midlands Regional Project Continue to proactively work with other agency partners, MSD including CYP, investing in Services for Outcomes (ISO), Education, Corrections, Policy, to develop and embed a way of working together that improves outcomes for the population that accesses multiple services. Also refer Youth Mental Health and Children’s Action Teams Measure Reporting Plans in place December 2014 Financial expenditure records increased expenditure Monthly monitoring of actions and milestones against the Social Sector Trial Action Plan Quarterly Monthly reporting to the Board Quarterly Midland Mental Health and Addictions Regional Network reporting Quarterly Quarterly reporting interagency activity Quarterly against Maternal and Child Health 2.4.9.1 Our Approach We intend to undertake actions to improve the access that pregnant women, babies, children and families have to services that maintain good health and independence through: 2.4.9.2 Supporting them to enrol with a GP and Well Child Tamariki Ora (WCTO) provider as early as possible Alerting health providers when a child or young person is due for a health milestone Better informing all providers about the progress of a child or young person Linkages Our Performance Story Impact: People stay well in their homes and communities Our Performance Story Impact: People take greater responsibility for their health Midland District Health Boards Regional Services Plan 2014/15 77 2.4.9.3 Action Plan Objective Actions to Deliver Improved Performance Timely Registration with an LMC Newborn Enrolment Measure TDHB will increase the number of women who register with an LMC by week 12 of their pregnancy by o Monitoring numbers at the MQSP Meetings o Maintenance and update of the ‘Find Your Midwife’ website o Ensuring midwife availability is known o GP education to have patients contact the Maternity Unit if they are unable to find a Midwife All newborn babies are enrolled with a PHO and registered with a GP, Well Child Tamariki Ora (WCTO) provider and Community Oral Health Services by: Increase new-born enrolments from 66% to 88% by December 2014 at 2 weeks of age 100% of new-borns are enrolled with general practice by 6weeks, measure B code uptake Continuing to ensure all babies are enrolled at discharge from the Maternity Unit o Education of parents and written information given on discharge to support this o Monitor and audit use of the discharge checklist to ensure all relevant services are discussed with the parents and babies are enrolled o Continue to work with Maori Health to ensure babies are registered for oral health services at birth – opt out system in place to gain consent for contacting parents for enrolment their child later on Through the Taranaki WCTO QIF – Access Indicator 1 – New-borns are enrolled with a PHO by two weeks of age. Work towards 100% enrolment. o Monitoring of the WCTO Quality Improvement Framework (QIF) Implementation Plan for Indicator 1 – new-borns are enrolled with a PHO by three months of age At least 80% of women register with an LMC by week 12 of their pregnancy Reporting Quarterly Quarterly By December 2014 delivery against identified actions in the WCTO QIF Plan 78 Objective B4 Checks School HPV Oral Health Actions to Deliver Improved Performance Measure Maintain B4 School Check coverage to 90% of the eligible population Providing additional B4 School Check Clinics to support increased coverage Reducing the enrolment age from 4.7 to 4.1 to enable more time to capture the children Enrolments of preschool- Maori children under 5 years of age will increase from 59% in July 2014 to 70% by July 2015 Quarterly Monitoring of the following indicators: o % of parents who wish to opt out from being contacted around enrolment o % of children who are enrolled but have never attended an appointment o Number of preschool children newly enrolled monthly Quarterly At least 90% of children receive a B4 School Check, including at least 90% of children living in high deprivation areas At least 70% of girls have received dose one, 65% of girls have received dose two and 60% of girls have received dose three – To be confirmed Quarterly Routinely recalling all those who DNA Combining VHT and B4 School Checks in high needs areas to reduce the number of visits for patients TDHB will continue a school based HPV programme starting February 2014 via the Public Health Nurses including education, sessions for parents and children Auditing of IT database Titanium to match with DHB Patient Management System to identify and contact those currently not enrolled Mobile dental units being utilised more efficiently during school holiday time Family based checks continue Text to remind changing to a local 0800 number to ensure more texts are sent back Implementation of the actions from the Menemene Mai Oral Health Project – aiming to improve the oral health among Maori children thus reducing the disparity in oral health outcomes between Maori and Non-Maori Delivery against the Taranaki WCTO QIF Indicator 16 – Children are caries free at five years of age Reporting Monthly & Quarterly Monitoring 14/15 achievement against targets as listed below PP10 Oral Health DMFT Score at Year 8 is 0.9 PP11 – 62% of five year olds carried free PP12 - 85% adolescent utilisation Quarterly Quarterly PP13 - 85% of preschool enrolled and 10% of children overdue for their scheduled examination Quarterly Increasing the numbers of Maori children who are caries free at five years of age from 35% currently to 40% by December 2014 Quarterly 79 Objective Actions to Deliver Improved Performance Services for Pregnant Women, Babies, Children and Families Services for pregnant women, babies, children and families are of high quality and are nationally consistent: TDHB will provide services for pregnant women, babies, children and families that are of high quality and are nationally consistent by: o Maternity Quality and Safety programme (MQSP) meeting regarding TDHB’s care and clinical outcomes with actions relating to these occurring o Mental health pathway for pregnant women – implementation to be continued o Continuing to work closely with Maori health to capture vulnerable women and families to ensure earlier access to appropriate services o Rollout of second phase of the Midland Regional Perinatal and Infant Mental Health project. Working across agencies To develop and establish a referral process and pathway for hospitalised pregnant smokers to Mana Wahine Hapu and specialist smoking cessations services by December 2014 Links to Smoking Cessation Section By August 2014 development of the training plan for Hospital Midwives and LMC’s furthering education and resources for smoking cessation Reporting against WCTO QIF Plan Outcome: Indicator 19 – Mothers are smokefree at two weeks postnatal Continue to implement Maternity Quality and Safety Programme, identify local quality improvement priorities that include addressing National Maternity Monitoring Group priorities, DHBs who are outliers in the NZ Maternity Clinical Indicators put programmes in place to reduce unnecessary variation in clinical practice Maternity Quality Safety & Measure Reporting Quarterly Improved performance against WCTO Quality Indicators measuring access as agreed with MoH Quarterly Regional and local Reporting against project milestones. Reporting against the MQSP milestones Improved quality and safety of maternity services including improved access, outcomes and consumer satisfaction as measured by national and DHB data analysis and surveys, reduced variation in performance against the NZ Maternity Clinical Indicators Quarterly 80 Objective Gestational Diabetes Actions to Deliver Improved Performance Improving Breastfeeding Rates Mama Pepe Hauora Programme on Improving Maternal Nutrition and Breastfeeding Implement the national guidelines for the screening, diagnosis and management of gestational diabetes TDHB awaits the national guidelines for the screening, diagnosis and management of gestational diabetes and will implement when appropriate to improve the care for Taranaki women (expected to be released in early 2014) Expand Breastfeeding Welcome Here (BFWH) framework Maintain the Baby Friendly Community Initiative (BFCI) Continue to deliver the Peer Support Counselling Service Complete the Lactation Consultant Scholarship Programme Reporting against WCTO QIF Plan Outcome: Indicator 13 – Infants are exclusively or fully breastfed at three months of age To improve women’s health during pregnancy and the post-natal period through promotion of healthy eating and physical activity : Supporting five priority communities to develop, implement, and evaluate at least one new maternal and child physical activity and nutrition initiative in each community Promote healthy feeding of babies including encouraging and supporting breastfeeding Expanding the Breastfeeding Welcome Here (BFWH) framework to accredit a minimum of two workplaces, early childhood providers, or other settings in each of the five priority communities Maintaining accreditation and expanding the content of the Baby Friendly Community Initiative (BFCI) with the existing four providers to include maternal and child physical activity and nutrition Measure Reporting A nationally consistent approach to the screening, diagnosis and management of gestational diabetes By July 2014 the four chosen indicators with actions will be and targets will begin implementation. Monitoring through quarterly reporting Quarterly By December 2014 10 settings in the community will be BFWH accredited By June 2015 all three organisations achieve annual BFCI education status By June 2015 120 New Peer Support Referrals received All four recipients become registered Lactation Consultants by November 2014 By December 2014 delivery against identified actions in the WCTO QIF Plan 6 Monthly By December 2014 Active Movement Training in a minimum of 20 settings in the five priority communities will be delivered Five new initiatives planned, implemented and evaluated by June 2014 6 Monthly By July 2014 six new Peer Support Counsellors are trained 6 Monthly By December 2014 10 settings in the community will be BFWH accredited 6 Monthly Each organisation will undertake annual education (including physical activity and nutrition) to maintain BFCI standards to achieve reaccreditation 6 Monthly Quarterly 6 Monthly 6 Monthly 6 Monthly 6 Monthly 6 Monthly 81 Objective Actions to Deliver Improved Performance 2.5 Measure To promote healthy feeding (including the introduction of healthy first foods) and physical activity of children at pre-school age Reporting By December 2014, Mama Pepe Hauora Toolkits delivered to 20 organisations/groups across five priority communities 6 Monthly NATIONAL ENTITY INITIATIVES 2.5.1 Our Approach We are expected to align our planning with the planning intentions key national agencies. Each of these national agencies has initiatives for the 2014/15 year, which will impact on our DHB. The following table outlines the initiatives each agency has identified as a priority. 2.5.2 Linkages Midland District Health Boards Regional Services Plan 2014/15 Module 4 – Financial Performance 2.5.3 Action Plan Initiative Brief Description Summary of Strategic Rationale Key Actions Taranaki DHB will undertake to contribute to the initiative HBL and DHBs are working together to implement a national Finance, Procurement and Supply Chain programme to combine their purchasing power through standardising the ways goods and services are ordered, delivered, stored and paid. HBL and DHBs are currently assessing options as part of completing the detailed business case for reducing the costs of Food services. It is a priority to improve the overall quality of hospital food service to ensure good nutrition for all patients. Detailed business case forecasts saving of $538 million over ten years - from an investment of $88 million - with all the savings being reinvested back into supporting frontline health services. The DHB will commit resources to the implementation of HBL’s FPSC initiative, and fully factor in expected budget benefit impacts. The Indicative Case for Change identified the potential for savings of $10 million a year. HBL and DHBs are currently assessing options as part of completing the detailed business case for reducing the costs of Linen & Laundry services, while improving service delivery quality. The Indicative Case for Change identified the potential for savings of $7 million a year. The DHB is committed to working in partnership with HBL to progress the Food Services, Linen and Laundry Services and National Infrastructure Platform business cases. The DHB will commit resources to the decision reached in relation to these Detailed Business Cases. As above. Health Benefits Ltd (HBL) Finance, Procurement & Supply Chain Food Linen & Laundry 82 National Infrastructure Platform Human Resources Management Information Systems Banking & Insurance The vision is for a national infrastructure platform with agreed standards and policies and a single governing organisation, delivered out of significantly fewer than the 40-50 current physical data centres. It will also align the health sector’s infrastructure services with the Government’s overall Information Communications Technology goal of harnessing technology to deliver better, trusted public services. The Indicative Case for Change for a staged approach to seeking improvements to Human Resource Management Information Systems, not payroll systems, is to be shared with DHB CEOs in early 2014. It focuses on improved workforce management practices. Collective approach to national banking arrangements across 20 DHBs for transactional banking services, cash management and working capital facilities; plus collective approach to insurance cover for DHB assets. Financial modelling in the Indicative Case for Change indicated that over the first 5 years (transition phase) a range of $71.4 - $169.8m in cost avoidance could be achieved. As above. Improved workforce management practices are expected to lead to cost savings - which will be confirmed as part of any decision made to proceed to a next stage. The DHB will commit resources to the decision reached in relation to progressing the Indicative Case for Change for the Human Resources Management Information Systems initiative to the next stage. Case already approved and actions underway. Actions have led to avoided costs which are expected to amount to around $4.5m for banking in 2013/14 and $11m for insurance in 2013/14 The DHB will continue to support the collective approach to banking and insurance to ensure maximum benefits are realised. Implementation of electronic reconciliation of medicines on admission and discharge from hospital. Without medicines reconciliation, studies have shown that there is up to a 50% error rate in the patient's drug chart. eMR reduces this rate to below 10%. eMR enhances both patient safety, the quality of clinical decision-making and the efficiency of managing the patient's drug chart. The DHB is aligned with the NHIT Board and is committed to the agreed implementation plan for the pilot of eMedicines Reconciliation (eMR). National Health Information Technology Board eMedicines Reconciliation (eMR) with eDischarge Summary In 2014/2015 the DHB will upgrade the current eMedicines Reconciliation system to the latest version and progress the implementation as per the programme. 83 Regional Clinical Workstation (CWS) and Clinical Data Repository (CDR) Implementation of a regional Clinical Workstation (Orion, Concerto) and Clinical data repository (mixed products). The CWS is a web based system, accessed via a single sign-on that connects multiple clinical applications and data sources to provide clinicians with secure access to patient data. Replacement of Legacy Patient Administration Systems National Patient Flow Self-Care Portal A CDR is a database of patient identifiable clinical information such as medications, laboratory results, radiology reports, care plans, patient letters and discharge summaries. The 8 DHBs with legacy PAS need to progress implementation of a supported system that is aligned with the regional plan. The PAS supports and manages the administrative details of a patients encounter with a hospital or DHB service. It supports the management of the hospital resources used to provide patient care such as clinical staff, rooms, beds and equipment. National Patient Flow will create a new national collection that provides a view of wait times, health events and outcomes in a patient’s journey through secondary and tertiary care. Portals are an on-line IT tool that will enable individuals to have access to their own health information. It will also allow hospital based services, in particular, ED, to have access to a summary view of primary care information. Clinical Workstation and Clinical Data Repository allow a patient centric view of clinical information from a hospital (or community) setting. It is the basis for a regional electronic health record and is the essential platform enabling support of other high value functionality like eMR, electronic orders, and results sign-off. It will also support a person's on-line access to their own health record The deployment of CWS (including the supporting CDR) will be considered as part of the eSPACE programme roadmap and rolled out in line with clinical and business priorities and Midland release planning. Hospital based patient administration systems are a fundamental enabler to support other high value functionality, like Clinical Workstation and National Patient Flow. 8 DHB's need to replace their obsolete systems The DHB is aligned with the Regional Patient Administration System (PAS). National Patient Flow aligns with the vision of better integrating care so that patients can receive the appropriate services, in the right setting and in a timely way to improve overall health outcomes. Patients, referrers and providers need to better understand demand for services and waiting times. This is an essential delivery to achieve the IT Board's vision of “a core set of personal health information available to [patients] and their treatment providers regardless of setting". Portals will enable people to take more control of their The DHB commits to collecting First Specialist Assessment (FSA) referral information, including outcomes of referrals, from July 2014 (Phase 1); and to collecting Phase 2 information from July 2015. Waikato and Lakes DHBs will be the only Midland DHBs to deploy in 2014/201515 and further deployment at other DHBs, will need to be confirmed. Note that Taranaki already uses the Orion Concerto and Sysmex Éclair products locally. The current PAS will be upgraded to the latest version during May/June 2014. The development and delivery of Self Care portals will be considered as part of the eSPACE programme roadmap and rolled out in line with clinical and business priorities and Midland release planning. 84 In later phases, it will enable patients to communicate with their primary health practitioners and add information to their health record. Each of the General Practice Patient Management System (PMS) vendors are developing portals, and Orion Health is developing a portal in conjunction with Canterbury DHB eSCRV project. own care. They will change the way care is delivered and save time for patients and practices. Recent surveys indicate that 15 to 20% of patients are interested in enrolling for portal access. DHB support for ongoing hosting costs of the national surveillance data warehouse from July 2015. Goal - Removal / reduction in preventable patient harm resulting from surgical site infections throughout the New Zealand Health and disability sector National and local surgical site infection surveillance system to generate verifiable information that drives practice change and improvement The DHB will commit to meeting infection control expectations in accordance with Operational Policy Framework - Section 9.8. Patient experience indicators help measure and report how consumers and patients actually experience the health system – what happened to them and how did it make them feel? By capturing this consistently and coherently across New Zealand’s health system, this information can be used to make substantial improvements to both the experience and the actual quality of care received. The DHB commits to surveying patient experience of the care they received using the national core survey, at least quarterly. Building sector capability and clinical leadership and a culture of quality and safety improvement The DHB will meet expectations in accordance with Operational Policy Framework Section 9.3 & 9.4.6. Health Quality and Safety Commission Surgical site infection programme (SSIP) National Infection Surveillance Data Warehouse Surgical site infection programme (SSIP) DHB Infections Management systems (ICNet NG system) Patient experience indicators Capability and Leadership DHB adoption of ICNet NG Infections Prevention and Control Systems investment and implementation including local integrations. Both Hospital and Community with National hosting. The Commission now holds the licence for the use by DHB's of Picker’s inpatient survey questions. About 40 of these which have a close relationship with the four “domains” of patient experience (communication, partnership, co-ordination and physical and emotional support) Programmes to support improvement science and increased clinical leadership. The DHB will continue development of infection management systems at our local DHB level. 85 E-medicine / E prescribing Joint work programme with NHITB for an electronic system to access patient medication information Improved electronic medication management The DHB will continue to commit resources to support the current ePrescribing and eMedicines installation in place within the agreed priority areas by [date]. One of HWNZ’s priorities is to have 100 diabetes nurse prescribers either in training or trained by July 2014. To date diabetes nurse prescribers have been in secondary services. This initiative could potentially be rolled out to include more general practice/community nurses working in diabetes management. The General Practice Education Programme (GPEP) includes opportunities for registrars to complete the equivalent of at least 120 days' training alongside a doctor registered in a vocational scope other than general practice. Training opportunities for the group of registrars entering year 2 of their training need to be available in DHB-funded services from 1 December 2013. The sonographer workforce needs to grow by 300 full time equivalent (FTE) employees over the period to 2023, more than double the current FTE numbers, to enable more timely delivery of healthcare services, and to meet increased demand from demographic change and growth of sonography as a diagnostic tool. Increasing the numbers of Diabetes Nurse Prescribers will contribute to improving services being offered for diabetes enabling healthcare to be delivered closer to home. Increasing the numbers of Diabetes Nurse Prescribers will also free up Diabetes Specialists to manage complex patients. The DHB supports the regional approach being taken to addressing key workforce requirements on diabetes nurse prescribers. GPs who have gained knowledge and experience from working with doctors of other vocational scopes will have enhanced understanding of the work of DHBs, will be able to deliver improved patient care, and are expected to actively reduce acute admissions. The DHB supports the regional approach being taken to addressing key workforce requirements on GPEP 2 registrars. Current numbers of sonographers across both the public and private sectors are unable to meet demand in many places and without workforce development, healthcare services will be compromised. The DHB supports the regional approach being taken to addressing key workforce requirements on sonographers. Health Workforce NZ 100+ diabetes mellitus nurse prescribers either in employment or in training by 1 July 2014. Implementation of training requirements for GPEP2 registrars to train with doctors of other vocational scopes. Sonographer workforce 86 Implementation of the new 70/20/10 funding criteria for post-entry training in medical disciplines, effective from 1 January 2014 The funding model is part of the DHBs' new medical contract for post-entry training agreement with HWNZ that comes into effect on 1 January 2014. The new funding model replaces the previous bulkfunding approach and provides a more transparent, inclusive and fair process. The model was developed by the HWNZ Board and NHB and seeks to clearly identify what training HWNZ is purchasing. The DHB will support the growth of the medical workforce by aligning training funding to the 70/20/10 model to be implemented by July 2015. Burden of Disease Review Prioritise future work programmes by undertaking review burdens of disease for two or three major programme budget spends. Likely to be musculoskeletal, endocrinology and cancer. A second tier of work will analyse specific disease states for suitability to undertake Health Technology Assessments The DHB will support the NHC work programme by engaging with and providing advice on the burden of disease documents. Sector Referral Round Call for sector to refer significant technology issues to the NHC for assessment. Development of recommendations and implementation strategies Working and Advisory groups to the NHC to facilitate the development of recommendations the sector will be able to consistently implement. Ensure clinical outcomes are improved and the cost curve for health is bent by using a programme budget to identify large and fast growing health sector spends where there are pathways of care which deliver outcomes which can be improved and there is a reliance on technologies for which the evidence is untested. Ensure clinical outcomes are improved and the cost curve for health is bent by identifying new and significantly expanding technology cost drivers for the sector which are not captured by the NHC through the burden of disease review process. Consistent implementation of recommendations is essential to being able to realise improved pathways of care and notional savings. National Health Committee (NHC) The DHB will support the NHC work programme by referring technologies that are driving fast-growing expenditure to the NHC for prioritisation and assessment where appropriate. The DHB will support the NHC work programme by providing expert clinical opinion to working and advisory groups on health technology assessments where possible. The DHB will not introduce emerging technologies where the NHC has recommended that these technologies should not be introduced. 87 Identification of notional savings Working and Advisory groups to the NHC to facilitate the development of recommendations the sector will be able to realise notional savings from. Consistent implementation of recommendations is essential to being able to realise improved pathways of care and notional savings. Health Innovation Partnership Trial promising technologies outside business as usual while evidence is gathered for final recommendations. Development of regional prioritisation networks Improve capability and capacity for consistent health technology prioritisation for issues which are significant at a regional level. Hold technologies, which may be useful, but for which there is insufficient evidence, out of business as usual while the evidence is gathered in a standardised manner Ensure clinical outcomes are improved and the cost curve for health is bent by identifying new and significantly expanding technology cost drivers for the sector which are not sufficiently material at a national level to be captured by the NHC through the burden of disease review and referral round process. The DHB will support the NHC work programme by providing expert business opinion to working and advisory groups on health technology assessments where possible. The DHB will support the NHC work programme by providing clinical research time to design and run field evaluations where possible. The DHB will support the NHC work programme by referring technologies that are driving fast-growing expenditure and that have not been prioritised for assessment at a national level, to the Regional Prioritisation Network where appropriate. Health Promotion Agency Health target promotional activities Alcohol and pregnancy HPA is often requested to undertake national health promotion activities to support the achievement of Government health targets. Our draft objectives for this work programme are to make significant contribution toward the prevention of children being born with Fetal Alcohol Spectrum Disorder (FASD) by: 1.reducing the number of women consuming alcohol while they are aware they are pregnant or planning to become pregnant 2.increasing public awareness of the risk associated with alcohol consumption during pregnancy 3. supporting health professionals (particularly GPs, obstetricians, midwives, well-child nurses, and other primary care providers) to respond in a routine This aligns to Government health priorities, health outcome impacts, and health system enabler The DHB will support national health promotion activities around the health targets. Aligns with Government priorities, particularly around the child health action plan and the recommendations by the Health Select Committee The DHB will support work undertaken by the Health Promotion Agency on preventing Fetal Alcohol Spectrum Disorder. 88 effective and consistent way to women who are drinking while pregnant or planning to become pregnant Implementation of alcohol law reform Sale and Supply of Alcohol Act (2012) requires Medical Officers of Health to work more collaboratively with regulatory agencies and have more involvement in the licensing process. Medical Officers of Health will require ongoing support to maximise opportunities through the law changes. Give effect to Government law, contributes to objectives of the Act including reduction in local alcohol harm The DHB will comply with the requirements of the Sale and Supply of Alcohol Act 2012, including enabling the Medical Officer of Health to comply with their specific responsibilities and duties outlined under the Act. The interim national procurement of medical devices will seek to obtain 'quick wins' from procurement of certain types of medical devices in advance of the full establishment of the standard financial management information system for all 20 DHBs (as part of HBL's FPSC implementation). Reflects transition from interim activity to steady state - which includes assessment of new devices, health technology assessment, active category management, category reviews and tendering. Reflects Cabinet requirement for PHARMAC to assume this role. The 2013/14 SOI notes expect net savings of $4.33m in 2014/15 and $14.76m in 2015/16. The DHB will support PHARMAC in commencing its interim procurement role for hospital medical devices, including committing to implement new national medical device contracts, when appropriate. Cabinet above. By 2017/18, expect PHARMAC to assume responsibility for full budget management of hospital medical devices. Cabinet requirement - as above. While hospital medical devices category management establishment has been identified as a national entity priority initiative, the DHB and the Ministry do not expect this to have an impact on the 2014/15 planning. While hospital medical devices interim budget management has been identified as a national entity priority initiative, the DHB and the Ministry do not expect this to have an impact on the 2014/15 planning. PHARMAC Hospital medical devices interim procurement Hospital medical devices category management establishment Hospital medical devices interim budget management requirement- as 89 Hospital pharmaceuticals management Development of hospital pharmaceuticals schedule for DHBs. Reflects Cabinet requirement for PHARMAC to assume this role. This is expected to materially bend the cost curve down over time. Hospital pharmaceuticals budget management Completing work towards full budget management of hospital pharmaceuticals (per community pharmaceuticals budget management). Cabinet requirement - as above. The DHB will support PHARMAC in progressing its hospital pharmaceuticals management function. Note – as no data is available on growth within the existing medicines usage, the DHB will need to use local cost forecasting to identify changes that may result. While hospital pharmaceuticals budget management has been identified as a national entity priority initiative, the DHB and the Ministry do not expect this to have an impact on the 2014/15 planning. The following table describes the planned funding allocated to the National Entities initiatives for the 2014/15 year: 2014/15 Plan Year One Inclusions in 2014/15 DHB Annual Plan 2014/15 Year One Capital Costs $'000's HBL Core funding- incremental costs to core funding of $6m pa Finance, Procurement & Supply Chain Food Linen & Laundry National Infrastructure Platform IT Procurement Human Resource Management Information Systems Banking & Insurance- incremental costs to current budget of $0.36m in 2013/14 NH IT Board eMedicines Reconciliation (eMR) with eDischarge Summary Regional Clinical Workstation (CWS) and Clinical Data Repository (CDR) Replacement of Legacy Patient Administration Systems National Patient Flow MoH contribution to National Patient Flow Self-Care Portal HQSC Surgical site infection programme (SSIP) - National Infection Surveillance Data Warehouse SSIP - DHB Infections Management systems (ICNet NG system) Patient experience indicators Capability and Leadership E-medicine / E prescribing PHARMAC Hospital medical baseline shift from DHBs to PAHRMAC Total Impact for Taranaki DHB 2014 / 15 Core funding- non-incremental costs share core funding of $6m pa Operating Costs One-Off Ongoing $'000's $'000's (67) (12) Operating Benefits $'000's (85) (41) Net Operating $'000's 0 (97) 0 0 0 0 (41) 0 (20) (20) 0 0 (139) 0 (132) (139) (132) 0 0 (15) 0 0 (15) 0 (67) (324) (35) (163) (85) (444) (163) 90 2.6 IMPROVING QUALITY Quality and patient safety are a top priority with many initiatives successfully in place and others underway. But there is always more to do. Staff want to make a difference for our patients and their ongoing actions are critical to patient safety. 2.6.1 Our Approach The Taranaki DHB is committed to the delivery and funding of quality services by all health and disability provider within the district. Quality assurance systems and procedures are in place to ensure services undergo performance measurements (usually focused on service content, delivery specifications and patient/client outcomes). Continuous quality improvement is the response to this quality activity and supports the mission of the Board – Taranaki Together, a Health Community. Improvements in patient and staff safety, practice service delivery and risk mitigation are supported by the Taranaki DHB, recognising that there needs to be a balance maintained between achieving the necessary improvements, mitigating risk and the costs of doing so. The tension and challenge lies in finding this balance. We continue to broaden our quality and risk management approach from the Taranaki DHB Hospital Provider as our key point of reference, to an approach that involves the entire health and disability sector in Taranaki, particularly engaging with clinicians and clinical services. Our Strategic Quality and Risk Plan facilitates the progressive achievement of the DHB’s vision by assisting us to meet the challenge of continuously improving service provision and quality of care by ensuring patient safety and robust systems and processes. The Strategic Plan outlines the Taranaki DHB’s: Quality and risk framework Strategic objectives Dimensions of quality and our associated goals Quality and risk committee structure Staff responsibilities Links into the Health Quality and Safety Commission’s areas of focus identified in their Statement of Intent We are committed to implementing the initiatives specified by the Health Quality and Safety Commission including the National Patient Safety ‘Open for Better Care’ Campaign focuses that commenced in May 2013 and goes through to June 2015. The key work areas are: Continuing to keep our patients safe by participating in the national patient safety campaign: o reducing falls resulting in harm led by the Falls Prevention Steering Group o reducing surgical site infection led by the Infection Control Committee o reducing peri-operative harm (including safety in theatres and Venous Thromboembolism prevention) via the Productive Operating Theatre programme, the Venous Thromboembolism working party o reducing medication errors led by the Safe Medication and Pharmacology and Therapeutics Committees - Improving our hand hygiene compliance - Reducing the number of patients who develop a pressure injury whilst in hospital - Minimising seclusion practice in mental health Continuing to improve the quality of end of life care for our patients Continue to work to improve our escalation process when a patient’s condition deteriorates Improve our customer care and responsiveness to patient/client needs Increase patient/client/family/whanau participation Implement a Midland DHB integrated electronic quality and risk management system 91 These areas were chosen because of the common themes identified from our monitoring processes including but not limited to audit, serious events and patient/client complaints received. Our first Taranaki DHB Quality Accounts document was very much a ‘beginning’ document that provided a snapshot of the many quality improvement and patient safety initiatives being undertaken and identified where improvement is still required. The 2014/15 Quality Accounts document will better reflect the DHB has a whole and will be informed by the Health Quality and Safety Commission’s guidance once this is provided. 2.6.2 2.6.3 Linkages Taranaki DHB Strategic Quality & Risk Plan 2012-2015 Quality & Safety Markers Serious and Sentinel Event processes including reporting, review, corrective action implementation and evaluation Patient/Client satisfaction Taranaki DHB Patient and Family/Whanau Centred Care Framework Taranaki DHB Quality Annual Report Action Plan Objective Improving Quality Actions to Deliver Improved Performance HQSC priorities for 2014/15 are subject to confirmation following the conclusion of the Health Sector Forum led prioritisation process Identify actions to support projects that make a difference to improving the quality of care, reducing patient harm (Quality & Safety Markers) and contribute to the national patient safety campaign ‘Open for better care’. Falls Risk Assessment. Continue with: o Raising staff awareness o Real time auditing and feedback o Improving our post falls review process o Analysing contributing factors (patients not seeking assistance, patient safety and privacy) o The feasibility of a Taranaki Integrated Falls Prevention Service in conjunction with ACC is investigated and implemented if considered feasible. Hand Hygiene. Continue with: o Staff education particularly targeting Health Care Assistants o Regular organisation wide good hand hygiene awareness activities Measure 100% of older patients are given a falls risk assessment Reporting Quarterly 90% compliance with good hand hygiene practice 92 Objective Actions to Deliver Improved Performance o Actions to Increase our pool of Gold Auditors from 2 to 5 o Continue our auditing activities expanding focus areas and moments audited as auditing resource is realised Surgical Safety Checklist o Explore options to increase compliance (with particular focus on the third part) as part of the perioperative harm campaign programme o Continue with our auditing and feedback to staff programme Prophylactic Cephazolin for hip and knee replacements o Negotiate with our Orthopaedic Surgeons to increase prophylactic Cephazolin from 1g to ≥ 2g for all total hip and knee replacements and not those patients who weigh more than 8okg o Continue with our auditing and feedback to staff programme Skin Preparation. Continue with: o The use of appropriate skin preparation. o Clipping and not shaving o Our auditing and feedback to staff programme Medication Safety. Continue with: o Our auditing, monitoring and reporting activities, including use of the Medication Trigger Tool and participating in the Commission’s medication safety focus on the national patient safety campaign o The review of the national short stay patient medication chart and whether adoption is appropriate. o The implementation our epharmacy programme locally and regionally Identify and implement actions to support the reduction of patient pressure injury development while in hospital Measure Reporting All three parts of the surgical safety checklist used 100% of the time 100% of hip and knee replacement patients receive Cephazolin ≥ 2g as surgical prophylaxis 100% of hip and knee replacement patients have appropriate skin preparation Meeting/exceeding the targets as outlined in our medication safety project documents. The National short stay patient medication chart is successfully implemented if appropriate. Decreased incidence of inpatient pressure injury development as identified through reporting and monitoring processes Quarterly 93 Objective Actions to Deliver Improved Performance Identify and implement actions to support the minimisation of seclusion practice in mental health Identify and implement actions to support an improved experience through increased patient, client, family, whanau involvement in decision making (at all levels), and the introduction of national survey questions as part of DHB systems for capturing patient/client feedback Identify and implement actions to improve quality of end of life care Identify actions to improve our escalation process when a patient’s condition deteriorates Identify actions to support continued implementation of an improved, representative and value-added Quality Accounts document Implementation of a Midland DHB integrated electronic quality and risk management system 2.7 Measure Monitoring of seclusion practice within mental health shows a decrease over time Patient and Family/Whānau Centred Care Framework implemented Increased patient/ client satisfaction levels over the 2014-15 year as identified from survey. Increased patient/client participation across the DHB defined through defined evaluation processes associated with the Patient and Family/Whānau Centred Care Framework Action Plan formulated and delivered according to timeframes assigned. This includes linking into the National Working Group, policy review/redevelopment, review of advanced care plans and care directives and use of the Map of Medicine Regular audit shows steady improvement in relation to the timely identification of a patient’s deteriorating condition and treatment The 2014-15 Quality Accounts document builds on the 2013-14 document to better reflect the evaluation of the DHB’s DAP measures, Quality & Risk Strategic Plan dimensions of Quality and better reflect the whole of the DHB rather that a Hospital and Specialist Services focus Successful implementation of an integrated system that results in improved effectiveness, efficiency and ultimately patient safety Reporting Quarterly Quarterly Quarterly Six monthly Quarterly Six monthly December 2015 June 2015 LIVING WITHIN OUR MEANS Current and projected constraints on government funds mean the health and disability system must focus strongly on maximising value from a limited set of resources. If we live within our means we won’t be distracted by short-term cost reduction measures when we want to be focused on the delivery of better, sooner, more convenient health care, improving the health status of the local and regional population and reducing or eliminating health inequalities. 2.7.1 Our Approach Taranaki DHB recognises it faces significant challenges in delivering services within available resources. We have outlined in Module 4 our financial forecast to 2017/18. In order to achieve those targets this Annual Plan contains cost containment strategies that align with our targets of a $1.436m deficit in 2014/15, $0.750m deficit in 2015/16 and a return to breakeven/surplus in 2016/17 and beyond. 94 Our DHB has well developed budgetary control systems to manage operating and capital expenditure. The major financial risks faced by the DHB are those relating to cost increases in our provider arm. We provide regular financial information to our Board and the MoH/NHB. We will be focusing on the following initiatives to enable us to live within our means: Working with Health Benefits Limited (to support and advance their initiatives to achieving savings and efficiencies for non-clinical initiatives) Productive Wards, Communities and Radiology Programmes (engages front line staff in improving quality and productivity through redesign and streamlining the working environment and daily processes) These initiatives will all have a role to play in ensuring we operate in a financially responsible manner (which means ensuring delivery on agreed financial forecasts within available funding). This is important for the health of the organisation generally and to meet the significant demands that arise from our building programme. 2.7.2 Linkages Stewardship Module Midland District Health Boards Regional Services Plan 2014/15 2.7.3 Action Plan Objective Living Within Our Means Actions to Deliver Improved Performance Operate within agreed financial plans (and fund capital investment from internal sources) Appropriate clinical and executive leadership Continued development of the Allied Response Teams (ART) utilisation within ED to assist in reducing unnecessary admission and inpatient length of stay. The team will also contribute to management plans for patients who present to ED on a regular basis. Patients who are admitted via the ART will be started on the correct clinical pathway earlier TDHB will continue to work on strategies to increase the number of appropriate surgical procedures that are completed as day cases TDHB will continue to redesign Mental Health services to ensure the right place for treatment and a reduction in seclusion rates IDF flow will be monitored with the aim of reducing outflow by bringing appropriately trained clinicians to TDHB to complete procedures within the hospital Measure System Integration 3: Ensuring delivery of Service Coverage Ownership OS3: Inpatient Length of Stay Ownership OS8: Reducing Acute Readmissions to Hospital Output 1: Output Delivery Against Plan Reduction in number of presentations to ED Day surgery rates to increase to 85% of appropriate cases Seclusion rates reduce Reporting Quarterly IDF outflow rates to reduce Theatre utilisation rates to reach 85% by end June 2015 95 Objective Actions to Deliver Improved Performance The Paediatric model of care will continue to be reviewed in order to ensure patients are treated appropriately across the primarysecondary care continuum TDHB will launch a Project to look at improving management of frailty for admitted patients TDHB will continue to run initiatives such as Releasing Time To Care and a Theatre User Group to realise operational efficiencies in measures such as LOS, readmission rate, and theatre utilisation TDHB will review the opportunity for further efficiencies from Laboratories 2.8 Measure Reporting Measures for frailty management to be agreed by project team SUPPORTING DELIVERY OF REGIONAL PRIORITIES 2.8.1 Our Approach Workforce and training plans illustrate the collaborative work of the Regional Director of Training and General Managers of Human Resources building whole of health solutions and also working alongside the Clinical Networks to meet some of their key deliverables that pertain to workforce and training. Within the Midland Regional Plan we aim to develop the principles of culture, capability, capacity and change leadership. We recognised that there are longstanding gaps and weaknesses in our knowledge around the current workforce, particularly relating to the capability and capacity. In 2014/15 the overarching imperative for TDHB to meet our goals, are collaboration and connectedness locally, regionally and nationally. 2.8.2 Linkages Stewardship Module Midland District Health Boards Regional Services Plan 2014/15 2.8.3 Action Plan Objective Actions Support Delivery Regional Priorities to of Actions to Deliver Improved Performance TDHB will participate in the Regional Trauma Team MDTs and in the regional training network TDHB will provide scenario training for ED staff to ensure staff competency in the event of major trauma TDHB will continue to provide a dedicated Trauma Nurse TDHB will utilised the Westmead Scale for the assessment of post traumatic amnesia and head injury Measure Reporting Attendance at regional trauma meetings Quarterly Number of scenario training sessions delivered to ED staff Westmead scale being utilised where clinically appropriate with procedures in place by December 2014 96 Objective Growing the Health Workforce through Strengthening Recruitment, Retention and Repatriation Strengthening Health Workforce Intelligence Shaping the Future Workforce through Transformative Change Building and Expanding the Capability of the Health Workforce Delivery of Regional IT Priorities Actions to Deliver Improved Performance Retention and recruitment strategies for rural and primary care workforces TDHB will support the provision of a demographic information and forecasting model for all workforces identified by the Clinical Networks and some base line intelligence to target vulnerable, hard to recruit, new & emerging workforces Identify the potential capacity and capability of the ageing workforce and model how this cohort will continue to contribute to healthcare delivery within the Midland Region Develop a Midland Region platform and suite of e-Learning programmes for the health workforce A current focus is on regional deployment the CSC ePharmacy application that will provide the underpinning for the regional deployment of the medication management pilot The other programme currently under review is the deployment of the Orion CWS application within the Midland region. This will require significant reprioritisation of current activities at both a local and regional level to enable this to be brought forward Further information is available in the Midland DHBs RSP for 2014/15 TDHB will contribute to and actively participate in the regionally agreed objectives and initiatives Measure Reporting Establish ‘warm welcome here’ sites in each DHB in order to recruit, orient and socialise new health professionals to rural areas and to facilitate collegiality within the sector Quarter 4 Participation and contribution to workforce planning to: - Improve our understanding of current demographics - Enable us to model workforces for future needs Quarter 4 Feasibility to introduce: - Flexible work arrangements - Phased retirement options - Third age (post retirement) employment Quarter 4 Develop a business case that proposes the future model of the Managed Virtual Learning environment (MVLE) Quarter 1 Successful introduction of the ePharmacy application Quarterly Quarterly reporting against RSP activities 97 98 99 MODULE 3: STATEMENT OF PERFORMANCE EXPECTATIONS We have worked with other DHBs in the Midland region, our primary care partners as well as other key stakeholders to develop this Statement of Performance Expectations (SPE) in which we provide measures and forecast standards of our output delivery performance. The actual results against these measures and standards will be presented in our Annual Report 2014/15. The performance measures chosen are not an exhaustive list of all of our activity, but they do reflect a good representation of the full range of outputs that we fund and / or provide. They also have been chosen to show the outputs which contribute to the achievement of national, regional and local outcomes (see modules 1 and 2). Where possible, we have included with each measure past performance as baseline data. Activity not mentioned in this module will continue to be planned, funded and/or provided to a high standard. We do report quarterly to the Ministry of Health and / or our Board on our performance related to this activity. 3.1 OUTPUT CLASSES DHBs must provide measures and standards of output delivery performance under aggregated output classes. Outputs are goods and services that are supplied to someone outside our DHB. Output classes are an aggregation of outputs, or groups of similar outputs of a similar nature. The output classes used in our statement of forecast service performance are also reflected in our financial measures and are described in Module 8.3. The four output classes that have been agreed nationally are defined in Module 8.2. They represent a continuum of care, as follows: 3.2 GUIDE TO READING THE STATEMENT OF PERFORMANCE EXPECTATIONS The following points provided should be kept in mind when reading the rest of this module: Further detail of the performance story logic and rationale is contained in Module 1 Baseline and National/Regional Result figures for the output performance measures are for the 2012/13 financial year unless otherwise stated (measures introduced in 2013/14 use latest available data for a baseline) In the performance measures table and where available the average column presents the national or regional average for the output performance measure Most measures have been adopted regionally 100 Term Impacts 3.3.1 People are supported to take greater responsibility for their health Impact Long PEOPLE ARE SUPPORTED TO TAKE GREATER RESPONSIBILITY FOR THEIR HEALTH Intermediate 3.3 Some measures fall across more than one impact. Where this is the case they have only been included once Measurement type key: qn = Quantity t = Timeliness ql = Quality There are some services we provide that support the rest of the health system so we have included these in a “Support Services” section of our performance story Detailed information about various programme definitions and rationale for each output measure is provided in Module 8.4 National data collections will be occurring during 2014/15 through the Quality and Safety Commission’s National patient Safety Campaign. Further baseline data for future quality markers will be available for the 2014/15 Annual Plan and TDHBs Quality Programme Outcomes will be presented in our 2014/15 Quality Account Report Fewer people smoke Reduction in vaccine preventable diseases Improving health behaviours Fewer People Smoke Output Class Measure Type Percentage of hospitalised smokers offered advice to quit (Health Target & MHP) Maori Non-Maori Total 1 qn/t Percentage of Primary Health Organisations enrolled smokers offered advice to quit (Health Target & MHP) 1 Outputs Baseline Target 2014/15 National/Regional Result National Regional 95% 96% 95% 95% 95% 95% 96% 95% 95% 96% 96% 96% qn/t National Regional 71% 90% 67% 68% High Needs Total Percentage of pregnant women who identify as smokers at the time of confirmation of pregnancy in general practice or booking with Lead Maternity Carer are offered advice and support to quit (Health Target and MHP) Maori Non-Maori Total 1 qn/t Progress towards New Measure 90% 90% 90% New Measure 101 3.3.2 Reduction in Vaccine Preventable Diseases Output Class Measure Type Percentage of eight month olds fully immunised (Health Target & MHP) Maori Non-Maori Total 1 qn/t Percentage of the population >65 years who have received the seasonal influenza immunisation (PHO Performance Programme & Maori Health Plan) High Needs Total 1 Outputs 3.3.3 Baseline Target 2014/15 National/Regional Result National Regional 89% 89% 89% 95% 95% 95% 88% 92% 91% 85% 90% 88% qn/t National 69% 70% 75% 75% 68% 69% Improving Health Behaviours Output Class Measure Type Percentage of infants who are fully or exclusively breastfed at 6 months (Maori Health Plan) Maori Non-Maori Total 1 qn/t The number of referrals to the GRx (Green Prescription) programmes (Local Contract) Adult Children 1 Reduce the teen birth rate per 10,000 Maori Non-Maori Total 1 Reduce the rate of teenage terminations of pregnancy per 10,000 Maori Non-Maori Total 1 Outputs Baseline Target 2014/15 National/Regional Result National 11% 24% 21% 27% 27% 27% qn/t 16% 27% 25% Regional Average 1132 96* 1490 35 350 144 195 <350 <144 <195 1987 67 National Regional qn/t qn/t 380 108 167 390 125 218 National Regional 163 120 131 <163 <120 <131 133 71 84 124 100 109 * GRx Active Families programme numbers boosted by Taranaki DHB’s Whanau Pakari research. 102 Impact Term PEOPLE STAY WELL IN THEIR HOMES AND COMMUNITIES People stay well in their homes and communities Impacts Intermediate Long 3.4 3.4.1 An Long-term improvement in childhood oral health Fewer people conditions are are admitted detected early to hospital for and managed avoidable well conditions More people maintain their functional independence An Improvement in Childhood Oral Health Output Class Measure Type Percentage of children (0-4) enrolled in DHB funded dental services (Policy Priority 13) Maori Non-Maori Total 2 qn Percentage of enrolled pre-school and primary school children (0-12) overdue for their scheduled dental examination (Policy Priority 12) 2 Percentage of adolescent utilisation of DHB funded dental services (Policy Priority12) 2 Outputs Baseline Target 2014/15 National/Regional Result National Regional 59% 82% 75% 85% 85% 85% qn/t 55% 74% 70% 56% 74% 69% National Regional 9% 10% 12% 9% National Regional 3.4.2 qn 77% 85% 72% 70% Long-Term Conditions are Detected Early and Managed Well Output Class Measure Type Percentage of population enrolled with a PHO (Maori Health Plan) Maori Non-Maori Total 2 qn Percent of the eligible population will have had their cardiovascular risk assessed in the last five years (Health Target & Maori Health Plan) Maori Non-Maori Total 2 Outputs Baseline Target 2014/15 National/Regional Result National Regional 85% 97% 95% 96% 96% 96% 89% 96% 95% 94% 98% 97% qn National Regional 63% 75% 73% 90% 90% 90% 63% 68% 67% 60% 74% 71% 103 Output Class Outputs Maintain or improve appropriate management of microalbuminuria or overt nephropathy in patients with diabetes (Policy Priority 20) Maori Non-Maori Total 2 Percentage of eligible women (20-69) have a cervical cancer screen every 3 years (Maori Health Plan) Maori Non-Maori Total 1 Percentage of eligible women (50-69) have a breast screen in the last 3 years (Maori Health Plan) Maori Non-Maori Total 1 Increase the number of packages of care available to youth under the Primary Mental Health Initiative Maori Non-Maori Total 2 3.4.3 Measure Type Baseline Target 2014/15 National/Regional Result 70% 82% 80% >70% >82% >80% Not Available qn/t National Regional 72% 87% 85% 80% 80% 80% 63% 79% 77% 66% 83% 80% qn/t National Regional 63% 77% 76% 70% 70% 70% 66% 73% 72% 59% 68% 67% New Measure 82 247 329 New Measure Fewer People are admitted to Hospital for Avoidable Conditions Outputs Output Class Measure Type 4 qn Baseline Target 2014/15 National/Regional Result National Regional Percentage of Rest Home residents receiving vitamin D supplement from their GP 75% 70% N/A 74% National Regional Triage level 4 & 5s presenting to the Emergency Department as a percentage of the total population Percentage of eligible population who have had their B4 school checks completed High Needs Total 2&3 qn 1 qn/t 25% <23% 11% 16% National Regional 86% 88% 90% 90% 80% 80% 83% 82% 104 3.4.4 More People Maintain their Functional Independence Output Class Measure Type Percentage of older people receiving longterm home support who have had a comprehensive clinical assessment and a completed care plan in the last 12 months (Policy Priority 18) 4 qn/t For those with aged related and chronic health conditions we aim to reduce the rate of rest home level of residential care to home based support and respite funding 4 Outputs 4 41% 95% Not Available ARRC:HBSS/ Respite 2.34:1 2.40:1 Not Available 156 >156 Not Available 91% 100% Not available ql PEOPLE RECEIVE TIMELY AND APPROPRIATE CARE People receive timely and appropriate care Intermediate Impacts National/Regional Result qn 3 Impact Long Term 3.5 Target 2014/15 qn Increased number of clients accessing respite services Percentage of patients aged 75 and over (Maori and Pacific Islanders 55 and over) that are given a falls risk assessment Baseline People receive prompt and status for People have appropriate appropriate access to acute and elective services arranged care Improved health More people people with a with end-stage severe mental conditions are health illness appropriately and/or supported addiction 3.5.1 People Receive Prompt and Appropriate Acute and Arranged Care Output Class Measure Type Baseline Target 2014/15 National/Regional Result Acute Re-admission rate (Ownership Dimension 8) 3 qn/t/ql 5.49% ≤5.22% National Regional 8.11% 7.40% Acute Re-admission rate 75+ years (Ownership Dimension 8) 3 qn/t/ql 8.90% ≤8.66% National Regional 11.49% 10.37% 4.07 days National 3.99 days Outputs Acute inpatient average length of stay (Ownership Dimension 3) 3 qn/t 4.07 days 105 Output Class Measure Type Proportion of patients referred with a high suspicion of cancer who receives their first cancer treatment with 62 days (Health Target)) 3 qn/t Proportion of patients with a confirmed diagnosis of cancer who receives their first cancer treatment with 31 days (Policy Priority 30) 3 Arranged Caesarean deliveries without catastrophic or severe complication as a % of total primary and secondary deliveries Percentage of operations where venous thromboembolism (blood clot) was considered as part of the surgical checklist 3 ql 3 ql Outputs 3.5.2 Baseline Target 2014/15 National/Regional Result Redefined TBC Not Available Redefined TBC Not Available qn National Regional 20% <18% 18% 17% 91% 100% Not available Target 2014/15 National/Regional Result People Have Appropriate Access to Elective Services Output Class Measure Type Percentage of patients waiting longer than five months for their first specialist assessment (Elective Service Performance Indicator 2) ) then four months by 1 January 2015 3 qn/t Number of surgical discharges under the elective initiative (Health Target) 3 Elective inpatient length of stay (Ownership Dimension 3) Did-not-attend percentage for outpatient services (Maori Health Plan) Maori Non-Maori Total Outputs Baseline Regional 0.11% 0% 1.5% qn 4,660* 4,369 N/A 3 qn/t 3.21 days 3.18 days National 3.36 days 3 qn/t National Regional 19% 7% 9% <9% <9% <9% 13% 5% 6% 15% 6% 8% *The number of surgical discharges performed during 2012-13 was greater than Plan. We expect that during 2014-15 we will manage the volumes to meet the Plan live within our means. 106 3.5.3 Improved Health Status for those with Severe Mental Illness and/or Addictions Output Class Measure Type Percentage of people referred for nonurgent mental health or addiction services are seen within 3 weeks (Policy Priority 8) Mental Health 0-19 yr olds 20-64 yr olds 65+ yr olds Addictions 0-19 yr olds 20-64 yr olds 65+ yr olds 3 qn/t Percentage of clients discharged with a transition (discharge) plan. (Policy Priority 7) <20 yr olds Maori Non-Maori Total 20+ yr olds Maori Non-Maori Total 3 Average length of acute inpatient stays (KPI 8) 3 Rates of post-discharge community care (KPI 19) 3 Outputs 3.5.4 Baseline Target 2014/15 National/Regional Result National Regional 61% 80% 87% 80% 80% 80% 67% 84% 82% 63% 77% 83% 86% 76% 83% 80% 70% 70% 80% 84% 83% 73% 64% 76% qn/t/ql National Regional 100% 97% 97% 95% 95% 95% 80% 85% 84% 82% 87% 86% 99% 99% 99% 95% 95% 95% 92% 92% 92% 90% 83% 86% qn/t/ql 15 days 14-21 days Not Available qn/t/ql 53% 90-100% Not Available More People With End Stage Conditions are Supported Appropriately Outputs A reduction in the percentage of palliative care clients who have had an Emergency Department presentation Output Class Measure Type Baseline Target 2014/15 National/Regional Result 11% ≤11% Not Available 3 107 3.6 SUPPORT SERVICES Outputs Improved wait times for diagnostic services accepted referrals receive their scan within 42 days (PP29) Output Class Baseline Target 2014/14 77% 44% 90% 80% 95% 95% 90% 90% 90% 90% National/Regional Result 2 Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Non-urgent community laboratory tests are completed and communicated to practitioners within the relevant category timeframes: Category 1: Within 24 hours Category 2: Within 96 hours Category 3: Within 72 hours Measure Type Not Available 2 Not Available 108 109 MODULE 4: FINANCIAL PERFORMANCE The consolidated financial summary below includes the Hospital Provider (Personal Health, Mental Health, Public Health and DSS), DHB Governance & Funding Administration, and the DHB Funder operations. Hospital Provider + Governance Funding (including other income) 179,571 Year 0 2013/14 Forecast 175,666 Non Hospital Provider Funding (NGO) 147,173 156,695 158,067 160,489 162,911 165,336 TOTAL FUNDING Hospital Provider + Governance Operating Expenses 326,744 189,389 332,361 189,119 338,170 191,038 342,660 192,019 348,152 194,241 353,821 194,985 Payments to Non Hospital Providers (NGO) 137,348 146,695 148,067 150,489 153,861 158,336 TOTAL OPERATING EXPENSES & PAYMENTS 326,737 335,814 339,105 342,508 348,102 353,321 -9,818 -13,453 -10,935 -9,848 -9,000 -6500 9,825 10,000 10,000 10,000 9,050 7,000 7 -3,453 -935 152 50 500 ($’000) 2012/13 audited Hospital Provider + Governance Operating Deficit TDHB Funder surplus CONSOLIDATED FINANCIAL RESULT Year 1 2014/15 plan 180,103 Year 2 Year3 2015/16 2016/17 plan plan 182,171 185,241 Year4 2017/18 plan 188,485 The net consolidated financial projection for the planning period 2014-18 is: 2014-15: Deficit $ 0.94M 2015-16: Surplus $ 0.15M 2016-17: Surplus $ 0.05M 2017-18: Surplus $ 0.50M These financial projections are to be read with the accompanying notes and assumptions. 110 4.1 KEY POINTS FROM THE BUDGETED FINANCIALS 2014-18 The Board has planned for a consolidated financial deficit for Year 1 of the planning period 2014-18, with a financial breakeven targeted for Year 2, Year 3 and Year 4. These financial projections reflect a common trend across the entire planning period 2014-18, clearly indicating that cost growth in the hospital provider operations is significantly in excess of funding received, leaving residual operating deficits. The relatively better consolidated financial result is solely on account of surpluses generated in the Funder operations during each of the fiscal periods under consideration, which is not sustainable. Stage 1 of the hospital redevelopment programme (Project Maunga) is scheduled for completion in April 2014, bringing the $ 80M project to completion. The hospital provider (and consolidated) financial result in Year 1 is materially influenced by the cost impacts of Project Maunga. Increased depreciation ($ 3.10M), cost of borrowing ($ 2.02M) , loss of interest income on deposits ($ 1.30M) and increased cost of utilities ($ 0.40M) has resulted in $ 6.82M addition to operating expenditure in 2014-15. The hospital provider budget for Year 1 (2014-15) has a target of $ 4.30M in new savings required from a number of cost reduction and efficiency initiatives, besides the savings plan already in place to realise savings for the current 2013-14 year. These savings are being sought from improved service level management, monitoring of contracted volumes, targeted cost reduction initiatives, reduced staffing costs and service reconfigurations amongst a range of other initiatives that are in the process of being explored. (Please refer to the “Cost & efficiency initiatives” section for details). In addition to the targeted $ 4.30M in new savings to be delivered by the hospital provider in Year 1, there is an expenditure to revenue gap of $ 0.50M in Year 1 and $ 0.90M in year 2 that are yet to be identified against initiatives and savings. Likewise, the DHB Funder operations is planning to reprioritise funding and drive initiatives to enable the DHB Funder operations to manage its costs down and deliver the operating surplus planned for 2014/15 and years following. It is difficult to estimate with certainty the likely costs and benefits to this DHB from Health Benefit Limited (HBL) driven business cases as these are in various stages of delivery. Outgoings in capital investment and contribution to HBL’s operating expenditure have been recognised based on estimates made available. Indicative savings through reduced pricing from collective procurement projects, All of Government (AOG) initiatives and other collaborative efforts have been factored into clinical supply and consumable costs over the plan period. Likewise, operating expenditure outflow to support these national initiatives has been recognised. TDHB’s share in supporting the Midland regional projects and contribution to HealthShare (the regional shared services entity) has been recognised. The total cost provided by TDHB towards supporting regional and national service agencies (HBL, Health Share, and other National entities) and contributions to business cases planned for 2014-15 is circa $ 1.70M. The operating budget is severely limited to absorb these new (and increasing) costs arising on different fronts. The Hospital Provider Arm is facing a significant cost to funding gap resulting in operating deficits in each year covered by this plan. This gap could increase if other identified risks and associated costs (estimated at $3.20M) were to materialise fully. With the residual risk at $2.08M, the resultant financial gap could be in the region of $13.50M. Likewise, the DHB Funder is also faced with exposure estimated at around $5.60M for 2014/15, with a residual risk equating to about $2.40M. (Please refer the “Sensitivity Analysis” section for details). These risks are in addition to the expenditure to revenue gap of $ 0.50M in Year 1 and $ 0.90M in year 2 that are yet to be identified against initiatives and savings. The Board recognises that the operating cost to funding gap in the Hospital Provider operations will need to be addressed through options that will result in significant changes to 111 models of care, service configurations and re-alignment of services within funding available. It acknowledges these changes are essential if the Hospital Services arm is to remain financially viable when faced with increased costs on several fronts, in particular Project Maunga. In is expected that the gains from Project Maunga will materialise in 2014-15 and future periods. Consolidation of specialist services and improved models of care and pathways will result in more efficient use of clinical resources and thereby reduction in core operating costs. The redevelopment will pave the way for a recovery plan for Hospital Services to align itself more efficiently – both clinical and financial. In the final analysis, the Board is faced with: 1. A continuing deficit in the Hospital Provider operations in each of the plan years. 2. Additional financial exposure in its expense budgets which could materialise in part or full. 3. The need to make radical changes and re-align service configurations in its hospital service operations to reduce the current deficit. 4. The financial recovery for its Hospital Provider operations being largely dependent on cost reductions incidental to services rationalisation, capacity and work force management for the current plan period, and efficiencies arising from the redevelopment of the hospital facilities in the years following. 5. Its Funder operations having to significantly reduce investment in additional services during the period the hospital operation is going through this transition. Recognising that additional risks continue to be carried both within and outside the financial budget, with reliance on timely outcomes from service changes and initiatives, Taranaki District Health Board’s financial risk assessment of the current District Annual Plan is rated “medium to high” risk under the assumptions and risks as stated. 4.2 KEY RISKS 4.2.1 Taranaki DHB’s Funder Operations 1. Taranaki DHB’s increase in funding from the Funding Envelope for 2014/15 is $5.02 million, comprising a $1.82 million (0.61%) contribution to cost pressures and $3.20 million (1.08%,) demographics. 2. Whilst the level of funding for Taranaki DHB is equitable when compared to the proposed increases for other DHBs, the level of increase is considerably lower than the cost and service pressures faced by the DHB Funder and Provider Arm 3. The Government has made no decision on out-year funding. To ensure consistency across all DHBs, Taranaki DHB has prepared the Annual Plan using the planning assumption that funding increases in out-years will be of the same nominal value as stated in the planning guidance. 4. Taranaki DHB’s population based funding share (PBFF) share is reducing over time. Taranaki DHB’s PBFF share in 2012/13 was 2.74%, this reduces to 2.73% in 2013/14 and in 2014/15 to 2.72%. The relative growth of the Taranaki DHB population is less than other parts of New Zealand but services still need to be planned for an absolute increase in the population numbers as demonstrated in Census Population Projections 5. The Funding Envelope advice indicates that there may be some further additional funding made available to DHB’s from non-devolved funding held by the Ministry of Health for 2014/15. Further advice on devolution of funding is awaited. However, it is assumed that any funding would already 112 be committed to contracts currently held by the Ministry and which would be transferred to DHB’s. 6. General hospital and specialist services delivered by the DHB’s own Provider Arm will be paid in a composite of National IDF prices and local prices acknowledging affordability and capacity issues. Mental health services delivered by the DHB’s Provider Arm are funded by a local price mechanism. Significant reconfiguration of the DHB’s hospital and specialist services is planned over the next three years to bring the cost of service delivery closer to the funding available. 7. In order to offset planned deficits in the Provider Arm, whilst service reconfiguration is undertaken to a lower cost base, the Funder is required to achieve significant surpluses. In 2014/15 the planned Funder surplus is $10 million this present a significant challenge for the Funder. 8. The key risks associated with achievement of this surplus include Achievement of planned deficits in the Provider Arm Growth in Inter District Flows Absence of a risk reserve will severely limit the Funder’s ability to fund transition costs of new models of care and respond to unexpected demands in year. Containment of Growth in pharmaceuticals 9. In order to deliver a net Funder $10 million surplus the DHB will plans to deliver further service configuration. These changes are transformational in nature and it is believed will deliver the same or better health outcomes for less cost. 4.2.2 Taranaki DHB’s Hospital Provider Operations 1. The funding contribution for cost pressure in 2014/15 is 0.61%. However, the real cost growth in hospital provider services is well in excess of this adjustor. The year on year cost movements across several expenditure lines are on an average between 3% and 5%. This gap between funding and real cost growth has resulted in a budgetary deficit of $10.94M after considering all current efficiencies and cost savings, including new costs totalling $ 6.82M related to Project Maunga. 2. Cost pressures are particularly evident in the following areas: a. b. c. d. e. f. g. Clinical staff costs – primarily nursing Outsourced clinical staff – primarily locum doctors and psychiatrists Diagnostics – primarily radiology Acute services such as cardiology, mental health inpatient services, emergency services. Increasing cost impacts of statutory compliances, quality and accreditation deficits and numerous legislative requirements Information and communication technology (ICT) capital investment and increased operating costs for network infrastructure and software licences. Operating cost contributions, capital investment and participation in national and regional initiatives and business cases. Overall, the Hospital Provider’s financial plan for the planning period is highly geared and has no flexibility to accommodate unplanned cost movements. Its operating budget carries financial risks and it is highly dependent on the realisation of targeted savings within planned timelines to meet its 2014/15 and out year financial targets. 113 3. In applying the budgetary assumptions we have recognised ongoing quality improvements and those compliance costs of which TDHB has been aware. The financial budget is vulnerable to small movements in costs over stated assumptions or increased costs resulting from clinical compliance expectations and legislative changes. 4. The Hospital Services Provider is dependent on sustainable revenue streams. With about 92% of its revenue derived from health funding (via DHB Funder and the Ministry of Health), the Hospital Provider has few alternate income streams for revenue growth. There is a marginal increase (+$ 0.32M) in ACC revenues planned for 2014/15 arising from increased theatre capacity post Project Maunga. Miscellaneous income also assumes $ 2.50M to be raised through community donations. In view of the increasing cost pressures, the financial budget for the Provider Arm continues to hinge on a number of efficiency initiatives, which have to generate $4.30M of reduced operating costs during 2014/15. (Please refer to the “Cost & Efficiency initiatives “section for details). In addition there is an expenditure to revenue gap of $ 0.50M in Year 1 that is yet to be identified against initiatives and savings. 5. During the plan period 2014-18, baseline capital expenditure will be contained within depreciation provisions, so that additional equity injection or borrowing is not required despite operating deficits. In summary, the gap between funding and the realistic cost model for services + the cost impact of Project Maunga has resulted in a very sensitive financial budget for the planning period 2014/15 and out years. Due to funding constraints, the hospital provider will have to bridge this budgetary gap in a decisive and time sensitive manner through a range of initiatives comprising rationalisation of services, workforce management, regional co-operations and realisation of gains from ongoing projects. These measures will have to be undertaken in order to exit costs and reduce the deficit in a planned manner to realistic funding levels. From a realistic view point, the quantum of cost savings required from the hospital services will likely span a 3 year planning horizon – if existing services and levels are to be maintained. 4.3 KEY FINANCIAL ASSUMPTIONS The following key assumptions have been employed in the preparation of the financial statements for the three-year planning period 2014-18. 4.3.1 Application of New Zealand Equivalents to International Financial Reporting Standards (NZ IFRS) The DAP financial template for the plan period 2014-18 and comparative years has been prepared in accordance with NZ GAAP. They comply with the NZ equivalent to International Financial Reporting Standards (NZIFRS), and other applicable Financial Reporting Standards , as appropriate for public benefit entities. 4.3.2 Equity and Borrowing a) The District Annual Plan 2014-18 has not assumed any additional Crown equity. b) Term borrowing of $ 45M from the Crown Health Financing Agency (DMO/MOH) to fund the first stage of the capital redevelopment programme has been included in the DAP 2014-18. The project is scheduled for completion in April 2014. 114 c) Base line capital expenditure is expected to be contained within the level of depreciation for 2014/15 and the three years following. d) Taranaki DHB was moved from “intensive monitoring” to “performance watch” status on the performance monitoring scale in December 2013. 4.3.3 Operating Expenditure assumptions: a) Wage costs: in principle, wage budgets for employee groups covered by national MECA settlements are essentially in accordance with the agreement(s) and in line with collective DAP assumptions agreed nationally. b) Clinical supplies: average around 2.5% for 2014/15 + estimated on increased activity levels + reduced for local efficiencies and procurement gains. c) General operating expenditure (excluding depreciation and interest): average 2.5% for 2014/15 + confirmed outflows + reduced for local efficiencies and procurement gains. d) Value for Money (VFM) impacts: Cost reductions and gains likely to ensue from the collective procurement contracts undertaken by HBL/ National VFM programmes have been recognised in the DAP financials. Equally, costs related to implementation have been considered to the extent information is available. Due to indicative timelines and budgetary constraints some of these will have to be managed within existing budgets, and as and when they occur. Gains from local initiatives and projects have been built into the relevant expense budgets. e) Other expenditure reductions: the 2014/15 expense budget assumes efficiencies and cost reductions arising from the following: Prioritised service levels Length of stay and patient throughput FTE management + reduced staffing costs Contract tracking + monitoring. Demand and capacity management 4.4 TDHB FUNDER – “RING FENCE PRINCIPLE” AND APPLICATION OF SURPLUS/DEFICITS 4.4.1 Mental Health Services In keeping with the guidelines on treatment of “Mental Health Ring fence surplus” the amount of any under-expenditure carried forward from previous accounting periods has been reported as a surplus in Taranaki DHB’s Statement of Financial Performance in the year the surplus is generated. The ring fenced surpluses as at the beginning of FY 2014/15 have been fully applied to Mental Health Services either in the Hospital Provider or community during the year. Based on expenditure to date and forecasts, no material surplus is likely to remain on 30 June 2014. No surpluses from Mental Health services are envisaged during the 2014-18 plan period and, if any surpluses do eventuate, these will be ring fenced and expended in the year(s) following. 4.4.2 Interest Rates Interest rates have been assumed along current monetary indicators and commitments and averaged as appropriate over the mix of funding streams and options as follows. Interest on DMO/MOH loans are as per the loan drawdown schedule. 115 Overdraft DMO/MOH Loans (existing) DMO/MOH Loans (new) Deposits Equity Year 1 (2014/15) Year 2 (2015/16) Year 3 (2016/17) 6.00% 6.50% 7.50% 7.02% - 3.73% 4.15% 4.15% 5.50% 6.00% 7.00% 8.00% 8.00% 8.00% Year 4 (2017/18) 7.50% - 4.15% 7.00% 8.00% Notes: 1. 2. 4.4.3 DMO/MOH total approved facility is $74M (inclusive of $ 29M of earlier loans), with the full limit having been drawn down with the completion of Project Maunga in April 2014. This is inclusive of the $45M new term debt from DMO/MOH approved for Stage 1 of the Base Hospital redevelopment project. TDHB is in the DHB collective banking & transactional arrangement with West Pac. Monthly closing cash balances are mostly positive, on odd occasions dipping into over draft for limited periods during certain month ends. Asset Revaluation and its Impact Under the provisions of FRS3, TDHB is required to undertake an asset revaluation exercise as at 30 June each year, and recognise any material increase in land and building values, and also its impact on depreciation and capital charge. No provision has been made in the 2014/15 financials arising from any impacts of asset revaluation as on 30 June 2014. A detailed revaluation exercise was completed on 30 June 2013, and updated upon completion of the new build (Project Maunga) in early 2014. It is therefore assumed that there will be no material movements requiring an adjustment to the current asset base. The impact of the new hospital redevelopment on current building values has been factored in the recent revaluations and treated appropriately. Conversely, should there be a material movement, it is assumed that any related capital charge increase will be funded/base line adjusted in accordance with current Treasury guidelines. 4.4.4 Depreciation Depreciation has been calculated on a straight line method for all existing assets, less disposals and recognising additions. 4.4.5 Capital Charge Capital charge have been calculated in line with existing methodology, adjusted for donations and monthly movements in operating results and closing balance of shareholders funds. 4.4.6 Leasing The District Annual Plan assumes certain items of plant and equipment will be leased after evaluation on a case-by-case basis. The Plan also assumes that operating leases will be explored for capital plant and equipment which have a short economic life or are prone to rapid changes in technology. Operating leases will adhere to current guidelines and tests to clearly differentiate these from finance leases. 116 4.4.7 Financial Covenants and Ratios There are no specific financial covenants stipulated by the DMO/MOH for its term lending to TDHB. No financial covenants have been stipulated by Westpac for transactional banking. The following are some key financial ratios as derived from the consolidated financial statements for the period 2014-18. Financial ratios 1 2 3 4 5 Revenue to net funds employed Operating margin to revenue Operating return on net funds employed Interest cover ratio Debt to debt equity ratio 4.4.8 TDHB 2013/14 forecast 2.08 3% 7% 5.50 46% Year1 2014/15 plan 2.14 5% 11% 5.62 47% Year2 2015/16 plan 2.20 6% 12% 5.84 48% Year3 2016/17 plan 2.24 6% 12% 6.09 48% Year4 2017/18 plan 2.28 6% 13% 6.23 48% Changes in Accounting Policies There have been no changes from the accounting policies adopted in the last audited financial statements other than any changes brought about by the adoption of NZIFRS in the financial statements. All policies have been applied on a basis consistent with the previous period. These are detailed in the Statement of Intent for 2014/15. 4.4.9 Capital Investment The capital investment planned during the Business Plan period and the proposed funding lines to finance the investment are as follows: Year 1 (2014/15) Year 2 (2015/16) Year 3 (2016/17) Year 4 (2017/18) Total (2014/2018) Clinical Equipment Other Equipment Motor Vehicles Minor Site Redevelopment (excluding prior year WIP) 5,000 450 70 3,500 450 - 3,000 450 - 3,000 450 - 14,500 1,800 70 1,500 1,000 750 550 3,800 Information Technology 4,980 6,050 6,800 7,000 24,830 TOTAL 12,000 11,000 11,000 11,000 45,000 - - - - - - - - - - - - - - - GRAND TOTAL 12,000 11,000 11,000 11,000 45,000 Sources of Funding Crown Equity Bank Borrowing DMO/MOH Term Loans Internal Cash Accruals 0 0 0 12,000 0 0 0 11,000 0 0 0 11,000 0 0 0 11,000 0 0 0 45,000 Capital Outlay ($‘000) Operating Strategic Community Oral Health Project Base Hospital redevelopment project TOTAL 117 4.4.10 Capital Divestment A: The disposal of surplus assets proposed during the period 2014-18 is as follows: Book value ($) Realisable Value ($) Gain/(loss) On sale ($) Timing * Miscellaneous equipment (discarded/obsolete) 0 Not material 0 2014/18 * Surplus land 0 0 0 n/a * Vehicles 0 Not Material 0 2014/18 Total 0 0 0 Asset Taranaki DHB will ensure that disposal of any land transferred to, or vested in it pursuant to the Health Sector (Transfers) Act 1993 will be subject to approval by the Minister of Health. Taranaki DHB will work closely with the Office of Treaty Settlements to ensure the relevant protection mechanisms that address the Crown’s obligations under the Treaty of Waitangi and any processes relating to the Crown’s good governance obligations to Māori sites of significance are addressed. 4.4.11 Personnel a) Paid / Contracted / Core FTEs: The movement of “contracted/worked FTE” numbers across the Annual Plan period is assumed along the following lines: CONTRACTED PROVIDER Medical Personnel Nursing Personnel Allied Health Personnel Support Personnel Management & Administration GOVERNANCE TOTAL Forecast 2013-14 Yr 1 2014-15 Yr 2 2015-16 Yr 3 2016-17 Yr 4 2017-18 142 545 242 80 270 1,279 153 539 248 81 270 1,291 154 530 245 81 270 1,280 156 525 240 82 270 1,273 158 525 240 82 270 1275 17 17 17 17 17 1,296 1,308 1,297 1,290 1292 The average “worked FTE” numbers for the four-year plan period are expected to be managed within the core staffing numbers indicated above. Project Whakapai – the initiative/project has become entrenched into the hospital services operations utilising proprietary workforce allocation and real-time monitoring software to actively manage supplementary staff costs arising from use of casuals, backfills, overtime and locums continue to provide the framework for management and budgeting of FTEs. This interactive workforce management tool has inbuilt levels of authority and decision matrixes with a centralised allocations unit. Project Whakapai promotes a significant change in the traditional methods of workforce allocation and management with resultant slowing down of the annual wage bill and optimised allocation of available workforce. Medical FTE count will increase on the assumption that vacancies are likely to be filled over the coming period in lieu of locum cover (with corresponding drop in locum costs). Nursing staff are expected to stabilise over the 4 year plan period due to more efficient management of staffing 118 (Project Whakapai) and efficiencies from services reconfigurations and changing models of care within the hospital and mental health services. Movements in Allied Health and support staff are likely to remain steady, whilst Management and Administration staff are also expected to remain at current levels, with possible reduction in back office and administration staff arising from efficiency reviews and reduction in staff managed through attrition. Capping FTE growth with improved productivity and more efficient and smarter workflows is a key goal for Taranaki DHB to manage the cost growth and the deficit. Taranaki DHB is currently tracking below the Ministerial cap set for Management and Administration staff having made significant reductions over the recent period through internal reviews and restructures, and is expected to remain below the cap over the plan period. In principle, the personnel budget has not planned for net FTE increases – other than FTEs required to deliver new projects and nationally driven initiatives. There will be the impacts from changes to services and models of care incidental to the hospital redevelopment project. The overall strategy is to cap FTE growth, however it is acknowledged that there will be demand for clinical resources due to increase in activity levels – both acute and elective. Additionally, as recent period statistics indicate, there has been an increase in specialling patients (one-on-one care) in ICU and Mental Health inpatient admissions. With introduction of management tools, TDHB will continue to aggressively pursue measures and initiatives to increase productivity of existing staff and reduce the demand for locums and casual staff within the hospital and specialist services. b) Accrued FTEs: The corresponding average “Accrued FTE” count for the four year plan period is as below: ACCRUED PROVIDER Medical Personnel Nursing Personnel Allied Health Personnel Support Personnel Management & Administration GOVERNANCE TOTAL Forecast 2013-14 Yr 1 2014-15 Yr 2 2015-16 Yr 3 2016-17 Yr 4 2017-18 145 569 242 82 275 1,313 156 563 248 83 275 1,325 157 553 245 83 275 1,313 159 548 240 84 275 1,306 161 548 240 84 275 1308 17 17 18 17 17 1,330 1,342 1,330 1,323 1325 4.5 CAPITAL EXPENDITURE 2014/15 (STRATEGIC) 4.5.1 Base Hospital Inpatient Facilities Development Programme Project Maunga – the Stage 1 of the redevelopment of the Base Hospital inpatient facilities with theatres and inpatient wards is scheduled for completion in April 2014. Total capital outlay is $ 80M. The primary focus of this project is to generate efficiencies and improvements to prevalent models of care through consolidation of hospital services and systems into a more compact footprint, which will lend more flexibility and efficiency to operations both in the immediate and long term. In doing so, it will also provide a more user friendly hospital and wellness environment to patients, staff and public. 119 The Master Plan envisages a 3 Stage redevelopment of the Base Hospital core inpatient facilities and support systems, such that it is both financially and operationally feasible over a defined timeline. The components of the programme are as follows: Stages Comprising Estimated Cost Construction Timeline Status 1 STAGE 1 Theatres, Ambulatory, Inpatient wards $80M Start: Aug 2011 Finish: April 2014 Completion in April 2014. 2 STAGE 2 Maternity, ED $37M Tentative: 2018-19 Supplementary business case to be progressed. 3 STAGE 3 OPD, Laboratory, Administration $28M Tentative : 2020-2021 Supplementary business case to be progressed. $145M 2011 – 2021 TOTAL Neonatal, Notes: 1. 2. 3. Stages 2 and 3 are discrete components of the overall Master Plan for the redevelopment of inpatient facilities at the Base Hospital. Once Stage 1 is completed it is envisaged that supplementary business cases will be developed for each of the remaining stages and forwarded to National Capital Committee for approval and funding. In short, each of the stages can be visualised as standalone projects, yet forming part of one coherent facilities redevelopment programme for the Base Hospital in New Plymouth, thus enabling affordability to both Taranaki DHB and the National Health capital budget. An updated Schedule of Capital Intentions has been submitted. 4.6 COST AND EFFICIENCY INITIATIVES Taranaki DHB is faced with the challenge of managing its service delivery within a defined fiscal envelope. In addition, it has to balance its long-term strategies with short-term objectives while continuing to provide a clinically safe and quality service. Under this capped environment, with increasing operating costs and demand for services, the Hospital Provider Arm will need to achieve sustainability – both clinical and financial. Taranaki DHB recognises the need for continuous service improvements and efficiency gains while it attempts to re-position itself continually to meet the challenge. The strategy is to continuously progress short term initiatives and service reviews to provide immediate gains, while progressing a series of more strategic service changes in conjunction with regional services planning to achieve longer term sustainability. The latter is needed to rationalise the growth in demand for services and operating costs, besides the need to arrest and reduce the hospital provider financial deficit. The following key initiatives are being considered within the Hospital Provider operations to generate efficiency gains, and contain or reduce operating costs. 120 Initiatives Campus wide cost management strategies including service efficiencies and prioritisation. Proposal Potential Est. ($) Impact Savings targets of 5% across specific expenditure lines to be managed at a Unit and Service level across all cost centres; and further initiatives to be identified. Review and Management of contracted services, with a view to reducing utilisation and cost. $2.60M Reduce operating costs $0.80M Reduce outsourced service costs. Service configuration Review configuration of services for improved cost management. $0.45M Reduce supply costs and personnel efficiencies Management of staffing costs Use of alternative staffing models, where clinically appropriate. $0.45M Reduce service costs Management of contracted services costs. TOTAL $4.30M The DAP 2014-15 has identified a cost to funding gap of $ 4.30M, which has to be bridged by a range of saving initiatives and cost reduction plans as outlined. The services initiatives commenced in 2013-14 will also generate cost savings in future periods, and have been recognised in out years. Other miscellaneous gains from local initiatives and cost reduction measures have been built into the relevant expense budgets. Faced with a gap in its operating budget, the Hospital Provider Arm will continue to explore all practical options with the aim of reducing its overall cost of services delivery, whilst improving productivity and efficiency of operations. This financial recovery plan is an ongoing process, will involve partnering with primary sector providers and is expected to span more than one fiscal year in view of their strategic components and broader implications. In parallel, the immediate focus post Project Maunga is to generate efficiencies and improvements to prevalent models of care through consolidation of hospital services and systems into a more compact footprint. This will in turn lend more flexibility and efficiency to operations. Overall, the project should generate permanent and sustainable benefits post 2013-14. 4.7 DEBT AND EQUITY The debt profile of Taranaki DHB as @ 01 July 2014 will be term loans of $74M with the Debt Management Office (DMO)/MOH, fully drawn down against the approved loan limit of $74M. The primary assumptions carried in the financial plan 2014/15 are: a) Overdraft facilities (as per OPF guidelines) are assumed to be available under the DHB collective banking arrangement with West Pac. b) No additional equity or deficit support is envisaged. It is expected that base line capital expenditure will be contained within the level of depreciation for 2014/15 and out years. 121 4.8 SENSITIVITY ANALYSIS: PLAN 2014/15 The District Annual Plan has outlined some key financial risks and while it is difficult to quantify all these risks with accuracy, the likely impacts on the bottom line if these were to materialise is factored below: DHB Hospital Provider Operations – key risks Unbudgeted financial risk Est. risk ($M) FTE + wage budget Timing of gains from initiatives Diagnostic costs 0.30 0.30 Clinical supplies General overheads Likely impact on 2014/15 planned financial result 0.40 1.50 0.400.30 0.30 0.60 $3.20M 75% risk ($M) 50% risk ($M) 25% risk ($M) 0.30 1.13 0.20 0.22 0.45 0.20 0.75 0.20 0.15 0.30 0.10 0.37 0.10 0.08 0.15 $2.30M $1.60M $0.80M Probability factor (% risk) 75% 75% 0.10 75% 50% 50% 0.10 $2.08M The analysis estimates an overall exposure of circa $3.20M for 2014/15, which could arise from a combination of cost drivers as identified above. The overall probability factor is estimated to be around 65% leaving a residual risk equating to about $2.08M. The risk is expected to be managed through a mix of: Internal cost controls Management of FTEs, Operational savings in discretionary expense lines through capped budgets Gains from National procurement programmes and initiatives Achievement of internal efficiency projects and service reviews DHB Funder Operations – Key Risks Unbudgeted financial risk Estimated risk ($’M) 75% risk 50% risk 25% risk ($’M) ($’M) ($’M) Probability factor (% risk) Pharmaceuticals 0.60 0.45 0.30 0.15 25% IDF outflows 2.00 1.50 1.00 0.50 50% Provider Arm expenditure 2.00 1.50 1.00 0.50 50% Older Peoples Service 1.00 0.75 0.50 0.25 25% 5.60M 4.20M 2.80M 1.40M 2.40M Potential impact on 2014/15 planned financial result The overall exposure is estimated at around $5.60M for 2014/15, while the probability factor is estimated to be around 40% leaving a residual risk equating to about $2.40M. These risks are expected to be managed through contract monitoring and efficiency gains from current NGO contracts. 122 0.10 4.9 STATEMENT OF COMPREHENSIVE INCOME TARANAKI DISTRICT HEALTH BOARD STATEMENT OF COMPREHENSIVE INCOME DISTRICT ANNUAL PLAN 2014-18 ($'000) Year -1 FORECAST Year 0 Consolidated Audited 2012/13 Hosp+Gov Funder Forecast Forecast 2013/14 2013/14 Consolidated Forecast 2013/14 Year 1 Provider Governan: Plan Plan 2014/15 2014/15 Hosp+Gov Plan 2014/15 Funder Plan 2014/15 Consolidated Plan 2014/15 REVENUE * MOH funding * Funding & Governance 159641 147173 161954 2597 2040 152446 * ACC Revenue 4201 4256 * CTA revenue 2137 1506 * Other revenue TOTAL REVENUE 75 161954 152446 165039 0 165039 2040 0 2466 2466 4331 4579 0 4579 1506 2060 0 2060 153998 165039 153998 2466 80 4659 2060 10995 5910 4174 10084 5959 0 5959 3989 9948 326744 175666 156695 332361 177637 2466 180103 158067 338170 28574 43428 15487 4071 19538 28865 42836 15634 4305 18104 28865 42836 15634 4305 18104 29467 42610 16530 4022 16002 0 0 0 0 1375 29467 42610 16530 4022 17377 111098 109744 109744 108631 1375 110006 18687 3033 17724 2333 17724 2333 16378 2115 0 0 16378 2115 21720 20057 20057 18493 0 18493 8615 1307 936 987 2443 3994 3508 8126 1358 1309 1083 2549 4267 4183 8126 1358 1309 1083 2549 4267 4183 7711 1240 1182 1082 2234 3931 4342 0 0 0 0 0 0 0 7711 1240 1182 1082 2234 3931 4342 0 21790 22875 22875 21722 0 21722 3160 3665 857 3843 2097 -2989 285 11662 1832 0 3149 4082 828 4122 2637 -304 285 12545 2020 0 3149 4082 828 4122 2637 -304 285 12545 2020 0 2953 4177 695 4485 2218 211 7 16032 3158 -501 1 0 30 0 413 329 315 0 0 0 2954 4177 725 4485 2631 540 322 16032 3158 -501 EXPENDITURE Personnel costs - medical - nursing - allied health - support - mgt & admin total 0 29467 42610 16530 4022 17377 0 110006 Outsourced services - clinical services - other outsourced total 0 16378 2115 0 18493 Clinical supplies - treatment disposables diagnostic supplies instruments & equip patient appliances implants & prostheses pharmaceuticals other clinical & client costs total 0 7711 1240 1182 1082 2234 3931 4342 0 21722 Infrastructure & other op.costs - hotel services & laundry facilities transport IT systems & telecom professional fees other op.expenses democracy depreciation interest cost & efficiency initiatives Payment to - NGO providers - personal health - mental health - disability support services - public health - maori health - IDF's total 60288 8623 34918 370 2650 35090 166351 TOTAL OPERATING EXPENSES 320959 5785 SURPLUS before capital charge - Capital charge 29364 63298 9536 35344 745 2750 35022 146695 63298 9536 35344 745 2750 35022 176059 33435 1088 182040 146695 328735 182281 2463 -6374 10000 3626 -4644 3 7079 6294 0 6294 10000 -3453 -10938 3 -10935 2954 4177 725 4485 2631 540 322 16032 3158 -501 34523 62859 9740 35166 921 2838 36543 148067 62859 9740 35166 921 2838 36543 182590 184744 148067 332811 -4641 10000 5359 5778 7079 7 -13453 15544 0 0 0 0 0 0 0 0 0 0 0 0 0 Total Other Comprehensive Income 15544 0 0 0 0 0 0 0 0 TOTAL COMPREHENSIVE INCOME FOR THE YEAR 15551 -13453 10000 -3453 -10938 3 -10935 10000 -935 Interest Cover ratio 15.85 NET SURPLUS/(DEFICIT) 6294 10000 -935 OTHER COMPREHENSIVE INCOME * Gain/(Loss) on asset revaluation *Gain/(Loss) on sale of assets *Share of surplus/(loss) from associates Revenue to Net Funds employed 5.50 5.78 2.00 1.10 2.08 1.12 Operating margin to Revenue ratio 9% 1% 3% 5% 2.14 6% Op. return on Net Funds employed 18% 1% 7% 5% 12% 123 TARANAKI DISTRICT HEALTH BOARD STATEMENT OF COMPREHENSIVE INCOME DISTRICT ANNUAL PLAN 2014-18 Year 2 Provider Governan: Funder Plan Plan Plan 2015/16 2015/16 2015/16 Year 3 Consolidated Plan 2015/16 Provider Governan: Funder Plan Plan Plan 2016/17 2016/17 2016/17 Year 4 Consolidated Plan 2016/17 Provider Governan: Funder Plan Plan Plan 2017/18 2017/18 2017/18 Consolidated Plan 0 REVENUE * MOH funding 167717 156329 * Funding & Governance 2507 * ACC Revenue 4904 * CTA revenue 2070 * Other revenue 4973 TOTAL REVENUE 179664 2507 167717 156329 170396 158658 2507 2549 82 4986 5229 2070 2080 4078 9051 4987 160489 342660 182692 29761 43036 16696 4062 17550 30057 43466 16863 4103 16324 1401 111105 110813 1401 16460 2126 16542 2137 18586 18679 7750 1246 1188 1087 2245 3951 4364 7789 1252 1194 1092 2256 3971 4386 21831 21940 2969 4198 728 4507 2644 660 324 16032 3158 -902 2983 4219 701 4530 2240 318 7 16032 3158 173074 160988 2549 84 2549 170396 158658 2591 5313 5729 2591 86 2080 2090 4169 9156 5001 162911 348152 185894 30057 43466 16863 4103 17725 30267 43867 17027 4144 16487 1414 112214 111792 1414 16542 2137 16402 2120 18679 18522 7789 1252 1194 1092 2256 3971 4386 7747 1243 1192 1084 2240 3964 4376 21940 21846 2984 4219 731 4530 2657 652 326 16032 3158 0 2976 4225 700 4537 2243 307 7 16032 3158 173074 160988 5815 2090 2591 4262 9263 165336 353821 EXPENDITURE Personnel costs - medical - nursing - allied health - support - mgt & admin total 29761 43036 16696 4062 16162 1388 109717 1388 0 0 30267 43867 17027 4144 17901 0 113206 Outsourced services - clinical services - other outsourced total 16460 2126 18586 0 0 0 0 16402 2120 0 0 18522 Clinical supplies - treatment disposables - diagnostic supplies - instruments & equip - patient appliances - implants & prostheses - pharmaceuticals - other clinical & client costs total 7750 1246 1188 1087 2245 3951 4364 21831 0 0 0 0 7747 1243 1192 1084 2240 3964 4376 0 0 21846 Infrastructure & other op.costs - hotel services & laundry - facilities - transport - IT systems & telecom - professional fees - other op.expenses - democracy - depreciation - interest - cost & efficiency initiatives - Payment to - NGO providers - personal health - mental health - disability support services - public health - maori health - IDF's total TOTAL OPERATING EXPENSES SURPLUS before capital charge - Capital charge NET SURPLUS/(DEFICIT) 2968 4198 698 4507 2229 329 7 16032 3158 -902 1 30 415 331 317 417 334 319 33224 1094 63517 9916 36044 944 2909 37159 150489 34188 1101 65105 10079 36944 967 2983 37783 153861 183358 2482 150489 336329 185620 2502 153861 341983 -3694 25 10000 6331 -2928 47 9050 6169 -451 6179 6119 6119 6119 152 -9047 50 -6570 6179 -9873 25 10000 63517 9916 36044 944 2909 37159 184807 1 30 47 9050 65105 10079 36944 967 2983 37783 189150 34185 186345 1 2977 4225 730 4537 2662 643 328 16032 3158 0 30 419 336 321 1107 67758 10242 37867 992 3058 38419 158336 67758 10242 37867 992 3058 38419 193628 2521 158336 347202 70 7000 6619 70 7000 6119 500 OTHER COMPREHENSIVE INCOME * Gain/(Loss) on asset revaluation 0 0 0 0 0 *Gain/(Loss) on sale of assets *Share of surplus/(loss) from associates 0 0 0 0 0 0 0 0 0 0 Total Other Comprehensive Income 0 0 0 0 0 0 0 0 0 0 0 0 -9873 25 10000 152 -9047 47 9050 50 -6570 70 7000 500 TOTAL COMPREHENSIVE INCOME FOR THE YEAR Interest Cover ratio Revenue to Net Funds employed 6.12 6.09 0 0 0 6.23 1.14 2.18 1.17 2.22 1.19 Operating margin to Revenue ratio 5% 6% 6% 6% 7% 2.26 6% Op. return on Net Funds employed 6% 12% 6% 12% 8% 13% 124 4.10 CONSOLIDATED STATEMENT OF FINANCIAL POSITION TARANAKI DISTRICT HEALTH BOARD DISTRICT ANNUAL PLAN 2014-18 CONSOLIDATED STATEMENT OF FINANCIAL POSITION ($'000) 2012/13 audited 2013/14 forecast 2014/15 plan 2015/16 plan 2016/17 plan 2017/18 plan CURRENT ASSETS * * * * Bank Account Prepayments +ST investments Debtors (net of provision) Inventory 4752 11530 6562 2513 4005 3640 6650 2575 4505 3640 7200 2775 4755 3640 7575 2875 5755 3640 7950 3000 6755 3640 8325 3125 25357 16870 18120 18845 20345 21845 29662 0 21598 25155 0 20977 24342 0 20862 19817 0 21812 17119 0 21812 13571 0 22212 51260 46132 45204 41629 38931 35783 -25903 -29262 -27084 -22784 -18586 -13938 * Net Fixed Assets * Investments * Trust funds 187335 1297 702 189334 187318 1297 701 189316 183286 1297 701 185284 178254 1297 701 180252 173222 1297 701 175220 168190 1297 701 170188 NET FUNDS EMPLOYED 163431 160054 158200 157468 156634 156250 720 980 72000 735 0 74000 775 0 74000 850 0 74000 925 0 74000 1000 0 74000 73700 74735 74775 74850 74925 75000 25083 68150 -3502 24124 68150 -6955 23165 68150 -7890 22206 68150 -7738 21247 68150 -7688 20288 68150 -7188 89731 85319 83425 82618 81709 81250 163431 160054 158200 157468 156634 156250 45% 46% 47% 47% 48% 48% CURRENT LIABILITIES * Creditors & other payables * Term Loans (current portion) * Provisions WORKING CAPITAL NON CURRENT ASSETS NON CURRENT LIABILITIES * Provisions - non current * Retentions * Term Loans CROWN EQUITY * Crown Equity * Reserves * Retained earnings NET FUNDS EMPLOYED Debt: Debt equity ratio 125 4.11 CONSOLIDATED STATEMENT OF CASHFLOWS TARANAKI DISTRICT HEALTH BOARD DISTRICT ANNUAL PLAN 2014-18 CONSOLIDATED STATEMENT OF CASHFLOWS ($'000) 2012/13 audited 2013/14 forecast 2014/15 plan 2015/16 plan 2016/17 plan 2017/18 plan OPERATING ACTIVITIES * MOH funding * Other revenue 314737 13509 317612 13784 323020 14040 328428 13297 333308 13909 338368 14518 total receipts 328246 331396 337060 341725 347217 352886 * Payment of salaries & operating exp. * Payment to providers & DHB's 167695 143797 181034 147337 175782 148379 176364 153712 177859 156959 178603 161884 total payments 311492 328371 324161 330076 334818 340487 16754 3025 12899 11649 12399 12399 1370 584 560 560 560 560 7 0 0 0 0 0 21887 8111 0 0 0 0 * Capital expenditure -53528 -12528 -12000 -11000 -11000 -11000 NET CASHFLOW FROM INVESTING -30264 -3833 -11440 -10440 -10440 -10440 -959 -959 -959 -959 -959 -959 15200 2000 0 0 0 0 588 -980 0 0 0 0 14829 61 -959 -959 -959 -959 343075 -341756 331457 -332204 336101 -335601 340766 -340516 346258 -345258 351927 -350927 NET CASHFLOW 1319 -747 500 250 1000 1000 Add: Cash (opening) 3433 4752 4005 4505 4755 5755 CASH (CLOSING) 4752 4005 4505 4755 5755 6755 NET CASHFLOW FROM OPERATIONS INVESTING ACTIVITIES * Interest & Dividends Received * Sale of fixed assets etc * (Increase) / decrease in investments FINANCING ACTIVITIES * Equity injections / repayments * Borrowings * Payment of debts NET CASHFLOW FROM FINANCING Total cash in Total cashout 126 4.12 CONSOLIDATED STATEMENT OF MOVEMENT IN EQUITY TARANAKI DISTRICT HEALTH BOARD DISTRICT ANNUAL PLAN 2014-18 CONSOLIDATED STATEMENT OF MOVEMENT IN EQUITY 2013/14 forecast 2014/15 plan 2015/16 plan 2016/17 plan 2017/18 plan EQUITY AT THE BEGINNING OF PERIOD 89731 85319 83425 82618 81709 * * * * -3453 0 -959 0 -935 0 -959 0 152 0 -959 0 50 0 -959 0 500 0 -959 0 85319 83425 82618 81709 81250 Net results for the period Revaluation of Fixed assets Equity Injections / (repayments) Other EQUITY AT THE END OF THE PERIOD 127 128 129 MODULE 5: STEWARDSHIP 5.1 MANAGING OUR BUSINESS Ability to adapt in a changing environment is critical if we are to provide effective, sustainable services. This module describes Taranaki DHB’s stewardship as owner, provider and funder of our assets, workforce, and infrastructure to build, adapt and maintain organisational capacity in order to perform the functions and conduct the operations that will deliver the outputs and impacts we seek. It provides further detail on the stewardship portion of our performance story. 5.1.1 Our People The central part of our capability is our people. Providing health and disability services now and into the future depends on having a workforce that is well matched to the health needs of the community and appropriately skilled and located. Key points of note about our workforce (as at 31 December 2013) are: We employed 1,215.33 FTE of staff 81% of staff were female We have a multi-cultural workforce with 37 different ethnicities working together to provide health services in many settings The Maori workforce made up around 7.7% of the overall staffing numbers with 33% in support roles (non-health support, administration, management) and 67% in clinical roles (medical, nursing, allied) New Zealand non-Maori make up the largest single ethnic group of employees (68%) 59% of our workforce is over the age of 45 years As at 31 December 2013, Taranaki DHB’s workforce was broken down as follows: Workforce Medical Nursing Allied Non Health Support Management/ Administration Total Subgroup SMO RMO FTE 74.55 64.50 500.12 235.80 77.43 262.94 1,215.33 5.1.2 Organisational Performance Management Our performance is assessed on both non-financial and financial measures. The table in Section 5.5.2 of this module provides an overview of the external reporting. Our overall planned performance as a funder and provider of health services for 2014/15 is outlined in this plan and will be reported to our senior management, Board and the Ministry of Health on a regular basis. 130 5.1.2.1 Non-financial Performance Reporting Non-financial performance, which relates to volume and performance expectations for health service provision (by Taranaki DHB Provider Arm, PHOs and the NGO’s we fund), is monitored regularly. It is one of the tools we use to identify issues and inform decision-making to improve our performance. As a funder we monitor the agreements we have with providers through effective portfolio management which includes regular performance reports and data analysis. We also monitor the quality of services provided through reporting of adverse incidents, routine audits, service reviews and issues-based audits. We report quarterly to the Ministry of Health on the required measures in the DHB Non-Financial Monitoring Framework and regularly feed into benchmarking and quality programmes to compare our performance with other providers. We support the national expectation that the public should be informed about health system performance by publishing our performance against the national health targets. We report to our Board through our regular narrative reporting process on performance against this Annual Plan. These reports are provided and discussed in Board Meetings and are available to the public as part of the relevant Board agenda. 5.1.2.2 Financial Performance Reporting As part of our annual planning process we submit a set of financial templates to the Ministry of Health. The templates inform the tables and narrative presented in Module 4. We report monthly to the Ministry of Health against the financial templates. We report on our financial performance monthly to our Board. This report includes commentary and financials as well as actions planned to improve financial performance. As part of our financial reporting we include full time equivalent (FTE) reporting. This covers areas like: Accrued FTE Management / Administration FTE Cap Clinical FTE Out Sourced Services FTE The information on our financial performance is one of the tools used by the organisation to identify issues and inform decision-making to improve our performance. 5.1.3 Funding and Financial Management The following table sets out our key financial indicators: Revenue (after adjustments) Net Surplus/(Deficit) Total Fixed Assets 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 $M $M $M $M $M $M ACTUAL FORECAST PLANNED PLANNED PLANNED PLANNED 326.744 332.361 338.170 342.660 348.152 353.821 0.007 (3.453) (0.935) (0.150) 0.005 0.500 187.335 187.318 183.286 178.254 173.222 168.190 Net Assets 89.731 85.319 83.425 82.618 81.709 81.250 Term Borrowings and 73.700 74.735 74.775 74.850 74.925 75.000 Provisions 131 5.1.4 National Health Sector Agencies We are expected to align our planning with the planning intentions key national agencies. Each of these national agencies has initiatives for the 2014/15 year, which will impact on our DHB. The national agencies are: Health Benefits Limited (HBL) National Health Information Technology Board Health Workforce New Zealand PHARMAC Health Quality and Safety Commission National Health Committee See Module 2, section 2.5 for activities we will undertake to support the work of these National Agencies. 5.1.5 Risk Management Taranaki DHB manages risk using AS/NZS ISO 31000:2009, a nationally accepted standard. We utilise a top down, bottom up enterprise-wise risk management process that is co-ordinated through the Quality and Risk team. The Executive Team own the Emergent Risk Register which is updated and reported to the Board on a monthly basis. Risk information is utilised to inform and drive organisation wide and service improvement and auditing activities. A subcommittee of the Board – The Audit, Finance and Compliance Committee review risks on a regular basis. Internal and external mechanisms are in place for evaluation of contracted providers; these are done on a planned and on an ad-hoc basis as required. Sector Services also provide a range of routine and special audits on behalf of Taranaki DHB with respect to primary care services and Fee for Service Agreements (including pharmacy, dental, homebased support services and aged care). All DHBs face pressure to meet additional expenditure which must be managed within allocated funding. There is pressure to devolve services to the primary area seen as a “lower cost platform” and to increased tertiary level interventions such as cardio-thoracic surgery and cardiology procedures. This creates increasing challenges for the viability of secondary services, particularly for provincial DHBs. In employment negotiations there will be a focus on increased workforce flexibility, increased productivity and wage increases that are affordable. The DHB will have to manage staff numbers to appropriate levels and may implement changes to service configuration. These efforts will have to be prioritised within the DHB’s service priorities and demographics. 5.1.6 Performance and Management of Assets Local: Taranaki DHB has a significant investment in fixed assets which are essential to enabling the DHB to deliver sustainable health services. The DHB is committed to the effective planning and management of its assets for efficient and effective use. The strategic planning for assets is undertaken through an asset management planning process which encapsulates future demand for assets flowing out of regional and local clinical services plans. The asset management process also covers the long term maintenance and refurbishment of assets. The DHB ensures capital expenditure is prioritised and affordable through a rigorous approval process. Business cases are produced for new asset purchases and performance indicators such as return on investment analysed to ensure the asset contributes positively to the organisation. 132 Regional: In line with national expectations we will participate in the provision of a regional commentary to sit alongside the midland DHB region Asset Management Plans. The regional commentary will take into account the long term direction on service delivery settings and clinical and economic sustainability. 5.1.7 Shared Decision-making 5.1.7.1 Clinical Governance A commitment to quality and patient safety places responsibility on the DHB to have effective mechanisms in place for planning, monitoring and managing the quality of clinical provided. Attempting to make the fundamental changes to the health system for the sector to “live within its means” will require strong clinical engagement and leadership. TDHB is driven by clinical engagement commitments through a range of initiatives. Clinical input into decision making is facilitated by a model of shared management and clinician leadership at all levels within the DHB. Our Clinical Directors are formally part of the TDHB leadership team and fully involved in the financial and clinical management of their services. The TDHB Clinical Board is a multidisciplinary clinical forum, whose membership includes representatives from the primary, secondary and community sectors, and the Clinical Board is chaired by the Chief Medical Officer. The Clinical Board oversees the DHB’s clinical activity, provides advice to the Chief Executive and Board on clinical issues and takes a proactive role in setting clinical policy and standards, encouraging best practice and innovation. Members support and influence the DHB’s vision and values and play an important clinical leadership role, leading by example to raise the standard of patient care. 5.1.7.2 Māori Participation We have a governance relationship, through a memorandum of understanding, with local Iwi/Māori represented by Te Whare Punanga Korero (TWPK) Iwi relationship Board. TWPK has representatives from each of the eight Iwi within Taranaki. The memorandum of understanding underpins a “good faith” relationship between the parties by recognising the legitimacy of the TWPK Board to represent the interests of Māori, as well as the legitimacy of the Board as the statutory body charged with the determination, prioritisation and funding of health and disability services. We have a number of established mechanisms to enable Māori to participate in and contribute to strategies for Māori health gain. These include: TWPK (as above) Partnership and contract with preferred Maori Health Provider - Te Kawau Maro Alliance Maori Health Team relationships within the community and provider networks 5.1.7.2 Primary Health Alliance Leadership Teams An Alliance Leadership Team (ALT) has been established across the Midland region with our primary care partners, the Midlands Health Network. The ALT is populated by clinical leaders and managers from across primary and secondary care. The purpose of the ALT is to lead and guide our Alliances as they improve health outcomes for our population. The aim of the ALT is to provide the direction to enable the provision of increasingly integrated and co-ordinated health services through clinically-led service development and its implementation within a “best for patient, best for system” framework. 133 5.1.7.3 Community input We regularly engage with a number of advisory groups, working groups, consumer groups and community health forums. Their advice and input assists in the development of DHB strategies and plans. Community Health Forums are made up of local people representing specific geographical regions. They support and advise us about local health issues, activities and priorities for their community. They are also mechanisms for ensuring communities are kept involved in and informed of DHB activities and issues. 5.2 BUILDING CAPABILITY This section outlines the capabilities we will need in the next three to five years as well as touching on the approach in the short term to work towards developing these. 5.2.1 HealthShare Limited HealthShare (HSL), established in 2001, is a regional Shared Services Agency jointly owned by Waikato, Bay of Plenty, Lakes, Taranaki, and Tairawhiti District Health Boards. From August 2011 HSL has taken on an expanded role as a regional provider of non-clinical service and now provides operational support in a number of areas identified as benefiting from a regional solution. The Midland region DHBs determine the services that HSL will provide, and the level of these services, on an annual basis. These determinations are made through the Regional Services Plan (RSP) and regional business case processes. Categories of possible regional service delivery include: Activities that support future regional direction and change through the development of regional plans Facilitating the development of clinical service initiatives undertaken by regional clinical networks and regional action groups that support clinical service change Key functions that support and enable change through the ongoing development of the region’s workforce and information systems Back office service provision that can drive efficiencies at a regional level, alongside new national back office shared services. The annually agreed regional services form the basis for HSL’s Business Plan which specifies the company’s performance framework; the services to be provided; and the associated performance measures. HealthShare’s Business Plan also details, at a service level, the activities that have been purchased by the shareholding DHBs. HSL has multiple planning and reporting relationships within the Midland region and to national agencies as depicted in the diagram: 134 Serving the Midland DHBs through network coordination and support excellence National Health Board Minister & Ministry of Health Annual Report Funding contracts & reporting Regional Services Plan & reporting Business plan & reporting Midland CEs Group HealthShare Board Regional Contracts Service level agreements DHB Shareholders Midland DHBs Taranaki DHB Lakes DHB Waikato DHB Bop DHB Tairawhiti DHB The following regional services are expected to be provided from HSL in 2014/15: Regional planning and reporting facilitation Regional Service Networks Midland Cancer Network Midland Mental Health and Addictions Regional Clinical Networks and Regional Action Groups including: Cardiac Network Child Health Action Group Elective Services Action Group Health of Older People Action Group Midland Maternity Action Group Midland Region Trauma System Radiology Network Stroke Network Regional Emergency Departments Services* Renal Action Group* Rheumatic Fever Action Group * Midland Region Training Network Workforce development and intelligence support Regional Information Services Shared services including: Third party provider Audit and Assurance Service* Regional Internal Audit Service (Waikato, Lakes, Taranaki, Tairawhiti)* Midland recruitment and selection service Midland Smokefree programme. * These areas are not included in the 2014/15 Regional Services Plan 135 5.2.2 Information Communications Technology The Midland Regional IS service will implement the Midland Region Information Services Plan and advance National Health IT Board priorities, specifically the implementation of the National Health IT Plan priority areas. Work in this area is done within the context of the affordability envelope of the Midland DHBs. The process of prioritising the ICT work effort is done via the IS executive group with is comprised of clinical leaders and business leaders from each of the Midland DHBs. This group reviews the programmes of work and provides recommendations to the regional capital committee for funding decisions. A current focus is on regional deployment the CSC ePharmacy application that will provide the underpinning for the regional deployment of the medication management pilot. The other programme currently under review is the deployment of the Orion CWS application within the Midland region. This will require significant reprioritisation of current activities at both a local and regional level to enable this to be brought forward. Further information is available in the Midland DHBs RSP for 2014/15 and see also section 2.5.3 re the National IT Board initiatives that TDHB is committed to working on. 5.2.3 Integrated Contracting We have been working with our local Preferred Provider of Maori Health Services (Te Kawau Maro Alliance) to progress a Whānau ora service delivery model within the contracting framework. This involves ensuring our current services are responsive and quality focused and sustainable. We (the DHB and its primary care partners) are also utilising the Results Based Accountability framework in order to assist in identifying the appropriate population and performance indicators that we can use to ensure that changes made are actually helping improve the health and well-being of our people. We will look to take up integration opportunities as appropriate. integration, considerations we will take into account are: Consistent population coverage Position in the continuum of health services History of service / contract delivery Integrating agreements will not result in service gaps When making decisions on 5.2.4 Capital and Infrastructure Development Capital expenditure is planned and prioritised at both a Midland regional and local level. DHBs capital intentions, which span 10 years, are consolidated to form a regional view. Large clinical investments are collaborated with the aim of achieving best fit for the region. The Midland region capital committee meets regularly to consider and approve business cases requiring regional sign-off. Business cases are prepared and approved at a local Board level before submission to the regional capital committee for approval. At a local level, our long term financial model provides a high level view on capital affordability of ‘big ticket items’. For the items identified as ‘non big ticket’, there is a rolling three year process. As part of this process a comprehensive annual prioritisation exercise is undertaken, which includes a quarterly review to identify any potential need for re-prioritisation. 136 5.2.5 Collaboration We collaborate with other health and disability organisations, stakeholders and our community, to decide what health and disability services are needed and how to best use the funding we receive from Government. These collaborative partnerships also allow us to share resources and reduce duplication, variation and waste across the whole of the health system to achieve the best health outcomes for our community. 5.2.5.1 Regional Collaboration In addition to the work happening regionally around our RSP development and implementation, there is work occurring in other areas. An example of such an area is Public Health. There are four Public Health Units in the Midland Region: Toi Te Ora Public Health Service servicing the Bay of Plenty and Lakes DHBs Te Puna Waiora, Tairawhiti District Health Public Health Unit, Taranaki DHB Population Health, Waikato DHB Midland DHBs Public Health Units have identified a number of areas where collaboration could be strengthened. In 2014/15 the Public Health Units will continue to develop collaborative working relationships by maintaining and developing regional linkages and contacts, sharing information, contributing to the National Public Health Clinical Network and collaborating on relevant regional projects. In line with national direction, the Public Health Units in the Midland Region have established the Midland Regional Public Health Network. The Network will provide leadership for and strengthen the performance and sustainability of Public Health Units. The Network will also develop and maintain relationships with the Midland Regional Services Planning Groups. The goals of the Network are to: Enhance the consistency, co-ordination and quality of public health service delivery across the Region Plan together where there are benefits in doing so The Network’s specific areas of focus for 2014/15 are outlined in the following table. Area of Focus Workforce development and retention Specific Areas of Work Collaborative approach across the Midland Region for general public health workforce professional development Midland Public Health Clinical Network Communication and actions as required to support national Public Health Clinical Network Maintaining and developing regional Regular public health regional teleconferences and linkages and contacts forums for staff groups Communicable disease protocols Develop regional protocols for an identified list of communicable diseases Information sharing and knowledge Explore opportunities to collaborate in the areas of management health intelligence and health needs analysis 137 Taranaki DHB Public Health Unit also maintains key linkages with the Central North Island Drinking Water Assessment Unit (CNIDWU) for drinking water assessment and continues to participate in developing the network. 5.2.5.2 Local Collaboration We work with other agencies (for example Ministry of Education, Ministry of Justice, Ministry of Social Development, Police, Tertiary Education Commission, Housing NZ as well as other central government agencies and local government) to improve the determinants of health. Whakatipuranga Rima Rau Trust (WRR) is an inter-agency trust established by Taranaki District Health Board, Ministry of Social Development, Te Puni Kokiri and Te Whare Punanga Korero. WRR was created to build an integrated approach focusing on the common objective of up-skilling and developing the Maori Health and Disability workforce in Taranaki. This is an innovative multi agency and multi funder model which introduces a range of initiatives to address Maori workforce development through collaboration. Other examples of intersectoral collaboration include: Whānau Ora Integrated Contracts Long-term Community Council Plans Strengthening Families Accident Compensation Corporation and DHB relationship Healthy Homes initiatives 5.2.6 Long Term Demand Forecasting We are experiencing an increasing mismatch of health service demand, supply and affordability. The health sector cannot continue to operate in the same way as it has been if we expect to be clinically and financially sustainable into the future. Long term demand forecasting is one of the tools we must use to inform decisions around reforming health sector configurations and related models of care if we are to move forward with a sustainable, affordable and fit for purpose health sector. These reforms have already begun in the shape of: Programmes like the better, sooner, more convenient health care initiatives expectations for closer integration of services across the care continuum to improve convenience for patients and reduce pressure on hospitals Regional service planning Facility Change Management – supporting staff in lean process redesign and change management for the completion of Project Maunga (New Plymouth Base Hospital campus redevelopment) We will continue to participate in demand forecasting work as well as exploring the use of modelling and simulation techniques to assist in shaping services. These techniques can improve both efficiency and quality of services through a range of applications including: Waiting time reduction Scheduling Bed capacity management Workforce planning Commissioning 138 5.3 WORKFORCE The health and disability sector continues to face increased demand for services along with rising public expectations as to how services are delivered. There is also a strong requirement for simpler, more standardised ways of doing things to release resources for better use elsewhere and build a platform to develop a workforce with more generic skills that is flexible and able to work in integrated service models across hospital and community settings. 5.3.1 Managing Our Workforce within Fiscal Restraints We continue to operate in a changing environment within a large and complex workforce. This requires sound strategic planning in order to meet our current obligations however this must be delivered within fiscal constraints. Given the impact of affordability and availability factors, New Zealand faces a critical challenge in maintaining a clinically skilled health workforce. Improving supply within the health workforce is only part of the answer. To find enduring solutions service providers will need to strengthen innovation, explore new ways of working, and to develop workforces that are sustainable into the future. Staff engagement and organisational health is central to ensure the provision of high quality and effective services that meet the health needs of our community. TDHB engages staff and unions in forums in change management, transformational initiatives and policy development. Staff involvement is important to achieve productivity gains and foster continuous improvement. Collaboration and connectedness locally, regionally and nationally is imperative for TDHB to continue to attract and retain people to Taranaki with emphasis on supporting the national Kiwi Health Jobs brand and leading the regional recruitment work plan. By working closely with our union partners, we will ensure organisational improvement, continuous improvement and productivity enhancements. In return we will ensure the terms and conditions of our peoples employment are in line with the state sector expectations. The fostering of a performance culture ensures that the aims and objectives of the organisation are being met at all levels within the organisation. 5.3.2 Strengthening Our Workforce Health Workforce New Zealand (HWNZ) has overall responsibility for planning and development of the health workforce. It aims to ensure that New Zealand has a fit-for-purpose, high quality and motivated health workforce, keeping pace with clinical innovations and the growing needs and expectations of service users and the public. The regional and local workforce and training plans recognise the emerging national collaboration between District Health Board – Shared Services and Health Workforce New Zealand. This collaboration will support collection and collation of workforce intelligence and training data. This will enable the ability to extract and critique credible and reliable data around its workforce, funded training positions and support development of health practitioner workforces to deliver new models of care. 139 Regional The DHBs in the Midland Region have established the Midland Regional Training Network9 (MRTN) as a platform to support coordination and optimal solutions for post entry education and training of the health workforce. The MRTN is a cooperative system of interacting roles and functions. The components operate autonomously in a virtual and adaptive model. A number of factors shape the network such as national direction, policies, strategies, and plans. The network provides an interface for relationships with local stakeholders and health training stakeholders more generally. The following list identifies activities we intend undertaking over 2014/15. Further detail is provided in the Regional Services Plan 2014/15 and also identified in section 2.8.3 earlier in this document: Recruitment and retention strategies for rural workforces Kia Ora Hauora – promotion of Maori Health as a career Strategies to achieve a sustainable supply for vulnerable, hard to recruit to and emerging workforces Strategies around the management of the ageing workforce Implementation of the Midland Training Network action plan focussing on e-Learning Development of the care assistant roles (health care assistance, orderlies, therapy assistants) Workforce is identified as a key enabler both within the DHB Annual Planning Priorities and the Regional Services Plan (RSP) Guidelines for 2014/15. Within the Midland Regional Workforce and Training Plan, that provides a framework for the five Midland DHBs, we aim to develop the principles of culture, capability, capacity and change leadership. We recognise that there are longstanding gaps and weaknesses in our knowledge around the current workforce, particularly relating to the capability and capacity. Critically evaluating the workforce as a number (headcount / FTE) does not provide sufficient evidence to enable clinical networks to develop new models of healthcare delivery. This workforce and training plan illustrates the collaborative work of the Regional Director of Training and General Managers of Human Resources building whole of health solutions and connectedness working alongside the Clinical Networks to meet some of their key deliverables that pertain to workforce and training. The DHBs have revised how regional workforce programmes are delivered. Regional workforce projects will be completed by the DHBs using a collaborative model. The collaboration process involves each DHB agreeing to a common approach for each project area first and then one DHB commits internal resource to develop the products for each DHB to select from. The decision about the strategy was made early to reduce the likelihood of redundant work and duplication. It also allows for the fact that each DHB has evolved to respond to its unique situation which has resulted in differences in the nature of services delivered, systems, processes, policies etc. The factors which have resulted in these differences remain today. We will support and actively participate and contribute to the regional approach to address key workforce requirements specifically the following: Diabetes prescribers GPEP 2 Registrars Sonographers and Career advice and planning for all HWNZ funded trainees 140 Local Change continues to be driven by workforce shortages and an ageing workforce, and ensuring that the DHB has an engaged and committed workforce. As agent for the Crown, the Minister of Health has highlighted the expectation for DHBs to have in place the appropriate clinical and executive leadership to deliver the Government’s objectives. This requires an improved retention of permanent clinical staff, a reduction of vacancy rates and strengthening clinical leadership and networks. Capability and capacity will be addressed by the implementation of initiatives that include supporting new service models across within the hospital setting with senior leadership roles, the delivery of the Long Term Conditions contracts that will enhance the interface between primary and secondary settings, and management of employment and cost growth and use of the workforce. Organisational culture features in 2014/15 and we will continue to strengthen TDHB’s “Behaviours in the Workplace” initiative that was introduced as collaboration with unions. A culture of learning is critical to building capability and capacity. We will work with staff on the development of their career and supporting them through a wide range of development opportunities aligned to their career. We have a continued commitment to: High quality clinical leadership and the development of strong, high performing clinical/management partnerships. This will drive engagement and accountability at all levels as we strive to live within fiscal constraints and to manage change. Progression of the Care Capacity Demand Management project system along with the “Releasing Time to Care” project, which drives the way we work. This provides a whole of organisation view to meeting service demand with quality care, providing a healthy and safe work environment, and delivering service efficiencies. Meet or exceed it good employer obligations by maintaining a safe, supportive ad healthy environment for staff, where a strong culture of leadership, accountability, health, safety and wellbeing is fostered. Building on our strong “Grow Our Own” programme targeting graduates, opportunities to attract vocational trainees back to Taranaki and a well-known health education scholarship programme. To achieve workforce equity for Maori, TDHB will continue to work closely with the Whakatipuranga Rima Rau Trust (WRR) to expose rangatahi Maori to career opportunities in the health sector. Priorities for Maori workforce development in 2014/15 is to embed Science Taster programmes for Year 9, 10 and 11 students, and Science Academies targeting Year 7 and 8 students. Our goal is to increase Maori participation in our workforce up to 9%. 5.3.3 Safe and Competent Workforce Local In order to provide a safe and competent workforce, Taranaki DHB will undertake the following initiatives to both strengthen and support vulnerable areas within our workforce. Staff will be able to contribute through forums and project groups in the development of the following workforce initiatives for 2014/2015: Initiatives Regionally, develop and implement a future focused Managed Virtual Learning Environment (MVLE). Develop and implement a Workplace Assessor model to assist the attainment of qualifications by employees in the nonregulated workforce. “Grow our Own” nurses by employing a minimum of 90% of Measure Quarter 1 Quarter 1 Quarter 2 141 Initiatives NETP graduates. We will continue to develop as an attractive employer using regional e-recruitment technology to connect new employees to the organisation in the shortest possible time by introducing an e-On Boarding solution. Measure Quarter 3 Promoting opportunities where there are known workforce gaps and reliance on overseas trained health professionals in; Rural hospital medicine – increase number of vocational Quarter 3 trainees Emergency medicine – increase FACEM qualified specialists Quarter 4 Increase the Maori workforce up to 9% of all employees. Quarter 4 Continue to progress an initiative to investigate the feasibility to establish in partnership with the University of Auckland Medical School a 5th Year programme that focuses on rural and GP immersion to meet the future workforce needs in these areas. Quarter 4 5.3.4 Child Protection Policies The Vulnerable Children’s Bill is currently progressing through the house. A number of Government Departments are affected by this. Once the Bill completes the process (expected to be in June, 2014) DHBs will be notified of any implications for Human Resource practice and policies. Taranaki DHB seeks to achieve a safe, supportive and healthy environment for staff, patients and their family/whanau. The Vulnerable Children’s Bill requirements will be implemented using current and proposed policy and procedures. To strengthen our procedures we will: Review candidate assessment processes for qualifications and police vetting; Develop a 3 Yearly Review cycle for all employees; Develop a Child Protection Policy. 5.3.5 Children’s Worker Safety Checking TDHB commits to the implementation of the requirements as identified under the Vulnerable Childrens Bill. This includes: Recruitment policies will include all aspects of safety checking the core children’s workforce Safety checking information will be available to provide to the Director General (s38) to meet the requirements in the Vulnerable Children’s legislation. Current TDHB policy states all new employees, students, volunteers and contractors must undergo a police vetting procedure, and organisational pre-screening questions informs all candidates of this requirement. TDHB intends to implement the requirements of the Vulnerable Children’s Bill once confirmed as statute, and will work with the General Managers of Human Resources national forum to develop guidelines for all 20 DHBs. This will provide a consistent framework that all DHBs will implement. Guidelines will be developed and implemented 142 5.4 ORGANISATIONAL HEALTH We need to make sure that we have the people, relationships, and processes that will enable us to achieve our outcomes, impacts, and outputs. We cannot be successful without well-qualified and motivated staff, sound management of resources and an effective working relationship between staff and stakeholders. 5.4.1 Governance We have an established governance structure based on the requirements of the NZPHD Act 2000, through which the DHB functions. Governance plays a key role in determining what we need to do to maximise the impact on our outcomes. Our Board assumes the governance role and is responsible to the Minister of Health for the overall performance and management of the DHB. Its core responsibilities are to set the strategic direction for the DHB and to develop policy that is consistent with Government objectives and improves health outcomes for our population. The Board ensures compliance with legal and accountability requirements and maintains relationships with the Minister of Health, Parliament and our community. The normal composition of the board is 11 members, seven elected and four appointed by the Minister of Health. As required, the Board has two Maori members. Three statutory (mandatory) advisory committees and three non-statutory committees have been established to assist the Board to meet its responsibilities. The membership of these committees is comprised of a mix of Board members and community representatives who meet regularly throughout the year. It includes both clinical and Maori members who contribute clinical and cultural experience and understanding to decision making. The Board has not approved delegations to committees. All matters are recommended to the Board through the minutes of the relevant committee. The public is welcome to attend meetings of the Board and its three statutory committees. However, for some items during a meeting the Board or committee may exclude the public. The Official Information Act states the grounds on which the public may be excluded. Such items are clearly noted on the agenda in question. Details of the meetings are publicly available on our website: www.tdhb.org.nz While responsibility for our DHB’s overall performance rests with the Board, operational and management matters have been delegated to the chief executive. This delegation is made on such terms and conditions as the Board thinks fit. The Chief Executive is supported by his direct reports, who are: General Manager Finance and Corporate Services General Manager, Planning, Funding and Population Health Chief Operating Officer & Chief Nursing Advisor Quality and Risk Manager Chief Advisor Maori Health Chief Medical Advisor 5.4.2 Providing Health and Disability Services As well as being responsible for planning and funding the health and disability services that will be delivered in the Taranaki region, we also provide a significant share of those services as the ‘owner’ of 143 hospital and specialist services. These services are provided through our Provider Arm Division from two key facilities being New Plymouth and Hawera Hospitals, supported by various clinics and facilities across the province. Hospital services comprise services that are delivered by a range of secondary, tertiary and quaternary providers using public funds. These services are usually integrated with ‘facilities’ classified as hospitals to enable co-location of clinical expertise and specialised equipment. These services are generally complex and provided by health care professionals that work closely together. They include: Ambulatory services (including outpatient, district nursing and day services) across the range of secondary preventive, diagnostic, therapeutic and rehabilitative services. Inpatient services (acute and elective streams) including diagnostic, therapeutic and rehabilitative services. Emergency Department services including triage, diagnostic, therapeutic and disposition services. Taranaki DHB provides Hospital Services in New Plymouth and Hawera. New Plymouth Base Hospital is generally a Level 4 facility, providing a full range of services medical, surgical, paediatrics, obstetrics, gynaecology and mental health. It is also a base for a range of associated clinical support services and allied health such as rehabilitation, speech therapy, physiotherapy, stroke and cardiac support, district nursing and drug and alcohol programmes. Hawera Hospital is a Level 2 facility providing emergency, medical and obstetric services. Hawera Hospital delivers a range of associated outpatient, allied and community clinical support services such as rehabilitation, physiotherapy, stroke and cardiac support and district nursing. There are a total of 237 beds at New Plymouth Base Hospital, including the Special Care Baby Unit, Maternity and Mental Health. Of these, approximately 153 in-patient beds are available for medical and surgical patients (including critical care and coronary care) and 10 for day stays (surgical/medical), with a further 22 for children and older people. 27 beds are designated for mental health patients. There are 26 beds available for maternity, including 8 for the special care baby unit. Taranaki DHB is currently undergoing facility redevelopment (Project Maunga) to better enable the DHB to provide health services to match population demand and expectations. The primary focus of this project is to generate efficiencies and improvements to prevalent models of care through consolidation of hospital services and systems into a more compact footprint, which will lend more flexibility and efficiency to operations both in the immediate and long term. In doing so, it will also provide a more user friendly hospital and wellness environment to patients, staff and public. Taranaki DHB will ensure that both Hospitals provide the amount of elective operations, procedures and assessments agreed to with the Ministry of Health. We will review the key operations we perform to ensure we are delivering the right level of service for the people in our region. We will demonstrate innovative strategies, or alternative delivery options aimed at increasing elective capacity, including initiatives across the primary/secondary interface. 5.4.3 Planning and Funding Health and Disability Services The Planning and Funding Division of our DHB is responsible for planning and funding health and disability services across our district. The core responsibilities are: Assessing our population’s current and future health needs Determining the best mix and range of services to be purchased 144 Building partnerships with service providers, Government agencies and other DHBs Engaging with our stakeholders and community through participatory consultation Leading the development of new service plans and strategies in health priority areas Prioritising and implementing national health and disability policies and strategies in relation to local need Undertaking and managing contractual agreements with service providers Monitoring, auditing and evaluating service delivery The Planning and Funding Division contracts services from a wide range of non-government organisation (NGO) providers, as well as other DHBs who often provide more specialist services. Planning and Funding is responsible for oversight of the total funding package for our DHB and linking on this with the Ministry of Health. Planning and Funding role incorporates ensuring equitable acceptable and effective spending of health funds and ensuring that all services funded are delivered in line with expectations. It acts for the DHB in local and national technical and strategic forums working on the development of funding and pricing as well as service and purchasing frameworks. In order to live within the available funding whilst maintaining sustainable services it is essential to ensure that services are funded at appropriate levels and that value from health expenditure is maximised in terms of both health gain and the DHBs priorities. Additional focus in these areas will be required given the fiscal constraints and the need for DHBs to make decisions based on information and analysis. Planning is an integral part of purchasing and providing healthcare services. Planning is undertaken in partnership with key stakeholders, including: 5.5 Ministry of Health National Health Board Midland DHBs Other DHBs Clinical leaders Primary Health Organisations Our primary care alliance partners Iwi / Maori Non-Government Organisations Clinical advisory groups Expert advisory groups Community health forums REPORTING AND CONSULTATION 5.5.1 Consultation with the Minister and the Ministry of Health When making decisions, we follow an appropriate planning and consultation processes to avoid adverse financial, resource and clinical impacts on the affected population(s) and avoid unnecessary service instability. A well-managed process provides the confidence that: A robust process is followed There are sufficient controls in place to avoid unnecessary service instability The change is clinically appropriate and public confidence is managed 145 There are a range of matters that we must consult / notify the Minister of Health, the National Health Board and Ministry of Health. These matters are: Proposed service changes Acquisition of shares or other interests Entry into joint ventures and / or collaborative or cooperative agreements / arrangements Capital expenditure if required by policy and / or legislation Otherwise as required by legislation, regulation or contract 5.5.2 External Reporting The Ministry of Health monitors our performance on behalf of the Minister. The mechanisms currently in place to achieve this are outlined in the following table. Table: External Reporting Framework Reporting Frequency Information requests Ad hoc Financial reporting Monthly National data collections Monthly Risk reporting Quarterly Health target reporting Quarterly Crown funding agreement non-financial reporting Quarterly DHB Non-financial monitoring framework Quarterly Annual Report and audited accounts Annual 146 147 MODULE 6: SERVICE CONFIGURATION 6.1 SERVICE COVERAGE Taranaki DHB acknowledges that it has responsibility to fund other services outside the district, and will do so accordingly. The impact of this responsibility in the 2014/15 funding environment will largely be limited to: Determining alternative levels of services purchased from those indicated by Ministry of Health forecasts where there have been indications that volumes need to be increased or decreased in line with need and prioritisation Funding any additional acute inpatient activity to meet demand Purchasing services from outside the region (IDF outflows) where the DHB is unable to provide services locally Purchasing services previously provided within the district from outside the district should local provision be disrupted - to enable continuance of service coverage until longer term solutions are put in place. Services not directly funded or provided by us include, but are not limited to: Well Child services through Plunket, health camps etc National contracts (Organ transplants and new services purchased nationally) Emergency ambulance services Strengthening Families Family Start Primary response in medical emergencies (PRIME) We have little influence in these areas in respect of service coverage. We will, however, seek to engage with the relevant providers as appropriate. There are also services such as Public Health and Disability support services for people under 65 years of age which are directly purchased by the Ministry of Health where the DHB along with other providers may deliver the services. In these areas the DHB will seek to engage and work collaboratively however decisions in relation to services purchased lie with the Ministry of Health. 6.2 SERVICE CHANGE Service coverage exceptions and service changes must be formally approved before they are included in Annual Plans. The DHB had not signaled any significant proposed service changes for the 2014/15 year prior to the deadline established by the Ministry of Health of February 2014. 6.3 SERVICE ISSUES The following table identifies emerging service issues other than what is already covered this plan or described within the context of the Midland Regional Service Plan. TDHB wishes to signal its intention to review and/or evaluate these in the coming year. It has yet to be determined that there is a proven need for all changes to take place. Should the DHB consider in due course that a change is warranted, a formal service change process as outlined under the Operating Policy Framework (OPF) will be followed to ensure service coverage and the Minister’s and the Ministry’s requirements are met. 148 Table: Approved Service Issues 2014/15 Type of Change Midland Regional Clinical Services Plan Reconfiguration Description of Change As part of the Regional Clinical Services planning process clinical action groups or networks have been established for identified areas. Home and Community Support Services Consolidation of Residential Mental Health Services Benefits of Change Reduce duplication of effort enabling DHBs to collectively develop sustainable solutions. Develop integrated approach to recruitment and retention within the global marketplace. Standardised planning, evaluation and procurement of new technology solutions within a clinical environment. Implementation of new Service Specification Regional approach Sustainability of services Greater sustainability of services Facilitates demand for and from DHB inpatient facility Reduced proportion of expenditure on overheads Clinical sustainability Improved cost effectiveness Fewer women delivering who are not registered with an LMC Explore most appropriate model of maternity services for rural Taranaki Expansion of intermediate care for older people New options for acute demand and urgent primary care Taranaki Integrated Health System Ongoing the redesign of non-acute services. This will involve many stakeholders working together to redesign the Taranaki Integrated Health System. Reduced inpatient LOS Reduced proportion of older people entering permanent rest home care Care closer to home Support achievement of ED Health Target Increase options available in primary care after hours Increased enrolment of patients with PHOs Developing new ways and potentially new locations for services to be delivered within the resources available Link to Lower Funding Path Yes Change Due to Local, Regional, or National Reasons This work is consistent with the national expectation of an increased focus on regional approaches, and with the strong focus on regionalisation agreed across the Midland DHBs. Yes Regional Yes Local Yes Local Yes Local Yes Local Yes Local A key to this will be the collective effort of local providers and communities, together with lessons from elsewhere 149 150 151 MODULE 7: NON-FINANCIAL PERFORMANCE MEASURES The DHB monitoring framework aims to provide the Minister with a rounded view of performance using a range of performance markers. Four dimensions are identified that reflect DHBs functions as owners, funders and providers of health and disability services. The four identified dimensions of DHB performance cover: • • • • Achieving Government’s priority goals/objectives and targets or ‘Policy priorities’ Meeting service coverage requirements and Supporting sector inter-connectedness or ‘System Integration’ Providing quality services efficiently or ‘Ownership’ Purchasing the right mix and level of services within acceptable financial performance or ‘Outputs’. It is intended that the structure of the framework and associated reports assists stakeholders to ‘see at a glance’ how well DHBs are performing across the breadth of their activity, including in relation to legislative requirements, but with the balance of measures focused on government priorities. Each performance measure has a nomenclature to assist with classification as follows: Code PP SI OP OS DV Dimension Policy Priorities System Integration Outputs Ownership Developmental – Establishment of baseline (no target/performance expectation is set) Performance Measure 2014/15 Performance Expectation/Target Age 0-19 PP6: Improving the health status of people with severe mental illness through improved access PP7: Improving mental health services using transition (discharge) planning and employment Age 20-64 Total 3.78% Maori 3.78% Total 4.02% Maori 5.34% Age 65+ 3.46% Long term clients Provide a report as specified Child and Youth with a Transition (discharge) plan At least 95% of clients discharged will have a transition (discharge) plan. Mental Health Provider Arm PP8: Shorter waits for non-urgent mental health and addiction services for 0-19 year olds Age <= 3 weeks <=8 weeks 0-19 80% 95% Addictions (Provider Arm and NGO) Age <= 3 weeks <=8 weeks 0-19 80% 95% PP10: Oral Health- Mean DMFT score at Ratio year 1 0.9 Year 8 Ratio year 2 0.9 Ratio year 1 62% Ratio year 2 64% % year 1 85% PP11: Children caries-free at five years of age PP12: Utilisation of DHB-funded dental services by 152 adolescents (School Year 9 up to and including age 17 years) PP13: Improving the number of children enrolled in DHB funded dental services % year 2 85% 0-4 years - % year 1 85% 0-4 years - % year 2 90% Children not examined 0-12 years 10% % year 1 Children not examined 0-12 years 8% % year 2 PP18: Improving community support to maintain the independence of older people PP20: improved management for long term conditions (CVD, diabetes and Stroke) Focus area 1: Long term conditions Focus area 2: Diabetes Management (HbA1c) Improve or, where high, maintain the proportion of patients with good or acceptable glycaemic control Focus area 3: Acute coronary syndrome services The % of older people receiving long-term home support who have a comprehensive clinical assessment and an individual care plan 95% Report on delivery of the actions and milestones identified in the Annual Plan. Improve or, where high, maintain the proportion of patients with good or acceptable glycaemic control 70 percent of high-risk patients will receive an angiogram within 3 days of admission. (‘Day of Admission’ being ‘Day 0’) Over 95 percent of patients presenting with ACS who undergo coronary angiography have completion of ANZACS QI ACS and Cath/PCI registry data collection within 30 days. Improve or maintain 70% 95% 6 percent of potentially eligible stroke patients thrombolysed 6% 80 percent of stroke patients admitted to a stroke unit or organised stroke service with demonstrated stroke pathway 80% PP21: Immunisation coverage (previous health target) Percentage of two year olds fully immunised 95% PP22: Improving system integration Report on delivery of the actions and milestones identified in the Annual Plan. PP23: Improving Wrap Around Services – Health of Older People Report on delivery of the actions and milestones identified in the Annual Plan. PP24: Improving Waiting Multidisciplinary Meetings Report on delivery of the actions and milestones identified in the Annual Plan. Focus area 4: Stroke Services Times – Cancer PP25: Prime Minister’s youth mental health project Provide quarterly narrative progress reports against the local alliance Service Level Agreement plan to implement named initiatives/actions to improve primary care responsiveness to youth. Include progress on named 153 actions, milestones and measures. PP26: The Mental Health & Addiction Service Development Plan Report on the status of quarterly milestones for a minimum of eight actions to be completed in 2014/15 and for any actions which are in progress/ongoing in 2014/15. PP27: Delivery of the children’s action plan Report on delivery of the actions and milestones identified in the Annual Plan. As a low incidence DHB, TDHB will provide an exception report only against DHBs’ rheumatic fever prevention plan PP28: Reducing Rheumatic fever Hospitalisation rates (per 100,000 DHB total population) for acute rheumatic fever are 40% lower than the average over the last 3 years 1. 2. 3. a. PP29: Improving waiting times for diagnostic services b. Coronary angiography – 90% of accepted referrals for elective coronary angiography will receive their procedure within 3 months (90 days) CT and MRI – 90% of accepted referrals for CT scans, and 80% of accepted referrals for MRI scans will receive their scan within than 6 weeks (42 days) 0.5 per 100,000 90% 90% CT 80% MRI Diagnostic colonoscopy – 75% of people accepted for an urgent diagnostic colonoscopy will receive their procedure within two weeks (14 days) and 60% of people accepted for a diagnostic colonoscopy will receive their procedure within six weeks (42 days) 75% Urgent 60% Non-urgent Surveillance colonoscopy c. 60% of people waiting for a surveillance colonoscopy will wait no longer than twelve weeks (84 days) beyond the planned date 60% Part A: Faster cancer treatment – 62 day indicator PP30: Faster cancer treatment (details of expectations to be confirmed) This indicator will be included within PP30 for quarter one 2014/15 only 85%. From quarter two 2014/15 this indicator will become a health target. Part B: Faster cancer treatment – 31 day indicator < 10 % of the records submitted by the DHB 154 This indicator will be included within PP30 for all quarters of 2014/15. Part C: Shorter waits for cancer treatment – radiotherapy and chemotherapy This indicator will be included within PP30 from quarter two 2014/15 (transitioning from health target). SI1: Ambulatory sensitive (avoidable) hospital admissions are declined. All patients ready-fortreatment receive treatment within four weeks from decisionto-treat. Age 0-4 95% Age 45-64 95% Age 0-74 95% SI2: Delivery of Regional Service Plans Provision of a single progress report on behalf of the region agreed by all DHBs within that region ( the report includes local DHB actions that support delivery of regional objectives SI3: Ensuring delivery of Service Coverage Report progress achieved during the quarter towards resolution of exceptions to service coverage identified in the Annual Plan , and not approved as long term exceptions, and any other gaps in service coverage SI4: Standardised Intervention Rates (SIRs) SI5: Delivery of Whānau Ora OS3: Inpatient Length of Stay OS8: Reducing Acute Readmissions to Hospital major joint replacement 21.0 per 10,000 cataract procedures 27.0 per 10,000 cardiac surgery 6.5 per 10,000 percutaneous revascularization 12.5 per 10,000 coronary angiography services 34.7 per 10,000 Report progress on planned activities with providers to improve service delivery and develop mature providers. Elective LOS 3.18 days Acute LOS 4.07 days total pop ≤6.9% 75 plus ≤10.9% New NHI registration in error A. Greater than 2% and less than or equal to 4% OS10: Improving the quality of identity data within the National Health Index (NHI) and data submitted to National Collections Focus area 1: identity data Improving the quality of B. Greater than 1% and less than or equal to 3% >1% ≤3% C. Greater than 1.5% and less than or equal to 6% Recording of non-specific ethnicity Greater than 0.5% and less than or equal to 2% Update of specific ethnicity value in existing NHI record with >0.5% ≤2% >0.5% ≤2% 155 a non-specific value Greater than 0.5% and less than or equal to 2% Validated addresses unknown Greater than 76% and less than or equal to 85% Invalid NHI data updates causing identity confusion >76% ≤85% %tbc %tbc NBRS links to NNPAC and NMDS Greater than or equal to 97% and less than 99.5% National collections file load success Focus area 2: Improving the quality of data submitted to National Collections Greater than or equal to 98% and less than 99.5% >97% ≤99.5% >98% ≤99.5% Standard vs edited descriptors Greater than or equal to 75% and less than 90% >75% ≤90% NNPAC timeliness Greater than or equal to 95% and less than 98% Focus area 3: Improving the quality of the programme for Integration of mental health data (PRIMHD) >95% ≤98% PRIMHD File Success RateGreater than 95% >95% PRIMHD data quality Routine audits undertaken with appropriate actions where required Volume delivery for specialist Mental Health and Addiction services is within: a) five percent variance (+/-) of planned volumes for services measured by FTE, Output 1: Mental health output Delivery Against Plan b) five percent variance (+/-) of a clinically safe occupancy rate of 85% for inpatient services measured by available bed day, and c) actual expenditure on the delivery of programmes or places is within 5% (+/-) of the year-to-date plan Developmental experience measure DV4: Improving patient No performance target set 156 157 MODULE 8: APPENDICES 8.1 GLOSSARY OF TERMS TERM MEANING Activity What an agency does to convert inputs to Outputs. Capability What an organisation needs (in terms of access to people, resources, systems, structures, culture and relationships), to efficiently deliver the outputs required to achieve the Government's goals. Cost Containment Reducing costs or cost growth in general, whether through improved efficiency, or other means such as contract negotiation/consolidation, changes to budget management, changes in structure etc. Crown Agent A Crown entity that must give effect to government policy when directed by the responsible Minister. One of the three types of statutory entities (see also Crown entity; autonomous Crown entity and independent Crown entity) Crown Entity A generic term for a diverse range of entities within one of the five categories referred to in section 7(1) of the Crown Entities Act 2004, namely: statutory entities, Crown entity companies, Crown entity subsidiaries, school boards of trustees, and tertiary education institutions. Crown entities are legally separate from the Crown and operate at arm’s length from the responsible or shareholding Minister(s); they are included in the annual financial statements of the Government. Crown Entity Subsidiary A crown company is a company that is incorporated under the Companies Act 1993 that are controlled by Crown entities and that are: (a) a subsidiary of another Crown entity under sections 5 to 8 of the Companies Act 1993; or (b) a multi-parent subsidiary of 2 or more Crown entities New CE Act 2013 s7 1(c) Efficiency Reducing the cost of inputs relative to the value of outputs. Effectiveness The extent to which objectives are being achieved. Effectiveness is determined by the relationship between an organisation and its external environment. Effectiveness indicators relate outputs to impacts and to outcomes. They can measure the steps along the way to achieving an overall objective or an Outcome and test whether outputs have the characteristics required for achieving a desired objective or government outcome. Impact Means the contribution made to an outcome by a specified set of goods and services (outputs), or actions, or both. It normally describes results that are directly attributable to the activity of an agency. E.g., the change in the life expectancy of infants at birth and age one as a direct result of the increased uptake of immunisations. (Public Finance Act 1989) Impact Measures Impact measures are attributed to agency (DHBs) outputs in a credible way. Impact measures represent near-term results expected from the goods and services you deliver; can be measured after delivery, promoting timely decisions; reveal specific ways in which managers can remedy performance shortfalls. Input The resources such as labour, materials, money, people, information technology used by departments to produce outputs, that will achieve the Government's 158 stated outcomes. Intervention An action or activity intended to enhance outcomes or otherwise benefit an agency or group. Intervention Logic Model A framework for describing the relationships between resources, activities and results. It provides a common approach for integrating planning, implementation, evaluation and reporting. Intervention logic also focuses on being accountable for what matters – impacts and outcomes (Refer State Services Commission ‘Performance Measurement – Advice and examples on how to develop effective frameworks: www.ssc.govt.nz) Intermediate Outcome See Outcomes Living within Means Providing the expected level of outputs within a break even budget or NHB agreed deficit step toward break even by a specific time. Management Systems Are the supporting systems and policies used by the DHB in conducting its business. Measure A measure identifies the focus for measurement: it specifies what is to be measured Multi-Parent Subsidiary A company (incorporated under the Act) is a multi-parent if, under sections 5 to 8 of the Companies Act 1993,— (a) the company is not a subsidiary of any one Crown entity; but (b) if 2 or more Crown entities were treated as 1 entity (a combined entity), with their rights, entitlements, and interests in relation to the company taken together, the company would be a subsidiary of the combined entity (New CE Act s7(1 – 2) Objectives Is not defined in the legislation. The use of this term recognises that not all outputs and activities are intended to achieve “outputs”. E.g., Increasing the take-up of programmes; improving the retention of key staff; Improving performance; improving Governance…etc are ‘internal to the organisation and enable the achievement of ‘outputs’. Outcome Outcomes are the impacts on or the consequences for, the community of the outputs or activities of government. In common usage, however, the term 'outcomes' is often used more generally to mean results, regardless of whether they are produced by government action or other means. An intermediate outcome is expected to lead to an end outcome, but, in itself, is not the desired result. An end outcome is the final result desired from delivering outputs. An output may have more than one end outcome; or several outputs may contribute to a single end outcome. A state or condition of society, the economy or the environment and includes a change in that state or condition. (Public Finance Act 1989). Output Agreement Output agreement/output plan - See Purchase Agreement An output agreement is to assist a Minister and a Crown entity (DHB) to clarify, align, and manage their respective expectations and responsibilities in relation 159 to the funding and production of certain outputs, including the particular standards, terms, and conditions under which the Crown entity will deliver and be paid for the specified outputs. Responsible Minister may set standards, terms, and conditions in respect of certain classes of outputs. Output Classes An aggregation of outputs. (Public Finance Act 1989) Outputs can be grouped if they are of a similar nature. The output classes selected in your non-financial measures must also be reflected in your financial measures (s 142 (2) (b) CE Act 2004). Are groups of similar outputs (Public Finance Act 1989). Outputs Are final goods and services, that is, they are supplied to someone outside the entity. They should not be confused with goods and services produced entirely for consumption within the DHB group (Crown Entities Act 2004). Ownership The Crown's core interests as 'owner' can be thought of as: Strategy - the Crown's interest is that each state sector organisation contributes to the public policy objectives recognised by the Crown; Capability - the Crown's interest is that each state sector organisation has, or is able to access, the appropriate combination of resources, systems and structures necessary to deliver the organisation's outputs to customer specified levels of performance on an ongoing basis into the future; Performance - the Crown's interest is that each organisation is delivering products and services (outputs) that achieve the intended results (outcomes), and that in doing so, each organisation complies with its legislative mandate and obligations, including those arising from the Crown's obligations under the Treaty of Waitangi, and operates fairly, ethically and responsively. Performance Measures Selected measures must align with the DHBs Regional Service Plan and Annual Plan. Four or five key outcomes with associated outputs for non-financial forecast service performance are considered adequate. Appropriate measures should be selected and should consider quality, quantity, effectiveness and timeliness. These measures should cover three years beginning with targets for the first financial year (2014/15) and show intended results for the three subsequent financial years. Priorities Statements of medium term policy priorities. Productivity Increasing outputs relative to inputs (i.e.: either more outputs produced with the same inputs, or the same output produced using fewer inputs) Purchase Agreement A purchase agreement is a documented arrangement between a Minister and a department, or other organisation, for the supply of outputs. Regional Collaboration Regional collaboration refers to DHBs across geographical ‘regions’ for the purposes of planning and delivering services (clinical and non-clinical) together. Four regions exist. Northern: Northland DHB, Auckland DHB, Waitemata DHB and Counties Manukau DHB Midland: Bay of Plenty DHB, Lakes DHB, Tairawhiti DHB, Taranaki DHB and Waikato DHB 160 Central: Capital and Coast DHB, Hawkes Bay DHB, Hutt Valley DHB, MidCentral DHB, Waitemata DHB and Whanganui DHB Southern: Canterbury DHB, Nelson Marlborough DHB, South Canterbury DHB, Southern DHB and West Coast DHB Regional collaboration for some clinical networks may vary slightly. For example Central Cancer Network contains eight DHBs, Taranaki DHB and Tairawhiti DHB in addition to the Central Region DHBs. Results Sometimes used as a synonym for 'Outcomes'; sometimes to denote the degree to which an organisation successfully delivers its outputs; and sometimes with both meanings at once. Standards of Service Measures Measures of the quality of service to clients focus on aspects such as client satisfaction with the way they are treated; comparison of current standards of service with past standards; and appropriateness of the standard of service to client needs. Statement of Performance Expectations (SPE) Government departments and Crown entities are required to include audited statements of objectives and statements of performance expectations with their financial statements. These statements report whether the organisation has met its service objectives for the year. Statement of Service Performance (SSP) Government departments, and those Crown entities from which the Government purchases a significant quantity of goods and services, are required to include audited statements of objectives and statements of service performance with their financial statements. These statements report whether the organisation has met its service objectives for the year. Strategy See Ownership Sub Regional Collaboration Sub regional collaboration refers to DHBs working together in a smaller grouping to the regional grouping. Typically this is groupings of two or three DHBs and may be formalised with an agreement e.g., Memorandum of Understanding. Examples include DHBs in the Auckland Metropolitan area, MidCentral and Whanganui DHBs (central Alliance), Capital and Coast, Hutt Valley and Wairarapa DHBs and Canterbury and West Coast DHBs. Targets Targets are agreed levels of performance to be achieved within a specified period of time. Targets are usually specified in terms of the actual quantitative results to be achieved or in terms of productivity, service volume, service-quality levels or cost effectiveness gains. Agencies are expected to assess progress and manage performance against targets. A target can also be in the form of a standard or a benchmark. Values The collectively shared principles that guide judgment about what is good and proper. The standards of integrity and conduct expected of public sector officials in concrete situations are often derived from a nation's core values which, in turn, tend to be drawn from social norms, democratic principles and professional ethos. Value for Money The assessment of benefits relative to cost, in determining whether specific current or future investments/expenditures are the best use of available resource. 161 8.2 OUTPUT CLASS DEFINITIONS Output Class 1 Category of Output Class Prevention 1 Health Promotion and Education Preventative services are publicly These services inform people about risks, encourage them to self- funded services that protect and manage, become healthier and, as a result, live longer. Success is promote whole measured by a continuum from awareness and engagement, sub- reinforcing the message by specific programmes and support, through health population populations or the identifiable comprising designed to enhance the health status of the population as distinct from treatment to seeing behaviours changing for the better. services services 2 These services sustainably manage environments to support people which and communities to make healthier choices and maintain health and repair/support health and disability safety. They include: compliance monitoring with liquor licensing and dysfunction. Preventative services smoke free environment legislation, assurance of safe drinking water, address individual behaviours by proper targeting population-wide physical and social environments 3 substances and effective Success is measured by or (b) conditions at an earlier stage. They include breast and cervical are reduced; statutorily mandated cancer screening and antenatal HIV screening. Success is measured health protection services to protect by high coverage rates. the public from toxic environmental risk and communicable diseases; and, population health protection Population Based Screening Screening Unit and help to identify either (a) people at risk of illness; prevented and unequal outcomes 4 Immunisation These services reduce the transmission and impact of vaccine- services such as immunisation and preventable diseases. The DHB works with primary care and allied screening services. High need and health professionals to improve the rate of immunisations across all at risk population groups are also age groups, both routinely and in response to specific risk. Success is more likely to engage in risky live hazardous These services are mostly funded and provided through the National promotion to ensure that illness is to of compliance with legislation. Preventative services include health and management quarantine and bio-security procedures. to influence health and wellbeing. behaviours Statutory Regulation measured by a high coverage rate. in environments less conducive to 5 Well Child Services choices. These services are aimed at our most vulnerable group – our children. Prevention services represent our Services and programmes targeted towards our children today will best target significantly impact upon our adult population of tomorrow. Success is improvements in the health of high measured by (a) a comprehensive range of services, including need populations and to reduce immunisation, assessment of children before they start school and (b) inequalities in health status and services provided to a broad range of children, including a focus on health outcomes. Māori and those children of high deprivation, to reduce health making healthier opportunity to disparities. 162 Output Class 2 Category of Output Class Early Detection and Management 6 Primary Healthcare and GP Services Early detection and management These services are offered in local community settings by teams of services are delivered by a range of general practitioners (GPs), registered nurses, nurse practitioners and health health other primary healthcare professionals, aimed at delivering Better, professionals in various private, not- Sooner and More Convenient services and improving, maintaining or for-profit and government service restoring our population’s health. Success is measured by high levels settings, including general practice, of enrolment with our PHOs (Primary Health Organisations) as it community indicates engagement, accessibility and responsiveness of primary services, and and allied Māori Pharmacist health healthcare services. services, Community Pharmaceuticals (the Schedule), child and adolescent 7 Oral Health Services These services are provided by registered oral health professionals to oral health and dental services. assist people in maintaining healthy teeth and gums. While high levels of enrolment, timely access and treatment are important, These services are by their nature ultimately success is measured by results – children who are caries- more generalist, usually accessible free, and reducing the number of decayed, missing or filled teeth. from multiple health providers and from a number of different locations within the DHB. On a continuum of care these services 8 are Primary Community Care Programmes These services are offered in local community settings by teams of preventative and treatment services healthcare professionals (other than general practitioners (GPs), focused on individuals and smaller registered nurses, nurse practitioners) aimed at delivering Better, groups of individuals. Sooner and More Convenient services and improving, maintaining or restoring our population’s health. Success is measured by rates of participation. 9 Pharmacy Services These services include the provision and dispensing of medicines and are demand-driven, i.e. by patients and prescribers (nurse specialists, GPs and specialists). As long term conditions become more prevalent, we are likely to see an increased dispensing of medicines. Success is measured by (a) medication management for people on multiple medications to reduce potential negative interactive effects and (b) maintaining or reduction the level of prescribed medicines. 163 Output Class Category of Output Class 10 Community Referred Testing and Diagnosis These are services to which a health professional may refer a patient to help diagnose a health condition, or as part of treatment. They are provided by health personnel such as laboratory technicians, medical radiation technologists and nurses. Success is measured by timely access to diagnostics to improve clinical referral processes and decision-making. 11 Mental Health Services These services are provided to people who are affected by mental illness or addictions. They include assessment, diagnosis, treatment and rehabilitation, as well as crisis response when needed. Success is measured by timely access to services, particularly for our children and youth, so that we can eliminate, or reduce the severity of, mental health conditions and addictions. 3 Intensive Assessment and 12 Treatment Specialist Mental Health Services These services are provided to people who are most severely affected and by mental illness or addictions. They include assessment, diagnosis, treatment services are delivered by treatment and rehabilitation, as well as crisis response when needed. a range of secondary, tertiary and Success is measured by (a) timely access to services, particularly for quaternary providers using public our children and youth, so that we can eliminate, or reduce the funds. These services are usually severity of, mental health conditions and addictions; and (b) a integrated into facilities that enable reduction in relapses. Intensive assessment co-location of clinical expertise and specialized equipment such as a ‘hospital’. These services are generally complex, more costly and provided professionals by that health care work closely together. 13 Elective (inpatient/outpatient) Services These are assessment and treatment services that are provided to people who do not need immediate hospital treatment and who require booked or arranged services. This includes elective surgery, but also non surgical interventions (such as coronary angioplasty) and specialist assessments (either first assessments, follow-ups or pre- They include: admission assessments). Success is measured by (a) timely services; (b) services that are provided in an effective and efficient Ambulatory services (including way and (c) that we make the best use of our resources. 1 1 While the OAG has indicated a preference for patient satisfaction survey results to be included as a qualitative measure, the Midland DHBs have elected not to include them because there are some questions regarding the reliability 164 Output Class outpatient, district nursing and day services across the range of secondary preventive, diagnostic , therapeutic, and rehabilitative services Category of Output Class 14 These are services that have an abrupt onset, are often short in duration and rapidly progressive, for which the need for care is urgent. They may lead to a hospital admission. Inpatient services (acute and elective streams) including diagnostic, therapeutic and rehabilitative services and intensive care services. Success is measured by (a) timeliness (waiting times), (b) productivity (length of stay), (c) outcome measures such as readmission rates, to indicate quality of service provision, and (d) managing demand by either maintaining or reducing the number of ED presentations, which is indicative of a strong primary/secondary integration. On a continuum of care these treatment services and focused on Hospital-based services include Emergency Departments (ED), short-stay acute assessments Emergency Department services including triage, diagnostic, therapeutic and disposition services services are at the complex end of Acute (Emergency Department/Inpatient/Outpatient) Services 15 Maternity Services These services are provided to women and their families through pre- individuals, rather than groups. conception, pregnancy, childbirth and for the first months of a baby’s life. These services are provided in the home, community and hospital settings by a range of health professionals, including midwives, GPs and obstetricians and include specialist obstetric, lactation, anaesthetic, paediatric and radiology services. Success is measured by (a) ensuring that our proportion of caesarian deliveries 1 is consistent with the national average; and (b) that we maintain our post natal length of stay (days). 16 Assessment Treatment and Rehabilitation These are services provided to restore functional ability and enable people to live as independently as possible. Services are delivered in specialist inpatient units, outpatient clinics and also in home and work environments. Specialist geriatric and allied health expertise and advice is also provided to GPs, home and community care providers, aged residential care (ARC) facilities and voluntary groups. Success is measured by an increase in the rate of people discharged home with support, rather than to ARC or hospital environments (where appropriate). 1 While some caesarians are necessary on either an arranged or acute basis, overall we want to see as many babies delivered with no surgical intervention as possible, particularly as surgery introduces an element of risk to either the mother or her baby. 165 Output Class 4 Category of Output Class Rehabilitation and Support 17 Needs Assessment and Service Coordination These are services that determine a person’s eligibility and need for Rehabilitation and support services publicly-funded support services and then assist the person to are delivered following a ‘needs assessment’ process coordination input Assessment by and determine the best mix of support services, based on their strengths, and resources and goals. The support is delivered by an integrated team Needs in the person’s own home or community. Success is measured by (a) Service increasing the number of assessments completed using a clinically Coordination (NASC) Services for a accepted assessment tool, (b) providing timely assessments and (c) range of services including palliative increasing the number of assessments provided to those who are care services, home-based support services and residential most likely to require an assessment (i.e. people 65+ and people who care have entered ARC). services. On a continuum of care these services individuals provide following support a 18 Palliative Care Services These are services that improve the quality of life of patients and their for families facing the problems associated with life-threatening or long health- term conditions, through the relief of suffering by early intervention, related event. assessment, treatment of pain and other supports. Success is measured by providing timely and appropriate palliative care that is patient-driven, and avoids unnecessary and/or painful treatment which does not positively impact on either the patient’s quality or length of life. 19 Rehabilitation Services These are services that restore or maximise people’s health or functional ability, following a health-related event. They include mental health community support, physical or occupational therapy, treatment of pain or inflammation and retraining to compensate for specific lost functions. Success is measured through increased referral of the right people to the right service. 20 Aged Related Residential Care (ARC) Services These services are provided to meet the needs of a person who has been assessed as requiring long term residential care in a hospital or rest home indefinitely. Success is measured, particularly with our ageing population and a decrease in the number of subsidised bed days, by (a) more people being successfully supported to continue living in their own homes, (b) balancing our level of home-based support (see below) and (c) the quality of ARC. 166 Output Class Category of Output Class 21 Home Based Support Services These are services designed to support people to continue living in their own homes and to restore functional independence. They may be short or longer-term in nature. Success is measured by (a) an increase in the number of people being supported as indicative of an increased capacity in the system (b) a decreased or delayed entry into ARC or hospital services. 22 Life Long Disability These are services designed to support people who have a lifelong disability to continue living in their own homes and to retain as much independence as possible. Success is measured by an increase in the number of people being supported as indicative of an increased capacity in the system. 23 Respite Care and Day Care Services These services provide people who suffer from dementia or a long term condition with a break, so that a crisis can be averted or so that a specific health need can be addressed. Services are provided by specialised organisations and are usually short-term in nature. They may also include support and respite for families, caregivers and others affected. Success is measured by an increase in the level of services provided over time, so that more people are supported and able to remain in their own homes. 167 8.3 OUTPUT CLASS REVENUE AND EXPENDITURE The following table outlines the funding and expenditure associated with the allocation of the output classes described above: Table: Output Class Revenue and Expenditure Prevention Planned Revenue ($000s)* 11,508 Planned Expenditure ($000s)* 11,557 Early Detection and Management 81,198 81,543 Intensive Assessment and Treatment Services 200,698 201,550 Rehabilitation and Support 44,766 44,956 TOTAL 338,170 339,606 Output Class 168 8.4 OUTPUT MEASURE RATIONALE Measure Rationale Output class / Category Dimension of Performance Percent of patients who smoke and are seen by a health practitioner in public hospitals are offered brief advice and support to quit smoking Percent of patients who smoke and are seen by a health practitioner in primary care are offered brief advice and support to quit smoking Percentage of pregnant women who identify as smokers at the time of confirmation of pregnancy in general practice or booking with Lead Maternity Carer are offered advice and support to quit Percentage of eight month olds fully immunised Providing brief advice to smokers is shown to increase the chance of smokers making a quit attempt Prevention Services/Health Promotion and Education Quantity Providing brief advice to smokers is shown to increase the chance of smokers making a quit attempt Prevention Services/Health Promotion and Education Quantity Pregnancy is a period during which women are motivated to quit smoking, and evidencebased tobacco cessation programmes can significantly increase the likelihood of this. Reducing smoking in pregnancy would be well supported by New Zealanders, is easy to understand and leads to significant positive outcomes across the whole of life span Immunisation can protect against harmful infections, which can cause serious complications, including death. It is one of the most effective, and cost-effective medical interventions to prevent disease Prevention Services/Health Promotion and Education Quantity Prevention Services/ Immunisation Prevention Services/ Immunisation/Well Child Prevention Services/ Immunisation/Well Child Quantity Breastfeeding is the unequalled way of providing ideal food for the healthy growth and development of infants and toddlers. This measure supports the sector to get ahead of the chronic disease burden. A Green Prescription (GRx) is a health professional’s written advice to a patient to be physically active, as part of the patient’s health management. Research published in the New Zealand Medical Journal indicates that a Green Prescription is an inexpensive way of increasing activity. Having babies at a very young age can increase maternal risk factors such as high blood pressure and preeclampsia. There is also the increased likelihood of those without parental/guardian support receiving less prenatal support. Teenage pregnancy is associated with difficulties in psychological, sexual and overall health. We also want to measure both teen pregnancy and termination rates to ensure that one does not increase while the other decreases. Research shows that improving oral health in childhood and adolescence has benefits over a lifetime. Prevention Services / Health Promotion and Education Quantity/ Timeliness Prevention Services / Health Promotion and Education Quantity Prevention Services/Health Promotion and Education Quantity Prevention Services/Health Promotion and Education Quantity Early Detection and Management Services/Oral Health Quantity Percentage of population over 65 years who are immunised against influenza Percentage of infants fully and exclusively breastfeed at six months The number of referrals to the GRx (Green Prescription) programmes Reduce the teen birth rate Reduce the rate of teenage terminations of pregnancy Percentage of children under five years of age (i.e. aged 0 – 4 years of age inclusive) who are enrolled with DHB-funded oral health services Percentage of pre-school and primary school children (0 – 12 years) who are overdue for their planned recall period Percentage of adolescents Quantity/ Timeliness Quantity/ Timeliness Quantity Quantity 169 Measure accessing DHB funded oral health services Percentage of population enrolled with a primary health organisation Percentage of people who are enrolled with a primary health organisation and have had their cardiovascular risk assessed in the last five years Maintain or improve appropriate management of microalbuminuria or overt nephropathy in patients with diabetes Percentage of eligible women (20-69) have a cervical cancer screen every 3 years Percentage of eligible women (50-69) have a breast screen in the last 3 years Increase the number of packages of care available to youth under the Primary Mental Health Initiative Percentage of Rest Home residents receiving vitamin D supplement from their GP Percentage of all Emergency Department presentations who are triaged at levels 4&5 Percentage of eligible children have their B4 School Checks completed Hospitalisation rates per 100,000 for acute rheumatic fever Percentage of older people receiving long-term home support who have had a comprehensive clinical assessment and a completed care plan in the last 12 months For those with aged related and chronic health conditions we aim to reduce the rate of rest home level of residential care to home based support and respite funding Increased number of clients accessing respite services Rationale Output class / Category Dimension of Performance Access to primary care has been shown to have positive benefits in maintaining good health. It can reduce the economic cost of ill health by intervening early. By increasing the percentage of people being checked for long-term conditions ensures these are identified early and managed appropriately, and aid in the promotion and protection of good health and independence. Early Detection and Management Services/ Primary Healthcare Quantity Early Detection and Management Services/ Primary Healthcare Quantity Cervical cancer is one of the most preventable of all cancers. Having regular cervical smears can reduce a woman’s risk of developing cervical cancer by 90 percent Breast screening is a proven way for finding breast cancers early to reduce the risk of dying of breast cancer Primary mental health initiative is funded to increase the availability of services in Primary Health Organisations for patients with mild to moderate mental health issues. In line with our Taiohi Health Strategy and the Prime Minister’s Youth Mental Health project we are expecting the actions in our Annual Plan will result in an increase in youth accessing these services. Vitamin D supplementation has been demonstrated to improve mineral bone density and reduce falls. Emergency department services utilise a scale of one to five triage, with one being the most urgent. Triage category four and five may more appropriately be seen in primary care. A nationwide programme offering a health and development check for four year olds Prevention Services/ Population Based Screening Quantity Prevention Services/ Population Based Screening Quantity Early Detection and Management Services/ Primary Mental Health and Addictions Quantity Prevention Services/Health Promotion and Education Quantity Intensive Assessment and Treatment Services/Acute Services Quantity Prevention Services/ Well Child Quantity Rheumatic fever arises as a result of a throat infection with Group A Streptococcal bacteria. It predominantly affects children between 5 and 14 years of age. In New Zealand, evidence points to poorer housing conditions (especially overcrowding) and general social deprivation as risk factors for rheumatic fever. More consistent and comprehensive assessment of the older person which enables determination of service capacity and service planning information Prevention Services/ Well Child Quantity Rehabilitation and Support Services/Needs Assessment and Service Coordination Quantity By focusing the models of care in community services such as home based support and respite services to have a more restorative approach we expect that the proportion of funding required to allocate to rest home residential care to comparatively reduce. In line with community services for older people having a more restorative approach Rehabilitation and Support Services / Age Related Residential Care Services Rehabilitation and Support Services Quantity Quantity 170 Measure Percentage of patients aged 75 and over (Maori and Pacific Islanders 55 and over) that are given a falls risk assessment Acute re-admission rate Average length of inpatient stay Percentage of patients who require radiation or chemotherapy are treated with 4 weeks Faster Cancer Treatment – Proportion of patients with a confirmed diagnosis of cancer who receives their first cancer treatment with 31 days Arranged Caesarean deliveries without catastrophic or severe complication as a % of total deliveries Percentage of operations where venous thromboembolism (blood clot) was considered as part of the surgical checklist Rationale and a focus on meeting the needs of informal carers we expect the number of clients accessing respite services will increase. Falls in the elderly contribute to a reduction in the quality of life including loss of independence, early entry into Rest Home residence and premature death. To ensure that the risk of inpatient falls in the elderly is minimised we aim to provide a risk assessment to all eligible patients. Unplanned readmissions will usually present to emergency departments, and may result in admission to hospital for further treatment. This puts pressure on emergency departments and inpatient hospital capacity, efficiency and productivity. An unplanned acute hospital readmission may often (though not always) occur as a result of the care provided to the patient by the health system. Reducing unplanned acute admissions can therefore be interpreted as an indication of improving quality of acute care, in the hospital and/or the community, ensuring that people receive better health and disability services. By shortening hospital length of stay, while ensuring patients receive sufficient care to avoid readmission, we will positively impact hospital productivity through freeing up beds and other resources so it can provide more elective surgery, reduce waiting times in the emergency department or make savings. Supporting patients to return home sooner may, in part, be achieved by reducing the rate of patient complications and better use of the time clinical staff spend with patients. Patients will also be less at risk of contracting nosocomal infections. Specialist cancer treatment and symptom control is essential in reducing the impact of cancer Implementation of Faster cancer treatment supports the overarching goal of Better, Sooner, More Convenient Health Services for New Zealanders. The key 2013/14 (strategic) planning considerations of integration, regionalisation and value for money are all supported by implementation of these indicators. The longer-term aim is to reduce the risks associated with an unnecessary Caesarean section, reduce the number of women at risk of a subsequent Caesarean section and reduce the number of women who experience difficulties with their second and subsequent births as a consequence of a primary Caesarean section. Venous thromboembolism can cause long term debilitating damage so the assessment and appropriate preventative actions to all surgical patients will increase not only the overall quality of life but also reduce the toll of long term ill health or even death. Output class / Category Dimension of Performance Intensive treatment and assessment. Quality Intensive Assessment and Treatment Services/Acute Services Quality Intensive Assessment and Treatment Services/Elective Services and Acute Services Quality Intensive Assessment and Treatment Services/Elective Services and Acute Services Quantity Intensive Assessment and Treatment Services/Elective Services Quantity Intensive Assessment and Treatment Services/Elective Services Quantity Intensive Assessment and Treatment Services Acute/ Elective Services Quality 171 Measure Rationale Output class / Category Dimension of Performance Percentage of patients waiting longer than five months for their first specialist assessment Patients have a much better chance of recovering and getting on with their lives where they are diagnosed and treated and returned home in a timely way. Intensive Assessment and Treatment Services/Elective Services Quantity/ Timeliness Number of surgical discharges under the elective initiative Elective surgery reduces pain or discomfort, and improves independence and wellbeing. Increasing delivery should will improve access and reduce waiting times. Reducing did not attends is a key objective in terms of removing waste in the system Intensive Assessment and Treatment Services/Elective Services Quantity Intensive Assessment and Treatment Services/Elective Services and Acute Services Quantity Access and shorter waits are very important to patients. Earlier treatment in the progression of illness links to better outcomes as evidenced in international literature. Timeliness is also a key quality indicator in calls for improvement to the health care system. Intensive Assessment and Treatment Services/Specialist Mental Health and Addiction Services Timeliness/ Quality When long term clients with serious mental illness have agreed relapse prevention plans that enable them to better co-produce their mental health and well-being outcomes Mental health and addiction services seek to support service users in the least restrictive environment. Performance on this indicator provides some information about the extent to which this is being achieved. Intensive Assessment and Treatment Services/Specialist Mental Health and Addiction Services Intensive Assessment and Treatment Services/Specialist Mental Health and Addiction Services Quantity Intensive Assessment and Treatment Services/Specialist Mental Health and Addiction Services Quality Percentage of people who did not attend (DNA) their schedule appointment for an outpatient service Percentage of people referred for non-urgent mental health services are seen within three weeks Improving the percentage of long-term clients with up to date relapse prevention/treatment plans Average length of stay in an adult mental health and addiction inpatient unit Quantity Length of stay is the main driver of variation in inpatient episode cost and reflects differences between mental health service organisations resources, service practices and service user case-mix. Rates of post-discharge community care A reduction in the percentage of palliative care clients who have had an Emergency Department presentation Improved wait times for This indicator, alongside others promotes a more complete understanding off an organisation’s overall model of service delivery. A responsive community support system for people who have experienced an acute psychiatric episode requiring hospitalisation is essential to maintain clinical and functional stability and to minimise the need for hospital readmission. Service users leaving hospital after an admission with a formal discharge plan involving linkages with community services and supports are less likely to need early readmission. Research indicates that service users have increased vulnerability immediately following discharge, including higher risk for suicide. The Taranaki Palliative Care Strategy highlighted the need for an increase in the generalist workforce who are trained and supported by our Specialist Palliative Care Provider to provide quality palliative care underpinned by Advanced Care Planning. We expect that delivery of enhanced palliative care pathways, particularly in aged residential care, will lead to a reduction in the percentage of palliative care patients who present to our Emergency Departments. Diagnostics are a vital step in the pathway to Intensive Assessment and Treatment Services Intensive Assessment and Quantity/ 172 Measure Rationale Output class / Category Dimension of Performance diagnostic services – accepted referrals for CT and MRI receive their scan within 6 weeks (Developmental Measure 2) Non urgent community laboratory tests are completed and communicated to practitioners within the relevant category timeframes Number of community pharmacy prescriptions access appropriate treatment. Improving waiting times for diagnostics can reduce delays to a patient’s episode of care and improve DHB demand and capacity management. Treatment Services/Elective Services Timeliness The new Community Pharmacy contract will encourage greater efficiency and a more patient focused service. We expect volume of prescriptions to decrease overall Early detection and management/Pharmacy Services Quantity 173 Table of Contents Overview 03 Summary of Indicators 04 Abbreviations 05 Population Profile 06 Māori Health Needs Assessment 07 Māori Community Development - Te Ara Tuatahi Pathway One Participation and Leadership - Te Ara Tuarua Pathway Two Health System Performance - Te Ara Tuatoru Pathway Three Social Determinants - Te Ara Tuawha Pathway Four 07 07 08 08 Improvements Under Way 08 Priorities and Indicators 09 National Priorities 10 N1- Data Quality N2.1- Access to Care, PHO Enrolments N2.2- Access to Care, ASH N3- Child Health N4.1- Cardiovascular Disease, Tertiary Cardiac Interventions N4.2- Cardiovascular Disease, CVD Risk Assessment N4.3 - Cardiovascular Disease, Presenting with ACS N5.1- Cancer, Breast screening N5.2- Cancer, Cervical screening N6.1- Smoking, Hospital N6.2- Smoking, Primary Care N7.1- Immunisation, 8 months N7.2- Immunisation, Seasonal Influenza N8- Rheumatic Fever N9 - Oral Health N10 - Mental Health Local Priorities L1 - Access to Services DNA's L2 - Primary Mental Health References 10 10 11 13 14 15 15 16 17 18 19 20 21 22 23 23 24 24 25 26 Page 2 of 26 OVERVIEW This Plan describes the Taranaki District Health Board’s (TDHB) priorities in Māori health for 2014-2015. The plan represents the TDHB’s main response to its obligations under the New Zealand Public Health and Disability Act (2000) which requires DHB’s to reduce disparities and improve Māori health outcomes. It aligns to the TDHB’s strategic framework that aims to achieve the vision of “Taranaki whanui, he rohe oranga” as well as the wider aspirations of Whānau ora as described in He Korowai Oranga, national Māori Health Strategy and Te Kawau Mārō, Taranaki Māori Health Strategy. The format of this plan and the indicators included follow the 2014-2015 Operational Policy Framework guidelines. In 2014-15, in addition to the national priorities, we will continue to focus on two local priorities identified in the TDHB’s 2012 Whānau Ora Health Needs Assessment of Māori living in Taranaki*, namely DNA rate for outpatient appointments and access by taiohi Māori to primary mental health services. The Sudden Unexplained Death of Infants (SUDI) priority made mandatory by the Ministry of Health in previous years, is no longer mandatory and is therefore excluded this year. The focus in previous years on children’s oral health has now become a national priority and will continue to be progressed as such, the relevant indicator being pre-school dental enrolments. The Māori Health Plan gives a one-year subset of actions and aspirational targets related to Māori health priorities and indicators. Longer term activities (2 – 5 years) to improve health for Māori and non-Māori are described in the 20142015 TDHB Annual Plan with which this Plan aligns. Four national Māori Health Plan indicators identified in this Plan are prioritised in the Midland Regional Services Plan to bring about regional focus on addressing these priority issues – Cancer screening, Breast feeding, Immunisation at 8 months and Cardiovascular Risk Assessments. Quarterly performance results for the Māori Health Plan indicators will be disseminated to key audiences. First, results will be submitted to a joint meeting of the TDHB and Te Whare Punanga Korero Iwi relationship Boards along with senior managers, to monitor progress against the Plan. Second, quarterly performance reports will be disseminated for review by the Midland Health Network as well as the Māori Health Services alliance Te Kawau Mārō Alliance Leadership Teams. These groups represent key governance and operational audiences which are directly engaged in delivery against the Plan. Finally the DHB’s Māori Health Plan performance will be presented in the DHB’s Annual Report. * Whānau Ora Health Needs Assessment, Māori Living in Taranaki, Dr M Ratima and B Jenkins, Taranaki DHB, 2012 Page 3 of 26 1. SUMMARY OF INDICATORS Health Issue Indicator(s)Target Target Baseline TDHB Māori Non-Māori National Priorities 1 N1 Data Quality 2 N2.1 Access to care 3 N2.2 Accuracy of ethnicity reporting in PHO registers as measured by Primary Care Ethnicity Data Audit Toolkit 1. Percentage of Māori enrolled in PHOs 98% 85.3% 97.3% 2. Ambulatory Sensitive Hospitalisations rates per 100,000 for the age groups 0-4 yrs 95% 68% 54% 59% 90% 117% 5,300 168% 3,835 156% 3,110 56% 34% 9% 73% 56% 2,555 73% 1,677 73% 1,458 68% 54% 23% 83% 70% 25% 50% 95% 100% 94% 70% 65% 79% 80% 73% 89% 95% 90% 98% 71% 96% 72% 95% 75% 89% 67% 89% 70% Total 4 5 6 7 N3.1 N3.2 N3.3 N4.1 Child Health 8 N4.2 2. 9 N4.3 3. 10 N5.1 11 N5.2 Cardiovascular disease Cancer Audit tool to be implemented or PHO enrolments as proxy 1. 1. 2. 12 13 N6.1 N6.2 Smoking 1. 2. 14 15 N7.1 N7.2 Immunisation 1 2 16 N8 17 18 N9 N10 Rheumatic Fever Oral Health Mental Health 45-64 yrs 95% 0-74 yrs 95% Exclusive breastfeeding at 6 weeks 3 months 6 months Percentage of the eligible population who have had their CVD risk assessed within the past five years (ht) 70 percent of high-risk patients will receive an angiogram within 3 days of admission. (‘Day of Admission’ being ‘Day 0’) Over 95 percent of patients presenting with ACS who undergo coronary angiography have completed ANZACS QI ACS and Cath/PCI registry data collection within 30 days Breast Screening, 70% of eligible women will have a BSA mammogram every two years Cervical Screening, percentage of women (Statistics NZ Census projection adjusted for prevalence of hysterectomies) aged 25-69 who have had a cervical screen in the past 36 months (by ethnicity) Hospitalised smokers provided with advice and help to quit (ht) Current smokers enrolled in a PHO and provided with advice and help to quit Percentage of infants fully immunised by eight months of age (ht) Seasonal influenza immunisation rates in the eligible population (65 years and over) 2014/2015 rheumatic fever target is 0.5 per 100,000 and a 40% reduction from baseline (3 year average 2009/10 – 2010/11) Preschool Enrolments Mental health Act: Section 29 Community Treatment Order indefinites comparing Māori rates with other (as per reporting to the Office of the Director of Mental Health) High needs 0.5/100,000 0.9 85% 59% 82% Improve on baseline 102/100,000 54/100,00 5% 19% 7% Improve on baseline 17% 49% Local Priorities 19 L1 Access to Services Did-Not-Attend (DNA) rate for outpatient appointments 20 L2 Primary Mental Health Access by Taiohi Māori to packages of primary mental health Care Page 4 of 26 ABBREVIATIONS ABC An approach to smoking cessation requiring health staff to ask, give brief advice, and facilitate cessation support. ALT Alliance Leadership Team ASH Ambulatory Sensitive Hospitalisation BFCI Breastfeeding Friendly Community Initiative BOPDHB Bay of Plenty District Health Board COL Colposcopy COPD Chronic Obstructive Pulmonary Disease CVD Cardiovascular disease CVD-IHD Cardiovascular disease – Ischaemic heart disease DEN Dental DHB District Health Board DIA Diabetes dmf Decayed, missing, or filled primary teeth DMFT Decayed, Missing, or Filled Teeth (permanent) dmft Decayed, missing, or filled teeth (deciduous) DNA Did not attend (used in the measurement of outpatient clinic attendance) ENT Ear, Nose and Throat KARO Knowledge, Actions, Results, Opportunity – reporting database through MOH MHN Midland Health Network MOH Ministry of Health MSD Ministry of Social Development NGO Non-Government Organisation NHC National Hauora Coalition PHO Primary Health Organisation PM Portfolio Manager PHN Public Health Nurse PMHI Primary Mental Health Indicator RFP Request for Proposal RS Respiratory SUDI Sudden Unexplained Death of Infants TDHB Taranaki District Health Board TLA Territorial Local Authority Page 5 of 26 POPULATION PROFILE 1.1. Taranaki DHB serves 3.03% of the Māori population of New Zealand. At the 2013 Census, 18,165 Māori were resident in Taranaki; this represents the 15th highest number of Māori serviced by any of the DHB’s. However Māori make up 16.6% of the total Taranaki DHB population which is slightly higher than the national of 14.1%. 1.2. In the regional context Taranaki DHB has the lowest number and lowest proportion of Māori living in its service area of all the Midland DHB’s. The highest proportion of Māori live in the Midland region. Age Distribution 1.3. The Māori population in Taranaki is very young compared to the overall population as shown in Figure 4 below. For Māori, 35.9% of the population resident in Taranaki is under 15 years of age compared to 21.8% for the total population. The difference is even more marked for older Māori, with 4.7% of the Māori population resident in Taranaki aged over 65 years compared to 14.8% for the total population. This is, in part, a reflection of the lower Māori life expectancy relative to non-Māori. Figure 4 Age Structure of Taranaki DHB, 2010 Māori Population (Black line) and Total Taranaki Population (Gray Shadow) 85+ Female Male 80-84 75-79 70-74 65-69 60-64 55-59 Age 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 8% 6% 4% 2% 0% 2% 4% 6% 8% % Population Source: Statistics NZ, Estimated Territorial Local Authority Population of TLA population June 2010. Iwi 1.4. As at the 2013 Census the following was the population makeup of the iwi of Taranaki: IWI Ngati Tama Ngati Mutunga Te Atiawa Ngati Maru Taranaki Ngaruahinerangi Ngati Ruanui Ngaa Rauru Kiitahi Tangahoe Pakakohe Other – Not Defined TOTAL Māori: non-Taranaki iwi Total Māori Population TOTAL IWI POPULATION 1,338 2,514 15,273 852 6,087 4,803 7,260 4,176 246 351 120 43,020 IWI POPULATION RESIDENT IN TARANAKI 387 759 3,828 291 1,689 1,779 1,827 717 96 144 21 11,538 6,627 18,165 % IN TARANAKI 28.92% 30.19% 25.06% 34.15% 27.75% 37.04% 25.17% 17.17% 39.02% 41.03% 17.50% 26.82% Geographic Distribution 1.5. TDHB comprises three territorial authorities. In 2013 the majority of the population was based in the New Plymouth District Council catchment (9369) while the largest proportion was based in the South Taranaki District (22.6%). Total Population Māori (%) South Taranaki District 26,580 22.8% Stratford District 8,991 11.2% New Plymouth District 74,184 14.9% Page 6 of 26 Population Growth 1.6. The Māori population in Taranaki is growing much faster than the non-Māori population, which is projected to decline. The Taranaki population is projected to increase from 109,608 in 2013 to 111,400 by 2031, an increase of 1.6%. 1.7. At the time of writing this Plan, Māori population projections based on the 2013 census were not available. However based on the 2006 census the Māori population is expected to increase to 22,800 by 2026, an increase of 44%. This means that, by 2026, Māori are expected to account for around 20.7% of the region’s population compared to 15.2% in 2006. The Māori population in the region will increase faster in the younger age groups. Based again on 2006 projections by 2026, Māori are expected to account for 36.7% (27.3% in 2008) of those aged under 15, and 33.6% (23.9% in 2008) of those aged between 15 and 24. 1.8. Māori who whakapapa to Taranaki iwi account for 63.5% of the local Māori population or 11,538 people, while almost 36.5% percent whakapapa to iwi outside of Taranaki. Around 26% of the 43,000 Taranaki uri live in the Taranaki region. Deprivation 1.9. Taranaki had a higher proportion of people living in deciles 6 to 10. Māori make up a significantly higher proportion of Taranaki residents in deprivation deciles 8 and 9 and a much higher proportion of Māori in decile 10. Conversely in deciles 1 to 4, the proportion of non-Māori is much higher. 2. MĀORI HEALTH NEEDS ASSESSMENT Leading Causes of Avoidable Mortality and Hospitalisation The leading causes of avoidable death and hospitalisation are ranked below. Similar issues ranked highly for Māori and non-Māori locally and nationally: Avoidable Mortality TDHB Māori Other CVD-IHD Lung cancer Diabetes COPD Cerebrovascular diseases CVD-IHD Cerebrovascular diseases COPD Lung cancer Colorectal cancer NZ CVD-IHD Lung cancer Diabetes COPD Road Traffic injuries CVD-IHD Lung cancer Colorectal cancer Suicide & self harm Road traffic injuries Avoidable Hospitalisation TDHB NZ Angina and chest pain Respiratory infections Asthma Cellulitis Dental conditions Angina Respiratory infections COPD COPD Asthma Angina and chest pain Angina Dental conditions Respiratory infections Cellulitis Cellulitis Skin cancers Road traffic injuries COPD ENT infections Health Needs Assessment The health needs of Taranaki Māori and priorities for action are identified in the Taranaki DHB’s Whānau Ora Health Needs Assessment (Ratima and Jenkins, 2012) and are summarised below: ** a. Te Ara Tuatahi Pathway One – ‘Development of Whānau, hapu, iwi and Māori communities’ The Māori community has a limited capacity to engage with work around Whānau Ora, and in this context Māori community development at whānau, hapū, iwi levels was important. A need to engage whānau in preventative and aspirational activities was identified. At the whānau level, work is required to strengthen whānau cohesion so that whānau are better positioned to exercise the positive functions of whānau. Strengthening cultural identity as a mechanism to achieve health gain was also identified. Whānau level development as a basis for Whānau Ora is a priority area. The challenge for funders and providers is to identify ways in which they may facilitate this development without taking leadership and risking engendering dependency. b. Māori Participation and Leadership - Te Ara Tuarua Pathway Two – ‘Māori participation in the Health and Disability Sector’ Building the capacity and capability of the Māori sector is a priority. The sector currently consists of the following components: Te Whare Punanga Korero Trust represents the eight iwi of Taranaki** and has a formal relationship with the Taranaki DHB to jointly work at a strategic level to improve Māori health outcomes; Ngati Tama, Ngati Mutunga, Te Atiawa, Ngati Maru, Taranaki, Ngaruahinerangi, Ngati Ruanui, Nga Rauru Kiitahi. Pakakohe and Tangahoe were represented by Ngati Ruanui on original set up of the Trust. Page 7 of 26 Te Kawau Mārō Alliance between Tui Ora Limited, Ngati Ruanui Tahua and Ngaruahine Iwi Health Service. The alliance is the preferred provider of Māori-specific primary health care services in Taranaki; There is one PHO in Taranaki. Māori account for 15.57% of the Midlands Health Network PHO enrolled population for Taranaki, or 16,419 of 105,437 as at February 2014; Two public hospitals - Taranaki Base Hospital in New Plymouth with 152 inpatient, 23 inpatient mental health, 21 emergency department, 18 maternity beds and 8 neonatal inpatient cots, and Hawera Hospital with 10 inpatient, 6 emergency department beds and 4 maternity beds; Whakatipuranga Rima Rau Trust is a joint venture project between Te Whare Punanga Korero Trust, Ministry of Social Development (WINZ) and Taranaki DHB to increase the Māori health and disability workforce over ten years. A staff of three under the leadership of a General Manager, develops and delivers a range of programmes aimed at increasing the health and disability workforce supply; Te Roopu Paharakeke Hauora is the Māori Health directorate of the Taranaki DHB. The unit is headed by the Chief Advisor Māori Health, a member of the Taranaki DHB Executive Management Team, and along with a small team, is responsible for influencing decision-making across the funder and provider arms of the DHB to achieve improved outcomes for Māori. In terms of the Māori health and disability workforce, there is a lack of reliable information available to assess this currently. The Taranaki DHB regularly collects information on its workforce though accuracy of the data is limited, while currently no mechanism exists for gathering NGO workforce data. As at January 2014, 7.7% of Taranaki DHB staff or 132 from a total of 1,713 identified as being of Māori ethnicity. c. Health System Performance and - Te Ara Tuatoru Pathway Three – ‘Effective health and disability services’ Increased access to health services at all levels, and particularly at the primary health care level are priorities and include geographically equitable access to quality health care across the Taranaki Region and the implementation of Whānau Ora oriented service provision. The priorities in terms of protective and risk factors and preventative care are smoking, alcohol and drug issues, breastfeeding, immunisation, breast screening and cervical screening. Priority health conditions identified are diabetes, cardiovascular disease, lung cancer, breast cancer, respiratory disease (i.e. COPD and asthma), oral health, mental health and disability. d. 3. Social Determinants and - Te Ara Tuawha Pathway Four – ‘Working across sectors’ It is well documented that there are systematic inequalities in access to social and economic determinants of health for Māori and that socio-economic status is a key factor contributing to health outcome disparity between Māori and non-Māori. There is clear evidence that Māori living in Taranaki have poor access to socio-economic determinants of health, and this is reflected in high relative levels of deprivation, compared to non-Māori. It is also reflected in barriers to health care and related needs (e.g. ability to pay for service provision and access to transport) identified through community engagement. Addressing determinants of health through intersectoral collaboration is therefore a priority area. IMPROVEMENTS UNDER WAY Good progress is being made in reducing health inequalities for Māori in Taranaki DHB in the areas of CVD risk assessment, breast screening, help for smokers to quit in the hospital setting, and immunisations at 8 months old. The system for addressing and monitoring Māori health improvement in Taranaki has been substantially strengthened with the implementation of Te Ara Whakawaiora, framework for accelerating Māori health improvement developed by Te Tumu Whakarae national DHB Māori Managers forum. Endorsed by the national CEO’s forum, the system makes the whole DHB responsible and accountable for Māori Health improvement, through implementation, monitoring and sharing of best practice models that address the priorities and indicators within the Māori Health Plan. Monitoring of progress by the Iwi Relationship Board Te Whare Punanga Korero jointly with the Taranaki DHB Board and senior DHB and PHO managers brings significant rigor to the focus on reducing Māori health inequalities. In terms of Health Sector Performance good progress has been to consolidate the Māori health sector. The TDHB preferred provider ‘Te Kawau Mārō’ alliance, a collective of Tui Ora and iwi providers evolved from an RFP process seeking a single provider of services for Māori. An outcomes-based contract which commenced on 1 July 2013, Page 8 of 26 merges 35 primary care contracts and $8.3M per annum, into a single 5-year contract. The formation of the alliance and the move to outcomes-based contracting is expected to result in; Reduction in operational overheads to release more funding to front line services for whānau Greater scope and flexibility for the alliance to deploy resources in more innovative ways to achieve better outcomes for whānau The burden of reporting being significantly reduced Clinical and cultural safety significantly strengthened The partners have committed to developing a common Whānau Ora system for Taranaki 4. PRIORITIES AND INDICATORS The following section of the plan presents Māori health priorities and indicators that have been selected as national and local priorities. The national indicators are determined by the Ministry of Health and are priorities for all DHB’s. These priorities are based on the leading causes of morbidity and mortality for Māori nationally and indeed reflect the priorities for Taranaki. Local priorities are determined by the Taranaki DHB Whānau Ora Health Needs Assessment (Ratima and Jenkins, 2012). The national and local priorities are presented in tables in the following sections that summarise: The outcome we want to achieve What we are planning to do to achieve it Who will be responsible How we will know if we have been successful Why this outcome is important Where Māori are at now relative to non-Māori and the extent of the inequalities gap Where we want to get to in the next year The ‘inequalities box’ at the bottom right of the tables provides a snapshot of the extent of disparities between Māori and non-Māori. The absolute measure of inequality provided is the ‘gap’ between Māori and non-Māori such as a percentage difference. As well, the ‘inequalities box’ provides an indication of progress made in addressing inequalities for Māori over time. Where data is available (data used to determine progress will be described in a footnote), the progress measure will report on trends over a number of years using the following symbols already used by TDHB in reporting progress on ethnic inequalities indicators. Quarterly, six-monthly and/or annual (as relevant to each indicator) quantitative assessment of disparities between Māori and non-Māori, where relevant, will be reported. The following symbols will be used to report progress on inequalities indicators: Symbol Key Progressing well ℗ Some progress No progress or worsening Ţ Not yet sufficient time to judge ? Further info or work required ↑ Increasing gap ↓ Decreasing gap Page 9 of 26 5. SECTION FIVE: NATIONAL PRIORITIES AND INDICATORS ACTION PLAN National Indicator 1 DATA QUALITY Who will be responsible: PM, Primary Care Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful Improve and maintain the quality of data collected locally and supplied to national collections. Continue to work with the Midland Health Network PHO to check, improve and maintain the accuracy of ethnicity data submitted to national collections by the PHO, by The MHN Alliance will review quarterly enrolment coverage versus census 2013 population data, via the MHN Health Intelligence reports, by March 2014 Providing guidance on ethnicity data quality improvement activities (ongoing) Where gaps are identified the MHN and TDHB through the Taranaki ALT will identify the appropriate mechanisms to work to support higher enrolment and accuracy. Accuracy of ethnicity reporting in PHO registers acknowledging that ethnicity is self selected by the patient. 98% of Māori will be enrolled in PHOs as a proxy for reporting on Ethnicity Data accuracy. Commentary on how the quality of ethnicity data is improving. Why is this outcome important: Accurate ethnicity data is essential for tracking progress in Māori health outcomes. The accuracy of ethnicity data in PHO databases is unknown at present. Māori Non-Māori Progress Gap (%) Midland Health Network PHO Enrolments 85.3% 97.3% 12% National Indicator 2.1 Outcome we want to achieve ACCESS TO CARE (PHO Enrolment) What we are planning to do to achieve it Who will be responsible: PM, Primary Care How we will know if we have been successful Increased access by Māori to primary health care services Working within the Alliance TDHB and MHN will review quarterly access reports via the MHN Health Intelligence reports. 98% of Māori will be enrolled in PHOs. Where gaps are identified and where capacity exists all parties will work to support equity of access. Why is this outcome important: PHO enrolment facilitates easier access to preventative health care and early condition management. PHO enrolment rates vary throughout the country. Thursday 27 June 2014, V3.0 Final Utilisation of services by Māori 1:1 or higher than non Māori. Māori Non-Māori Progress Gap (%) 85.3% 97.3% 12% Page 10 of 26 National Indicator 2.2 ACCESS TO CARE (ASH Rates) Outcome we want to achieve What we are planning to do to achieve it Reduced ambulatory sensitive hospitalisation (ASH) rates among all age groups: 0-4 years 45-64 years 0-74 years 1. Audit the most recent ASH data to identify the current leading causes of ASH for Māori in the 0-4, 45-64, and 0-74 year age groups by condition, domicile, NZDep, and hospital location. DHB and MHN action by December 2014. 2. Develop evidence based interventions targeted at Māori, in collaboration with all local stakeholders including MHN PHO, by June 2015. 3. Develop performance indicators for new interventions for agreement by the MHN Alliance and other interested stakeholders and monitor quarterly. Report findings to the joint TWPK/TDHB monitoring group and discuss successful and new interventions with the MHN and TKM Alliance. 0-4 years 4. Maintain or improve B4 School Check coverage for tamariki Māori, on-going to June 2015. 5. Work with the Midland Health Network Taranaki Alliance Leadership Team to ensure tamariki under six years have access to free after hours primary care, on-going to June 2015. 6. Continue to work with TDHB dental, maternity and child health teams as well as primary care providers to support the Menemene Mai project to enrol pre-school children in dental services and to support whānau engagement with dental and other pre-school service initiatives. 45-64 years 7. Taranaki DHB and the Midland Health Network continue to work together to implement the Primary Options to Acute Care for Taranaki and the GP/ED Overflow Clinic at Medicross Accident and Medical. 8. Continue to support Midlands Health Network PHO to: a. implement Diabetes Improvement packages of care in Clinical Pharmacy, Social Work, Dietetics and Podiatry. b. support GP Practices to increase checks for CVD and Thursday 27 June 2014, V3.0 Final Who will be responsible: PM, Primary Care and Chief Advisor Māori Health How we will know if we have been successful ASH rates in all age groups will demonstrate movement towards the national rate for the total population in that age group. Over the 2014-15 year, ASH rates for Māori will approach the targets derived from the Ministry of Health ASH target formula as follows: 0-4 years: 95% 45-64 years: 95% 0-74 years: 95% Page 11 of 26 Diabetes with the aim of meeting the 90% of the eligible population having had a CVD Risk assessment. c. upskill the Primary Health workforce in the care and management of Diabetic patients and Insulin Initiation. 0-74 years 9. Continue to support the Taranaki Map of Medicine Clinical Pathways Steering Group to localise the prioritised clinical pathways. This piece of work will support Primary Options which is being launched on 14 June 2014. 10. Continue to support implementation of outreach influenza vaccination clinics to achieve increase access for the eligible population. Why is this outcome important: Māori – TDHB Non-Maori – TDHB All – National Effective primary care can reduce ASH rates and ethnic inequalities in ASH rates. ASH rates are a proxy measure for access to primary care services, preventative management, and the quality of care delivered. Ambulatory sensitive hospital admissions are preventable with the appropriate quantity and quality of primary care. Thursday 27 June 2014, V3.0 Final Progress Inequalities Gap – TDHB 0-4y 45-64 0-74 117% 5,300 56% 2,555 100% 4,532 168% 3,835 73% 1,677 100% 2,287 ↑ 95% 2,158 156% 3,110 73% 1,458 100% 1,988 ↓ 61% 2,745 Page 12 of 26 ↓ 83% 1,652 National Indicator 3 CHILD HEALTH (BREASTFEEDING) Outcome we want to achieve What we are planning to do to achieve it Increase in breastfeeding rates for Māori and reduce inequalities in breastfeeding rates between Māori and non-Māori Maintenance of BFHI status with 3 providers including TDHB, TKM alliance partners. Work with the TDHB Provider Arm, Māori health and Public health teams, MHN PHO and TKM Alliance to review the breastfeeding information given to Māori women, and support associated education around breastfeeding. Distribution of Mama Aroha Talk cards to LMC’s, WCTO providers and PHO’s to support education antenatally and in the community. Audit Māori women coming through our service to establish why more are not breastfeeding, audit to be completed by Dec 2014. Service Manager – TDHB Provider Support the Mama and Pepi Hauora project delivered by TKM to develop and deliver a toolkit to 5 priority communities to improve skills, knowledge, behaviour and attitudes with respect to nutrition, physical activity, and breastfeeding for mothers and infants including Breastfeeding Welcome Here accreditation and Active Movement training. Link with existing Breastfeeding Peer Support and Community Lactation Services to strengthen collaborative approaches Support 4 Scholarship Recipients to successfully register as Lactation Consultants by November 2014. Monitor of breastfeeding data will take place quarterly by the joint TWPK/TDHB monitoring group. Successful and new interventions will be discussed with the provider arm, public health and Māori health teams of the TDHB as well as the MHN and TKM alliance. Who will be responsible: PM, Population Health; Service Manager, Child and Maternal Health How we will know if we have been successful Report on exclusive breastfeeding at 6 weeks, 3 months, and 6 months. Service Manager – Provider Māori infants will have attained breastfeeding rates consistent with the age-related targets from the Well Child Tamariki Ora Quality Improvement Framework of: Exclusive and fully breastfed at 6 weeks 68% Exclusive and fully breastfed at 3 months 54% Exclusive, fully and partially breastfed at 6 months 59% Why is this outcome important: Breastfeeding contributes significantly to infant, maternal, and whānau health in both the short and long term. The benefits of breastfeeding are unequivocal. In recent years breastfeeding rates in Taranaki have been declining, the Breastfeeding Community Support Service is implementing strategies to improve rates of breastfeeding particularly for Māori. Thursday 27 June 2014, V3.0 Final Māori Non-Māori Target Progress (inequality) Inequalities Gap (%) 6 wks 56% 68% 68% 12% 3 mths 34% 54% 54% 6 mths 9% 23% 59% 20% 14% Page 13 of 26 National Indicator 4.1 CARDIOVASCULAR DISEASE (Risk Assessment) Who will be responsible: PM, Primary Care Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful Reduced mortality through improved cardiovascular health Working within the Alliance TDHB and MHN will review six monthly performance against the agreed clinical targets. Primary care will achieve agreed clinical targets Where gaps are identified and where capacity exists the MHN PHO, TKM alliance and TDHB will work to analyse and identify gaps, develop and implement workable solutions support higher enrolment and accuracy. 90% of the eligible population have had their CVD risk assessed within the past five years (ht) 1. Using NGO resource, identify and target missed opportunities by implementing systems to capture activity undertaken outside of the general practice environment 2. Fully integrate catch up and coordination services for key health targets including the utilisation of telephone catch up services 3. Increased use of MDT for diabetes & CVD 4. Enhance the electronic tools/resources available to general practice to include self-management 5. Workforce education and training in the delivery of LTCMP 6. Enhancement of existing funding strategy to further encourage general practices to deliver quality care and management and to best target resources Why is this outcome important: CVD is the leading cause of death and the leading cause of avoidable hospitalisation for Taranaki Māori. Given the extent of the burden of CVD and wide ethnic inequalities in cardiovascular health outcomes, access to risk assessment and effective condition management are important interventions to improve outcomes. CVD is substantially preventable with early identification, lifestyle advice and treatment. Thursday 27 June 2014, V3.0 Final Māori Non-Māori Progress Gap (%) 73% 83% ? 10% Page 14 of 26 National Indicator 4.2 CARDIOVASCULAR DISEASE Outcome we want to achieve What we are planning to do to achieve it Reduced mortality through improved cardiovascular health 1. 2. The Cardiac ANZACS-QI register enables reporting measures of ACS risk stratification and time to appropriate intervention The data recorded in this registry enables patients level information to be reviewed by ethnicity Why is this outcome important: CVD is the leading cause of death and the leading cause of avoidable hospitalisation for Taranaki Māori. Given the extent of the burden of CVD and wide ethnic inequalities in cardiovascular health outcomes, access to risk assessment and effective condition management are important interventions to improve outcomes. CVD is substantially preventable with early identification, lifestyle advice and treatment. National Indicator 4.3 CARDIOVASCULAR DISEASE Outcome we want to achieve What we are planning to do to achieve it Reduced mortality through improved cardiovascular health On-going monitoring of existing procedures to maintain performance on this indicator Why is this outcome important: CVD is the leading cause of death and the leading cause of avoidable hospitalisation for Taranaki Māori. Given the extent of the burden of CVD and wide ethnic inequalities in cardiovascular health outcomes, recording and monitoring the key data associated with these events will help ensure services are clinically appropriate and equitable services are delivered to meet the needs of Taranaki Māori Thursday 27 June 2014, V3.0 Final Who will be responsible: Clinical Services Manager, Medical How we will know if we have been successful 70 percent of high-risk patients will receive an angiogram within 3 days of admission. (‘Day of Admission’ being ‘Day 0’) Māori Non-Māori Progress Gap (%) 25% 50% ? 25% Who will be responsible: Clinical Services Manager, Medical How we will know if we have been successful Over 95 percent of patients presenting with ACS who undergo coronary angiography have completion of ANZACS QI ACS and Cath/PCI registry data collection within 30 days Māori Non-Māori Progress Gap (%) 100% 94% -6% Page 15 of 26 National Indicator 5.1 CANCER (BREAST SCREENING) Who will be responsible: PM, Cancer Services Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful Reduced cancer mortality and morbidity Continue to work with BreastScreen Aotearoa, PHOs and providers to strengthen local reporting of breast screening rates by DHB and ethnicity. 70% of eligible women will have a BSA mammogram every two years. Continue to work with BreastScreen Aotearoa, PHOs and Te Kawau Mārō alliance to identify and implement effective interventions tailored toward Taranaki Māori women. Activities include: Continue to support the Māori Health subgroup of the Local Cancer Network, with a focus on increasing screening rates of Māori women across Taranaki Working with BreastScreen Coast to Coast to influence the location of the mobile screening bus in 2014/15 to target areas with a high Māori population Continue to identify opportunities for BSA to work with Te Kawau Mārō alliance to expand delivery of the screening outreach programme across Taranaki Monitor delivery against planned actions as well as sixmonthly monitoring of the overall coverage target Why is this outcome important: Māori Non-Māori Progress The purpose of Breast Screening is to detect breast cancer at an early stage, in order to reduce breast cancer morbidity and mortality. In Taranaki, the screening coverage rate among Māori women is lower than for other ethnicities. Gap (%) Achieving high rates of breast screening coverage for Māori women is important, given that according to national data, Māori women are more likely to be diagnosed at a later stage of breast cancer spread than non-Māori and that for many cancers at each stage Māori-specific mortality rates post diagnosis are higher. Thursday 27 June 2014, V3.0 Final 65% 79% ℗ 14% Page 16 of 26 National Indicator 5.2 CANCER (CERVICAL SCREENING) Who will be responsible: PM, Cancer Services Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful Reduced cancer mortality and morbidity Continue to work with the National Cervical Screening Unit, PHOs and Te Kawau Mārō alliance to establish and deliver six monthly reporting on rates for Māori and non-Māori in Taranaki. Work with the Taranaki Regional Screening Unit to continue to work with the National Cervical Screening Unit, PHOs and providers to develop and implement strategies to improve cervical screening rates for Taranaki Māori women Health promotion activities continue to focus on Māori and include for example WINZ youth service programme Pae Pae in the Park (Patea) Kaumatua at Te Roopu Pahake O Waitara Tui Ora Kaumatua group 80% Cervical Screening percentage of women (Statistics NZ Census projection adjusted for prevalence of hysterectomies) aged 25-69 who have had a cervical screen in the past 36 months The Taranaki region has a three year plan (July 2011 – June 2014) with a strong focus on PHO/community involvement. The next three year plan is currently being rewritten collaboratively by the PHO and the Regional Screening Unit. We have no evidence to gauge if recent initiatives are working as there have been no Cervical Screening statistics from the NSU since Dec 2013. We continue to work closely with the PHO to increase coverage with 85% of activities being completed by the PHO. We also take advantage of any unplanned opportunities that arise during the year. Activities continue with kaimahi making direct phone contacts for cervical screening with referrals from practice nurses for our Outreach service. All sessions are evaluated. Why is this outcome important: The cervical screening coverage for Māori women in Taranaki is lower than for non-Māori. The focus is on increasing coverage for Māori women. Cancer is a leading cause of mortality for Māori in Taranaki. Cervical cancer is largely preventable through regular three yearly cervical smear tests which can reduce a women’s risk of developing cervical cancer by 90%. Thursday 27 June 2014, V3.0 Final Māori Non-Māori Progress 73% 89% Gap (%) 16% ℗ Page 17 of 26 National Indicator 6.1 SMOKING (HOSPITAL) Outcome we want to achieve What we are planning to do to achieve it Less people smoking National Vision and Government Goal: Smokefree Aotearoa 2025 Our Tamariki and Rangatahi deserve a future where smoking is history Continue to work with TDHB provider arm to apply a focus on Māori patients and their whānau to: Current unit procedures support ongoing process to ensure all Māori patients who smoke are asked about their smoking status, given brief advice to stop smoking and are offered/given effective smoking cessation support for hospital based and maternity services To promote and monitor the use and access of Pharmacotherapy medicine for hospitalised Māori Smokers o Determine a baseline by 31 September 2014 To improve and monitor the number of referrals for hospitalised Māori smokers to Quitline and specialised smoking cessation services Maternity services to monitor the use and access of Nicotine Replacement Therapy for hospitalised Māori pregnant smokers o Determine a baseline by 31 September 2014 Maternity services to establish a referral process and pathway for hospitalised Māori pregnant women smokers to Mana Wahine Hapu and other specialist smoking cessation services o Determine a baseline by 31 September 2014 To implement the recommendations from the National Smokefree mental health project within the hospital Why is this outcome important: Smoking is a significant risk factor for Māori in the Taranaki Region. Māori have a higher prevalence of smoking than other New Zealanders. Some 47% of Taranaki Māori females and 38% of Māori males are regular smokers, compared to around 21% of New Zealand Europeans. The prevalence of regular smoking in Taranaki Māori females is also higher than the national average. Smoking kills an estimated 5000 people in New Zealand every year and smoking-related diseases are a significant opportunity cost to the health sector. Thursday 27 June 2014, V3.0 Final Who will be responsible: Clinical Services Manager, Medical How we will know if we have been successful 95% of hospitalised Māori patients who smoke and are seen by a health practitioner are provided with brief advice and support to quit smoking Progress towards 90% of Māori pregnant women who identify as smokers at the time of confirmation of pregnancy in General Practice or booking with Lead Maternity Carer are offered advice and support to quit Increase percentage of Māori hospitalised smokers receiving pharmacotherapy medicine by June 2025 Increase of Māori direct referrals numbers to Quitline and specialist smoking cessation services by June 2015 Increase percentage of hospitalised pregnant smokers receiving Pharmacotherapy medicine by June 2015 Increase of direct referral numbers to Mana Wahine Hapu and specialist smoking cessation providers by June 2015 Implementation of National Smokefree Mental Health guidelines and resources within the hospital by June 2015 Māori Non-Māori Progress Gap (%) 98% 96% 2% Page 18 of 26 National Indicator 6.2 SMOKING - PRIMARY CARE Who will be responsible: PM, Population Health Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful New Zealanders living longer, healthier and more independent lives National Vision and Government Goal – Smokefree Aotearoa 2025 Our Tamariki and Rangatahi deserve a future where smoking is history PHO to ensure all Māori patients who smoke are asked about their smoking status, given brief advice to stop smoking and are offered/given effective smoking cessation support o MHN Network Liaison Team to provide quarterly reports to all practices on their performance against the Annual Quality Plan targets o To provide a MHN centralised practice support approach for identified practices that require support for Māori smokers not contacted in 12 months o Explore options for a range of dedicated smoking cessation support in the Primary Care Setting Smokefree Pregnancy o Professional Mana Wahine Hapu community champions to deliver promotional sessions to health and community professionals o 5 Mana Wahine Hapu Whānau champion trainers to recruit and provide training support packages o Whānau champions to deliver Smokefree pregnancy conversations o Mana Wahine Hapu service to provide smoking cessation/behavioural support group interventions to pregnant women and their partners/whānau Taranaki representation on the Smokefree Midlands Māori Caucus Group Why is this outcome important: Smoking is a significant risk factor for Māori in the Taranaki Region. Māori have a higher prevalence of smoking than other New Zealanders. Some 47% of Taranaki Māori females and 38% of Māori males are regular smokers, compared to around 21% of New Zealand Europeans. The prevalence of regular smoking in Taranaki Māori females is also higher than the national average. Smoking kills an estimated 5000 people in New Zealand every year and smoking-related diseases are a significant opportunity cost to the health sector Thursday 27 June 2014, V3.0 Final 90% of Māori patients who smoke aged 15 years and over and are seen in General Practice by a health practitioner are offered brief advice and support to quit smoking Make progress towards 90% of pregnant women who identify as smokers at the time of confirmation of pregnant in general practice are offered advice and support to quit Agree with MRHN a evidence based model to best support General Practice by 30 September 2014 To deliver Mana Wahine Hapu promotional sessions reaching 250 health and community professionals by 31 March 2015 40 whānau champions recruited and trained by 31 March 2015 400 smokefree pregnancy conversations recorded by 31 March 2015 125 women received three facilitated group support sessions (partners included based on ratio 85% women 15% partners) by 31 March 2015 100 pregnant women enrolled in Innov8 Smokefree telephone support by 31 March 2015 Ongoing attendance at Regional meetings Māori Non-Māori Progress Gap (%) 71% 72% ? 1% Page 19 of 26 National Indicator 7.1 IMMUNISATION Who will be responsible: PM, Child & Youth Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful Improved children’s health Maintain an immunisation alliance steering group that includes all the relevant stakeholders for the DHB’s immunisation services including the Public Health Unit; and that participates in regional and national forums Work with primary care partners to monitor and increase new born enrolment rates to 100% Monitor and evaluate immunisation coverage at DHB, PHO and practice level, manage identified service delivery gaps Identify immunisation status of children presenting at hospital and refer for immunisation if not up to date In collaboration with primary care stakeholders develop systems for seamless handover of mother and child as they move from maternity care services to general practice and WCTO services In collaboration with NGOs and government agencies, describe how the DHB is working across agencies to increase immunisation coverage Why is this outcome important: • • Immunisation is linked to primary care access and management Immunisation can prevent a number of diseases and is a cost-effective health intervention. Thursday 27 June 2014, V3.0 Final 95% of infants are fully immunised by eight months of age (ht) Māori Non-Māori Progress Gap (%) 89% 89% 0% Page 20 of 26 National Indicator 7.2 IMMUNISATION Who will be responsible: PM, Primary Care Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful Reduced communicable disease Continue to support the NGO sector through the DHB Immunisation coordinator and the Taranaki Immunisation Steering Group to provide opportunistic immunisations at health promotion days on Marae and in the community. Achieving the target for seasonal influenza immunisation rates in the eligible population (65 years and over) (by ethnicity) Why is this outcome important: The complications of influenza (more commonly known as ‘flu’) in elderly can be serious or life threatening. As a result, the Government funds the cost of influenza vaccinations and their administration for people aged 65 and over and Thursday 27 June 2014, V3.0 Final Māori Non-Māori Total Progress Gap (%) 67% (High needs) 70% ℗ 3% Page 21 of 26 National Indicator 8 RHEUMATIC FEVER Who will be responsible: PM, Population Health Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful Reduce the incidence of Rheumatic Fever Implement the TDHB Rheumatic Fever Prevention Plan by: o Ensuring that primary care providers and other health professionals likely to see high risk children follow the National Heart Foundation Sore Throat Management Guidelines o Ensuring people with Group A streptococcal infections are treated appropriately within 7 days of developing symptoms o Ensuring that all cases of acute rheumatic fever are notified to the Medical Officer of Health within 7 days of hospital admission o Reviewing all cases of rheumatic fever to identify any identifiable risk factors and system failure points o Ensuring patients with a past history of rheumatic fever receive monthly antibiotics not more than 5 days after due date Why is this outcome important: Rheumatic Fever left untreated can damage the heart leading to life long heart problems. Working to reduce and eliminate rheumatic fever can reduce the incidence of heart disease and/or related complications. Thursday 27 June 2014, V3.0 Final Rheumatic fever number and rate reductions are 40% below the 3-year average (2009/10 – 2010/11), towards a target of 0.5/100,000 (by ethnicity) Māori Non-Māori Progress Gap (%) 0.9 Total ℗ NA Page 22 of 26 National Indicator 9 ORAL HEALTH Who will be responsible: Service Manager, Child Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful Improved dental health of Māori Children and Maternal Health Work with maternity services to ensure all children are enrolled at birth with the dental service Work with providers such as Tamariki Ora, Plunket and PHO’s to ensure all pre-school children are enrolled with the dental service. Why is this outcome important: There is disparity between Māori children and non-Māori children’s oral heath in Taranaki, this needs to be addressed to aim for equal oral health outcomes for all children. 75% of preschool children are enrolled with Dental Services. Audited quarterly with target achieved by June 2015. Children enrolled and ‘on our books’ earlier enable us to track and trace them to ensure/support oral health checks and treatment. Working alongside Māori health workers and community Māori health teams to locate children and families easier if the child is enrolled already. Māori Non-Māori Progress Gap (%) 59% 82% ? 23% Oral health reflects and impacts on general health and well being. Having healthy teeth as a child leads to healthy adult teeth and less associated co-morbidities and health risks. National Indicator 10 MENTAL HEALTH Who will be responsible: Outcome we want to achieve What we are planning to do to achieve it How we will know if we have been successful Improved mental health outcomes for Māori • • • Reduction in the number and proportion of Community Treatment Orders issued under Section 29 of the Mental health Act for Māori. Establish a baseline through data reporting Identify emerging trends. Develop a plan to address Why is this outcome important: Māori 102 per 100,000 of pop Identify and address the disparity between Māori /Non Māori in relation to MHA/CTO rates. Establish baseline- as of July 2014/2015 this data will be part of the MH&A PRIMD data set to facilitate better reporting. Monitor this data monthly via the MH&A business unit. Variations will be reported to the Service Manager. Negative variations are to form part of the agenda for discussion at the Monthly Clinical Governance Forum – with a view to establishing a plan for improvement. Non-Māori 54 per 100,000 of pop Progress ? Gap 52 per 100,000 of pop ( equivalent of 9 clients for TDHB population) Thursday 27 June 2014, V3.0 Final Page 23 of 26 LOCAL PRIORITIES AND INDICATORS ACTION PLANS Local Indicator 1 ACCESS TO SERVICES – DNA’S Outcome we want to achieve What we are planning to do to achieve it Who will be responsible: Clinical Services Manager, Medical How we will know if we have been successful Improved access to secondary care Complete the profile of Māori DNA FSA’s and follow up appointments for CVD clinics DNA rate for Outpatient appointments reduced to <9% by July 2015 Review patient pathways including whānau feedback to identify issues that need to be addressed Drawing on successful experiences of other DHB’s, develop and implement the action plan to reduce DNA rates in the particular specialties examined Establish a review process to regularly monitor progress towards reducing DNA’s and make adjustments in approach where needed Look at implementing successful interventions across other DNA specialties. Why is this outcome important: Māori 19% Māori have double the DNA rate for first specialist outpatient appointments compared to “Other” ethnic groups in Taranaki and around three times the DNA rate for follow-up appointments. While DNA rates for the Taranaki DHB population are consistently lower than the national figures they have been increasing over the three year period and the extent of ethnic inequalities between Māori and non-Māori is similar. Higher disease burden coupled with higher DNA rates will result in ongoing unmet health need. Non-Māori 7% Progress Gap (%) ↑ Thursday 27 June 2014, V3.0 Final 12% Page 24 of 26 Local Indicator 2 PRIMARY MENTAL HEALTH Outcome we want to achieve What we are planning to do to achieve it Taiohi are emotionally and mentally well and are achieving their best possible educational outcomes Increase the uptake of counselling vouchers for Māori Taiohi – through schools and PHNs Improve pathways for earlier intervention of young people identified with mild to moderate mental health and addictions issues. Work with the social sector trial and increase the interventions available to Youth. Why is this outcome important: At least 20% of young people experience emotional and mental health issues during the course of their adolescent years. There are a number of risk factors which impact on a young person being able to maintain good mental health including, family/whānau, cultural identity, peers and friendships, activities they are involved in, boredom and being engaged with the education system. Utilisation of primary mental health interventions can significantly reduce Young Māori are over represented in a range of statistics, including teenage birth rates being double the national average at 92.0 per 1000 population. Māori are also more likely to present to hospital for self related harm. In 2011/12 38% of admissions for taiohi were for Māori. School completion and educational attainment rates are 57% for Māori compared to 71% for non-Māori. Thursday 27 June 2014, V3.0 Final Who will be responsible: Portfolio Manager, Mental Health & Addictions How we will know if we have been successful >=25% of vouchers for access to counselling are available for Māori Taiohi under the Primary Mental Health Initiative. Number of referrals from mini HEADSSS and HEADSSS assessments by PHN’s and School Counsellors for Māori Taiohi. (access indicator) The number of Māori youth accessing Social Sector Trial interventions from base line of 0 in March 2014 to >=25% of total contacts for Māori Taiohi by 30 June 2015 Māori 17% Non-Māori 49% Progress ? Gap (%) 32% Page 25 of 26 REFERENCES 1. Whānau Ora Health Needs Assessment, Māori Living in Taranaki, Ratima and Jenkins, Taranaki District Health Board, February 2012 2. TDHB Māori Health Plan 2013-2014 3. Te Kawau Mārō, Taranaki Māori Health Strategy 2009 – 2029 4. Ministry of Health, 2014/15 Operational Policy Framework 5. Statistics NZ, District Health Board Area summary tables, Statistics NZ 2013 Page 26 of 26
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