primary health care plan 2007-2010€¦ · primary health care plan 2007-2010 sets out the pathway...

P r i m a r y H e a l t h C a r e P l a n2 0 0 7 - 2 0 1 0

I n c o n s u l t a t i o n w i t h :C o u n t i e s M a n u k a u P r i m a r y H e a l t h O r g a n i s a t i o n s

Mission Statement

Through a valued and skilled workforce,primary health care services will:

• be easier to access;

• help people make healthier choices;

• deliver quality services that reduce inequalities and effectively address the needs of our communities in promoting good health;

• involve communities in identifying their health needs and shaping service development.

The aim of the plan is to achieve improvedpopulation health by encouraging people to

access community-based services early;to understand and be supported to adopt,

where possible, a self care approach;to empower communities to foster wellness;

and to understand the links between lifestyle choicesand environment that affect health status.

The Counties Manukau Primary Health Care Plan

2007-2010 sets out the pathway for further development of

primary health care services inCounties Manukau.

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C O N T E N T S & V I S I O N

Within primary health care we recognise that the Treaty of Waitangi establishes a partnership between Maaori and

The Crown to work together under the auspices of Kaawanatanga(Governorship),Tino Rangatiratanga (Self Determination) and

Oritentanga (Equal Entitlement).Within Counties Manukau district this commitment is expressed in a

variety of ways which include:• The establishment of POU as a Board committee at Counties Manukau DHB; this has

provided Maaori with a forum to be involved in the decision making processes of the Board. The inclusion of members from the Board, Maaori Providers,Tainui MAPO and Manawhenua provides a base for an inclusive decision making process

• Increasing delivery of health services by Maaori provider organisations to Counties Manukau residents from a kaupapa Maaori base e.g.Te Kupenga O Hoturoa PHO

• Increasing capacity of the CMDHB Maaori Health team to provide Maaori strategic and operational impetus for the district

• Involvement of Maaori communities in the development, implementation and evaluation of new and existing services

• Development of the Whaanau Ora Plan

• Development of Maaori Health Plans by all Primary Health Organisations across Counties Manukau

We have identified the following concepts to guide the enactment of Treaty obligations, as identified in the Whaanau Ora Plan:

• Sharing responsibility for Maaori health and disability gain, with Maaori taking a lead role

• Inspiring whaanau to be educated, knowledgeable and motivated about their own health and disability

• Encouraging whaanau to adopt healthy lifestyles

• Facilitating Maaori participation in decisions about resourcing priority health and disability goals

• Developing the health and disability sector workforce, with a particular focus on Maaori capacity and capability

• Measuring and reducing inequalities

• Increasing whaanau choice and use of quality kaupapa Maaori providers and generic providers

• Continuously improving the DHB’s funding, planning and service delivery roles to proactively respond to Maaori health and disability need

• Engaging with Manawhenua on service development and planning

Our Commitment to the Treaty of Waitangi

C O N T E N T S & V I S I O N

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P a g e

O u r C o m m i t m e n t t o t h e Tr e a t y o f Wa i t a n g i 1

F o r e w o r d f r o m t h e C h i e f E x e c u t i v e O f f i c e r C o u n t i e s M a n u k a u D H B 3

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1 . 1 T h e C o n t e x t o f t h e S e c t o r w i t h i n C o u n t i e s M a n u k a u 4

1 . 2 Wo r k i n g a c r o s s S e c t o r s 5

2 . 0 S t r a t e g i c L i n k a g e s t o 2 0 0 7 - 2 0 1 0 6

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4 . 2 T h e S i x M a i n P r i o r i t i e s w i t h i n t h i s P l a n 9

4 . 3 H o w We D e v e l o p e d a n d A l i g n e d t h e P l a n 1 0

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7 . 1 A p p e n d i x O n e : P o p u l a t i o n C o m p o s i t i o n 1 5

7 . 2 A p p e n d i x Tw o : W i d e r P r i m a r y H e a l t h S t a k e h o l d e r s a n d Wo r k f o r c e 1 7

7 . 3 A p p e n d i x T h r e e : Ke y L i n k a g e s w i t h L o c a l P l a n s 1 8

7 . 4 A p p e n d i x F o u r : K P I s f o r 2 0 0 2 P l a n 2 0

7 . 5 A p p e n d i x F i v e : M e s s a g e s f r o m C o m m u n i t y C o n s u l t a t i o n 2 0

7 . 6 A p p e n d i x S i x : E l a b o r a t i n g o n P r i o r i t i e s 2 2

7 . 6 . 1 C o m m u n i t y P a r t i c i p a t i o n 2 2

7 . 6 . 2 I n c r e a s i n g A c c e s s a n d R e d u c i n g H e a l t h I n e q u a l i t i e s 2 2

7 . 6 . 3 I n n o v a t i v e M o d e l o f P r i m a r y C a r e 2 2

7 . 6 . 4 C h r o n i c C a r e M a n a g e m e n t a n d S e l f C a r e 2 4

7 . 6 . 5 C l i n i c a l Q u a l i t y I m p r o v e m e n t 2 6

7 . 6 . 6 Wo r k f o r c e D e v e l o p m e n t 2 6 - 2 7

7 . 7 A p p e n d i x S e v e n : O u t l i n e o f t h e Wo r k P r o g r a m m e Ta r g e t A r e a 2 8

7 . 8 A p p e n d i x E i g h t : Wo r k P r o g r a m m e A c t i o n P l a n s 2 9 - 3 0

7 . 9 A p p e n d i x N i n e : H e a l t h Ta r g e t A r e a s N e w Z e a l a n d 2 0 0 7 3 1D i r e c t o r G e n e r a l o f H e a l t h

8 . 0 R e f e r e n c e s 3 1 - 3 2

Table of Contents

As a district health board Counties Manukau DHB

(CMDHB) works in partnership with its communi-

ties, Primary Health Organisations (PHOs) and other

providers of services to improve the health status of

the peoples of Counties Manukau. A wealth of inter-

national evidence shows that health systems oriented

towards primary care achieve better health out-

comes for lower overall costs than systems focused

on hospital care .

CMDHB’s strategic plan is based on the premise of

effective primary care services in order to deliver

health gain and reduce health inequalities. Locally

based primary and community health services are

the key to this.

Population growth, ageing and the obesity epidemic

will lead to more chronic diseases over the next 20

years in Counties Manukau. This will place demands

on the health system in its current form which it

simply will not be able to address. Healthier

lifestyles, early intervention, increased levels of clini-

cian supported self care for individuals and

families/whaanau and effective management by pri-

mary care teams are fundamental to making the

health system ‘fit for purpose’.

Realisation of this plan requires: some brave innova-

tions in services design and delivery; community

understanding of the role of primary health;

improved health literacy and supported self manage-

ment. The highest standards of clinical quality must

be the norm.

Primary health care professionals in Counties

Manukau work very hard to deliver services in a

challenging environment and I wish to acknowledge

and thank all the health workers involved in caring

for patients

The role and contribution of General Practice is cen-

tral to the success of both the Counties Manukau

Primary Health Care Plan and the national Primary

Health Care Strategy. General Practice teams have

to continue to meet the urgent needs of their

patients while still considering the ongoing require-

ments for good health including preventative care

and provision of health information and education.

Working in this acute model is necessary to meet

patients’ needs but more is required if we are to

meet the challenges of the future. We need to reori-

ent the system to ensure new clinical roles will

emerge and people will be treated by a team, not

just a family doctor

The opportunities for working intersectorially to

impact the wider determinants of health care are

well recognised by CMDHB. Extending this concept

to develop integrated services that are collectively

focused around ‘doing the right thing’ for consumers

is a key feature of the innovative model of the future

referred to in this plan.

As a planner for health services we often focus on

how to improve the system and hence talk about

what needs to change. Bear this in mind as you read

this plan as it is forward looking and focuses on

areas for development and improvement. Rest

assured that we do acknowledge much of the cur-

rent system works well.As you can see from my ear-

lier comments General Practice and other primary

health care services are very much valued and essen-

tial to the success of the DHB.

This plan represents an exciting opportunity to raise

the health status of the people of Counties Manukau

over the next three years. Counties Manukau DHB

is committed to working with our Primary Health

Organisations, the wider sector and consumers to

implement the plan. I look forward to progress

being made towards delivering its objectives and the

improvement in the health of our population that

will result.

Geraint Martin

Chief Executive

P R I M A RY H E A LT H C A R E

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Forward

A definition of Primary Care can be taken from the

New Zealand Primary Health Care Strategy 20012,

which states that:

Primary health care covers a broadrange of services that include:

• Participating in communities and working with community groups to improve the health of the people in the communities

• Health improvement and preventative services such as health education and counselling,disease prevention and screening

• Generalist first level services such as General Practice Services, Nursing Services, Community Health Services and Pharmacy Services that include advice as well as medications

• First level services for certain conditions such as maternity, family planning, sexual health and dentistry or those using particular therapies such as physiotherapy, chiropractic and osteopathic services, traditional and alternative healers

(Based On World Health Organisation,Alma Ata Declaration)

As a District Health Board (DHB) Counties ManukauDHB (CMDHB) works in partnership with PrimaryHealth Organisations (PHOs) and other organisa-tions to improve the health status of the whole com-munity. The DHB’s role is to plan, fund, provide,develop and manage contracts services to meet the

health needs of the community.

Provision of primary health care is delivered via arange of PHOs and other contracted serviceproviders.

PHOs are accorded a key role in coordinating theseservices in addition to providing ‘essential services’for their enrolled populations. PHOs are the entitythrough which the national Primary Health CareStrategy is delivered. General Practice in CountiesManukau is now almost exclusively contractedthrough PHOs.

The Primary Health Care Strategy is the foun-dation policy document for this Plan, and identifiesthe following six key directions:

1. Work with local communities and enrolled populations

2. Identify and remove health inequalities3. Offer access to comprehensive services

to improve, maintain and restore people’s health

4. Co-ordinate care across service areas5. Develop the primary health care work

force6. Continuously improve quality using good

information

This plan will review progress in implementing thePrimary Health Care Strategy and also address thechallenges facing Primary Health Care in the future.

The community of Counties Manukau is unique anddiverse (some general characteristics are discussedbelow with more detailed population characteristicsprovided in Appendix One).Counties Manukau is one of the fastest growingareas in New Zealand, with the population continu-ing to grow at over 2 per cent per annum. The res-ident population for 2006 was estimated to bearound 443,000.The key characteristics of the community are thehigh numbers of Maaori and Pacific people, and therelative youthfulness; around a quarter of the popu-lation are aged 14 years or under.It is a community with high health needs and one ofthe highest levels of deprivation in New Zealand.Counties Manukau has 117,000 people living inareas that can be classified as very deprived - that is34% of the district’s population (and 45% of thechildren). For virtually every health measure under-

taken, poor people do worse than wealthy.

We have one of the largest urban and rural Maaoripopulation mixes in New Zealand, with disparitiesfrom issues of low socio-economic status andreduced access and utilisation of effective healthcare leading to poor health outcomes.

Counties Manukau has the largest Pacific populationin New Zealand, with the highest birth and fertilityrates, low socio-economic status, and resultantpoor health status and outcomes.

Marked health inequalities exist between the leastand most deprived people in Counties Manukau,and between ethnic groups. Maaori and Pacific peo-ple are heavily concentrated in areas of greater rel-ative deprivation. This poverty impacts a higherthan expected rate of overall hospitalisations com-


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Introduction

1.1 The Context of the Sector within Counties Manukau

Primary Health Care is the first level of health careaccessible in the communities in which people liveand work. The success of primary care in positivelyinfluencing health outcomes is therefore heavily influ-enced by other agencies that can have a determiningcontribution to people’s health status. These includebut are not limited to:

• Ministry for Social Development, including:� Work & Income� Child,Youth & Family Services

• Education

• Local Territorial Authorities and Councils

• Housing New Zealand

• Department of Justice

• Employers

• Retailers

• Food Industry

• Leisure Industry & Sports bodies

A plan that scopes three years of activity cannotrealistically effect health related change across theentire sector as it is described above.Both intra-sectoral and inter-sectoral change thatachieves significant and long term health gains forcommunities is achieved via longer term strategies,planning and work programmes driven at policy levelbetween sector leaders.

Examples of such inter-sectoral work that CMDHBand Counties Manukau PHOs are involved withinclude: Let’s Beat Diabetes, Lotu Moui, HealthyHousing, Health Promoting Schools,AimHi, andProviding Access to Health Solutions (PATHS).

Such initiatives give effect to the DHB HealthServices Plan - projecting health needs 20 years intothe future; and the CMDHB District Strategic Plan -directing medium term strategy, actions and out-comes 5-10 years into the future. The common prin-ciples in both types of plan are that they are futureorientated, focussed on whole population health out-comes and grounded in intersectoral collaboration.We will see further development of this approach inparticular in the social services and family violence

pared to the national average.

There are ethnic and socio-economic differences inaccess to services, especially General Practice andDiagnostic services that also need to be addressedto ensure that people of all ethnic groups and allsocio-economic backgrounds obtain the health carethey need.

Within Counties Manukau, the work that results inPrimary Health Care services being delivered to thecommunity needs integrating across many areas andincludes, but is not limited to:

• Essential Services delivered through PHOs which includes services delivered by General Practice and other primary health care service providers

• Pharmacy, laboratory and radiology services

• Maaori Health Services

• Pacific Health Services

• Well Child Services

• Family Planning & Sexual Health Services

• Oral Health and Dental Services

• School based services

• Allied health services e.g. physiotherapy

• Accident & Medical Clinics

• Alcohol & Other Drug services

• Mental Health Services

• Needs Assessment and Service Coordination

• Rehabilitation Services

• Residential and Aged Care Services

• Personal Health and Disability Support Services

Many groups make up the total sector including:PHOs, Non-Government Organisations (NGOsincluding Special Interest Groups,VoluntaryGroups etc), private businesses (Pharmacy,Dentistry, Allied Health, General Practice etc);and government agencies (e.g. DHB provider armcommunity services - mainly Intermediary Care,Public Health Nursing and Mental Health servic-es). Not forgetting the most important stake-holder of all - the members of the public thatmake up the community served.

The Primary Care workforce is equally diverse,as highlighted above and many of these profes-sions and community groups provide first pointof contact, primary health care related services.A number of these are funded in whole or partby the DHB, but others remain primarily depend-ent on user payment and/or voluntary contribu-tion. For further information on the PrimaryHealth Sector Workforce see Appendix Two .

It is important to understand how these individ-uals, providers, organisations and communitiescan contribute to the improved health status ofthe Counties Manukau population and to whatextent they are part of the wider Primary HealthCare Team, DHB and PHO networks.


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1.2 Working across Sectors

areas in the future. Primary health care providershave a critical role to play in such initiatives and theactivity comes together in this plan under the inno-vative model of care concept being developed as partof the Primary and Community Health Service initial-ly focussed on Mangere but eventually to cover theentire Counties Manukau district.

The Counties Manukau Primary Health Care Plan2007-2010 shares the above principles. It has beendrafted after consultation with the community todetermine the key issues that influence understand-ing and use of primary health care services and

actively seeks to improve sector responsiveness tothe needs of the population to realise improvedhealth for all. The Plan identifies the contributionCMDHB, PHOs and Primary health care providerswill make to developing healthy futures for the popu-lation served over the next 3-4 years.

It is critical that PHOs, in particular, link to intersec-toral agencies to coordinate care for individuals andassist them to navigate their way through the systemas these inter-agency services may have a greaterimpact on a person’s health and wellbeing than manyspecific health interventions.

It is appropriate before moving forward with thenew plan to take stock of what has been achieved inthe preceding years. The original CMDHB “PrimaryHealth Care Plan; Moving Forward Together” waswritten in 2002 as a response to the Government’sPrimary Health Care Strategy and in the infancy ofboth CMDHB and Counties Manukau PHOs.

The Public Health and Disability Act (2001) chargedDHBs to be responsible for the health of their entirepopulation and subsequently the national PrimaryHealth Care Strategy attempted to reorient the sys-tem to shift the main focus and investment in healthcare from individual sickness in hospitals to wellnessin whole communities.

To discuss every strategy and work programme thatthe Primary Health Care Plan is aligned with wouldprovide a list of activities too numerous to docu-ment in detail.

It is outside the scope of this Plan to address everyarea of integration. Suffice to say that the Primary

Health Care Plan 2007-2010 cannot exist or suc-ceed in isolation. It is dependent on integrationwith complimentary strategies, planning and workprogrammes that impact on the overall success ofprimary health care.

Some of these are included in table one below:


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2.0 Strategic Linkages to 2007-2010 Plan

3.0 Our Achievements: Outcomes of the 2002-2006 Plan

Table One: Strategic LinkagesNational Local CMDHB

The New Zealand Health Strategy

The Primary Health Care Strategy

The Maaori Health Strategy

The Disability Strategy

The Mental Health Strategy & Plans

The Cancer Strategy

The Pacific Health & Disability Strategy

The Health of Older People Strategy

Primary Health Care Strategy Implementation

Work Programme 2006.

PHO Performance Management Programme

The Counties Manukau DHB District Strategic Plan

The Counties Manukau DHB Health Services Plan

The Counties Manukau DHB District Annual Plan

Let’s Beat Diabetes Strategy

Whaanau Ora - Maaori Health Plan

Tupu Ola Moui – Pacific Health Plan

The Child Health Plan (Well Child)

The Youth & Sexual Health Plan

Maternity & Maternal Health Strategies

Elective Services Plan

The Oral Health Plan

Cancer Control Strategy

Palliative Care Strategy

Advanced Care Planning

Counties Manukau Primary Health Care Workforce

Development and Action Plan (2004)

Counties Manukau Workforce Development Plan : Investing in our Primary & Community Health Care Workforce 2007-2011.

Activities covered within the local plans above are for the most part not repeated here. However, there are somespecific aspects of work that are intimately related and these are discussed in Appendix Three.

The 2002 PHC plan focussed on achieving this re-orientation with some success. The aim was to startthe journey in reconfiguring Primary Health Care asdescribed in table two, below.

This transition was to support the beliefs that:

• Supporting primary care as the first and usual way for people to access and use health services is the key to a healthy community and to reducing the health inequalities which are so evident in the community of Counties Manukau

• The possibilities for improving health and preventing avoidable hospital admissions lie in the primary health care sector

It is important to emphasise that in the transition toachieve the above changes there has also been signifi-cant activity within the wider primary health caresector. In particular PHOs have been through a rapidestablishment phase and are now delivering a signifi-cant number of additional services. This is a signifi-cant achievement given that the first PHOs onlycame into being five years ago.

The following progress has been made as a result ofthe original plan:

I. A strategic direction for CMDHB that is reliant on the success of primary health care.This direction champions:

• Prevention of illness and injury and a focus on wellness and health promotion

• Providing early access, detection and intervention before disease takes hold

• Providing an improved level of community service to off-set the growing need for hospital management

II. Successful implementation of the first phase of the new systems and structures required for success including:

• The establishment of 8 PHOs within the Counties Manukau Region

• Nearly 100% uptake of PHOs by General Practice

• A move from fee-for-service to capitation based funding

• A shift to “low fees” environment

• The establishment of Services to Increase Access (SIA) and Health Promotion (HP) funding programmes

• Improved access to primary health care services• Improved understanding of a population health

approach

• A partnering approach being adopted between the DHB and PHOs

• Emerging collaboration between PHOs

• Development of a PHC Nursing team as a result of the 2003 MOH PHC Innovations

• PHC Nursing, other provider and community leadership at governance level

III. Implementing Intersectoral and Integrated Care Initiatives with a Population Health Approach such as:

• Let’s Beat Diabetes

• Lotu Moui

• The Primary Options for Acute Care Programme (POAC)

• The Chronic Care Management Programme (CCM)

• The Frequent Adult Medical Admissions Project (FAMA)

• Healthy Housing Initiatives

• Healthy Schools Initiatives

• Providing Access To Health Solutions (PATHS)


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Table Two: Sector ReconfigurationOld Sector Approach New Sector Approach

Focuses on individualsProvider focused

Emphasis on treatmentDoctors are principal providersFee-for-service

Service delivery is mono-cultural

Providers tend to work alone

Looks at health of the whole population/communityCommunity and people focused

Education and prevention have an equal emphasisTeams – facility and outreach based -are providersNeeds-based funding for population care

Cultural competence in both mainstream and ethnic specific services

Intersectoral - connected to other health and non-health agencies

CMDHB wishes to acknowledge the gains made inrestructuring and change management undertaken bythe sector and the trends towards improved access,the reductions in admissions to hospital (particularlyin children) and the decrease in inequalities.This wasachieved whilst maintaining services to the communityunder increasing pressures and workforce constraintsthat raise important insight into future planning fordemand and capacity. It is important to recognise thisgood work and the pride in the sense of value thatthe community places on health professionals. Thesector should carry this sense of achievement forwardthrough the next phases of change

These programmes of work have demonstrated thegains that can be achieved through such an approachand has secured the foundation for effective workingrelationships between health professionals and inter-sectoral partners, underpinned by evidence-basedpractice and information technology. A list ofprogress against detailed Key Performance Indicators(KPIs) relating to the 2002 plan is available inAppendix Four.

Although we celebrate our accomplishments to date,it is now time rise to new challenges.The CountiesManukau Primary Health Care Plan 2007-2010 iden-tifies where further improvements in access to anddelivery of quality primary care services can be madeand the necessary actions to achieve this.Establishing new ways of delivering health care that

reflect the health needs of our changing and growingpopulation and that deliver the necessary improvedhealth outcomes are fundamental to the Plan’s suc-cess. If the aims and intention of this Primary HealthCare Plan are met then an effective reduction inhealth disparities and a healthier population in thelonger term should result.

We welcome the challenge of the Primary HealthCare Strategy. As a response this Plan sets out toachieve the vision of healthy communities, whounderstand the links between lifestyle, environmentand health status and who are fully engaged with andsupported by health services throughout their life tomanage their health optimally.

Furthermore, while CMDHB has formed the viewthat there needs to be some rationalisation of PHOsto better fit with the locality based approachdescribed in our Health Services Plan, there is nodoubt that PHOs are the key to success of popula-tion health improvement and have the potential toeffect further positive change though developing theircommunity linkages.

There is a good level of optimism that the goals inthis plan are achievable given the initiatives describedand the goodwill that exists amongst the highly com-mitted Counties Manukau Health Workforce and theunique and special community, which it is our privi-lege to serve.

4.1 Underlying Principles As part of developing this plan stakeholders agreedfour underlying principles to further the partnershipswithin the sector. These principles are fundamental tothe plan:

I. Unity - The entire sector wants to head in aunified direction to achieve the vision of a healthycommunity in Counties Manukau.

II. Change - Given population growth in CountiesManukau combined with the prevalence of chronicdisease, ageing workforce challenges and the currenthealth status of the population we cannot continue tomaintain the status quo within the sector.

III. Community Partnership - The sector wishesto work with its local communities in ways whichidentify and remove health inequalities and which offeraccess to services that improve, maintain and restorehealth.

IV. Quality Development - It is the intent of theentire health sector to promote the coordination ofhigh quality care and the sharing of information toenable this, and that all within the sector are commit-ted to building the capacity, capability and primaryhealthcare workforce.

It is recognised that improvement in population healthoutcomes (and in particular gains for communitieswith high health needs) requires significant investmentin Primary health care services. The establishment ofbrand new ways of designing and delivering health careand the creation of more effective linkages betweenhospitals, other health providers and the community isfundamental to achieving the aims and objectives ofthis Plan, as is effective coordination between thehealth sector with other agencies e.g. housing andeducation.


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4.0 Outline of the 2007 – 2010 Plan

After consulting with the community and sectorproviders, we have identified that the most significantgains to the overall health status of the people ofCounties Manukau to be made within the time frameof this Plan, will be realised by focussing the workprogramme on six key areas (feedback from commu-nity consultation is listed in Appendix Five)

1. Community Participation in Service Delivery and Design:To actively involve the individual and their family/whaanau in the management of their own conditions and furthermore to go beyond consultation about services and service delivery by actively involving the community in decision making. This will be achieved through defined processes and models of governance; working directly with them in making service decisions and developing ideas and solutions regarding improved community health and well being.

2. Increasing Access and Reducing Health Inequalities:Supporting primary care as the first and usual way for people to access and use health services is the key to reducing the health inequalities. The DHB and PHOs will work collaboratively on programmes and services such as innovative models, Services to Increase Access (SIA) and Health Promotion (HP) activities and the funding, of population screening and structured care programmes to make access to health care easier and to work to reduce health inequalities.The biggest impact on health inequalities will be the recognition and improved management of cardiovascular risk in the population. In line with the CMDHB Vision the primary care sector will place particular emphasis on Maaori and Pacific Peoples and other Communities with health disparities.

3. Innovative Models of Primary Care:The further development of initiatives that shape and influence service provision and redesign across the sector with particular emphasis on work with Primary Health Organisations, General Practice and wider sector linkages in locality based services as described in the CMDHB Health Services Plan.

4. Supported Self Care and Chronic Care Management:The further development of initiatives and services that shape and influence community understanding of the links and relationship

between lifestyle, environment and health status. Two key aspects of improving health outcomes for those with long term conditions are the provision of best practice healthcare (based on current clinical guidelines) and supported self care. Self-care support is defined as the systematic provision of support, self management education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, share in decision-making,monitor and respond to their health condition appropriately, and the adoption of a healthier lifestyle.

The DHB and PHOs will work collaboratively to continually improve the current chronic care management programme to support clients to receive optimal medical care and supported self-care.

5. Clinical Quality Improvement:The support and further development of a performance based culture, concentrating on PHO leadership and clinical governance to ensure that PHOs are delivering continuous quality improvement, value for money and are configured in a way that optimises integration and population health coverage.

6. Workforce Development:This explicitly linked with the Counties Manukau Workforce Development Plan 2007-2011. While we need more people working in primary and community health care, it is recognised that more people alone will not address the future health needs of our community. The workforce also needs to be configured differently. This change in approach has significant implications for the primary and community health care workforce, with new roles and skills needing to be developed.Valuing our workforce and providing better support for the multidisciplinary team will be a key enabler to achieve the goals of this plan.

In keeping with the time projections, the scope ofthe plan will be narrower than the other CMDHBstrategies mentioned in section 2.0 above.Accordingly the aspired outcomes are targeted atthe short to medium term adopting a multi-year‘programme’ approach.

Further detail concerning these priorities including asummary of the evidence is discussed in Appendix Six


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4.2 The Six Main Priorities within this Plan

The Plan was written after fourteen consultationevents with the community and sector providersamongst other planning activities. These consulta-tions were held to consolidate strategic directionand to determine key issues/areas that influence andimpact on understanding and use of primary healthcare services.

The Counties Manukau Primary Health Care Plan 2007-2010 aims to develop the primary health care sector forthe people of Counties Manukau so that services :

• are easier to access

• help people make healthier choices

• deliver quality services that reduce inequalities and effectively address the needs of our community and promote good health

• involve communities in identifying their health needs and shaping service development

As a result the Plan focuses the sector in the followingways to ensure sustainability and success:

• Successful change management

• Upstream investment i.e. an equal focus on health prevention and maintenance as well as intervention in sickness

• A ‘whole of community’ approach to health and well being

• A focus on outcomes

• Accountability and high quality performance (reliable, cost effective,quality services)

• Future sustainability of services in terms of delivery components and configuration

• Evolving models of care; configuration,workforce and structure that match the needs of a changing population

• The reduction of barriers and health inequalities

• An increase in access to primary care across the whole community

• Whole sector coordination and integration

This Plan will be supported by multi-year work pro-grammes outlined in the District Annual Plans (DAPs).

Community and sector engagement, successfulchange management, communication and partnershipare fundamental factors that will determine success.

The Plan is a component of the Counties ManukauDHB District Strategic Plan:Healthy Futures 2005-2010, aligning to the six out-comes framework and intent of this strategy. Thetable below outlines the six key outcomes that wereagreed with the community to achieve improvedhealth for all in the next 5-10 years.

The Plan actively seeks to progress sector responsive-ness to the needs of the population in order to realiseimproved health for all. It identifies the contributionthat the Counties Manukau District Primary HealthCare Sector will make to developing healthy futures

for the population served over the next 3-4 years.

It focuses on improving community understanding ofhow to attain and maintain good health and emphasis-es community engagement as key to understanding


10

4.3 How We Developed and Aligned the Plan

CMDHB Visionto work in partnership with our communities to

improve the health status of all,with particular emphasis on Maaori and Pacific Peoples

and other Communities with health disparities

Table Three: The District Strategic Plan Outcomes FrameworkOutcome 1 Outcome 2 Outcome 3 Outcome 4 Outcome 5 Outcome 6

ImproveCommunity WellBeing

Improve Child & Youth Health

Reduce theIncidence &Impact of Priority Conditions

Reduce Health Inequalities

Improve Health SectorResponsivenessTo Individual & Family/WhaanauNeed

Improve theCapacity of theHealth Sectorto Deliver QualityServices

community needs.Paramount is the need to increase access to servicesand reduce inequalities to improve the overall healthof the community. However there is also particularemphasis on the quality of provider: patient relation-ships and provider: family/whaanau relationships, cul-tural responsiveness and patient and family supportedself care.

The development of new models of care delivered atGeneral Practice level including; the development ofhealth education and information, early detection andscreening, multi disciplinary teams and structured careto manage long term conditions are a key focus forimprovements in service design and delivery with ashift in focus from the individual interaction andresponding to issues one at a time to a whole of sys-tem and population based approach.

The Plan also concentrates on the ongoing support

• The establishment of new ways of designing and delivering health care within the primary sector

• The creation of more effective linkages and collaboration between Primary and Secondary care and the Health sector with other agencies

Appendix Seven highlights the target areas andAppendix Eight detail the actual work programmedevelopments for the next 3-5 years

The seven themes supporting our strategic directionare tabled below:

The Primary Health Care Plan is a strategic approachto achieving a healthier future for the population ofCounties Manukau. The plan is based on seven keythemes, endorsed by representatives of the commu-nity and the providers within it.We believe thatdesigning our work programme in alignment withthese themes is important for success.The workprogramme is structured to achieve:

• Change in the way the community understands, accesses and uses the primary sector:

� Improvement in the level of understanding within the community of the link between lifestyle, environment and health status

� The community uses primary health for prevention not just treatment


11

4.4. Key Themes in the Strategy

and development of a performance based culture, con-centrating on PHO leadership, clinical governance,configuration and design to ensure that PHOs aredelivering added value.

Ultimately the strategic intent of the plan is to achieveimproved health for the population served via having thecommunity understand and adopt a wellness approach,empowering them to understand the links betweenlifestyle choices, environment and health status andencouraging them to access community services earlierby seeking general practice support rather than hospitalemergency care. Furthermore that the sector will pro-vide high quality, efficient and effective services for thatcommunity in an integrated and coordinated manner.

Seven key themes were identified in planning activitieswith the sector, these were endorsed in communityconsultations and helped define the strategic directionof the Plan.


12

Table Four: Seven Strategic Themes in the PlanThemes Primary Care Strategic Intent DSP Outcomes Links

1CommunityEngagement &Lifestyle Change

2Evidence BasedClinical Work

3Sector Change

4Reducing Barriers

5PerformanceEvaluation & QualityImprovement

6WorkforceDevelopment

7IntegratingInformationTechnology

As we enable more & more people to take control of their own good health at an individual and whaanau level;a collective community shift towards good health will gainmore & more energy.

Building on successes and continuing to support effectivework that makes a positive difference; managing long termconditions, well child initiatives and preventing unnecessaryhospital admissions.

Transforming the way we deliver services to achieve thechange we seek. Success depends on relationships andcooperation as a whole community/sector

Each member of our diverse community in CountiesManukau is enabled to make healthy choices and easilyaccess primary health services.They understand the services available to them and can use them appropriately.

Continuous quality improvement means constantly evaluating and improving what we do. Systems must be put in place to measure service quality and outcomes i.e.find out if we are getting it right. We are accountable to the community.

The workforce needs to be representative of our community, have the skills to provide what is needed andcan respond when those needs change. Many solutions toworkforce challenges exist within the community itself.

There have been enormous gains to patient care alreadyachieved by information technology in primary health. Thepotential for further improvements and coordinationbetween providers is enormous and work in this area mustcontinue.

1-Community Well Being2 -Child & Youth3 -Priority Conditions4 -Health Inequalities5 -Sector Responsiveness

2 -Child & Youth3 -Priority Conditions4 -Health Inequalities

3- Priority Conditions5 -Sector Responsiveness6 -Capacity & Quality

1-Community Well Being2 -Child & Youth3 -Priority Conditions4 -Health Inequalities

5 -Sector Responsiveness6 -Sector capacity & Quality

5 -Sector Responsiveness6 -Sector capacity & Quality

6 -Sector capacity & Quality

The Counties Manukau Primary Health Care Plan2007-2010 actively seeks to progress sector respon-siveness to the needs of the population in order torealise improved health for all. It identifies the con-tribution Counties Manukau Primary Care will maketo developing healthy futures for the populationserved over the next 3-4 years.

The success of the Plan will be assessed against thefollowing key performance indicators (KPIs) outlined

in table six below.These key performance indictorsare high level and the annual progression stepsand/or targets will be detailed in the associatedannual work programmes.

The indicators were set in consultation withCounties Manukau PHOs whose input and support iscritical to the Plans overall success.


13

5.0 Measuring Success

Table Five: KPIs for the 2007-2010 Primary Health Care Plan:

DSP Outcome Domain Indicator Target

PHC Plan KPIs Deliverable by June 2010

1. ImproveCommunityWell Being

2. ImproveChild & Youth Health

3. Reduce theIncidence & Impact ofPriority Conditions

CommunityEngagement

Healthy Lifestyles

Prevent infectious diseasein children

Reduce complicationsseen fromDiabetes

Reduce the incidence ofCardiovascularevents

All PHOs have a plan with identified processes and KPIsfor engagement with communities and/or their enrolledpopulation

Each PHO includes in its annual report progress againstthe above plan including processes to measure the communities and/or enrolled population’s satisfaction withservices and the results.

Increase the percentage of Maaori and Pacific engaged inphysical activity

Increase the proportion of 2 year olds that are fully immunised.

Proportion of the estimated number of people with diabetes receiving annual screen

Proportion of those on Diabetes Register who have anHBA1C of 8.0 or less. (Maaori & Pacific agreed at 65%)

Proportion of those on Diabetes register who have hadretinal screening in the last 2

Increase the % of those enrolled in Diabetes CCM with asystolic BP < =130

Increase the proportion of Diabetes CCM Patients with anLDL < = 2.5

Proportion of people with a high [1] albumin: creatinineratio who are on an ACE inhibitor

Cardiovascular Risk Screening coverage of ‘at risk’[2]CMDHB population

Percentage of people with Cardiovascular Risk of >= 15%who are on Aspirin, Statin and ACE inhibitor

100%

100%

95%

75%

75%

75%

75%

80%

90%

50%

60%

[1] High albumin:creatinine ratio is defined as >2.5 in men and >3.5 in women or those with overtnephropathy

[2] For cardiovascular risk the ‘at risk’ population is defined as Maaori, Pacific and Indian Males 35 yearsand older and Maaori, Pacific and Indian Females 45 years or older and ten years older for other eth-nicities

These KPIs will be achieved by June 2010The KPIs are aligned with the Health Targets for New Zealand released by the Director General forHealth in March 2007. These target areas include some which are mostly dependent on the PrimarySector for success; childhood immunisation, avoidable hospital admissions, diabetes indicators andNutrition and Physical Activity. The complete range of targets is available in Appendix Nine .


14

(Table Five Continued): KPIs for the 2007-2010 Primary Health Care Plan:

DSP Outcome Domain Indicator Target

PHC Plan KPIs Deliverable by June 2010

4. Reduce Health Inequalities

5. Improve Health SectorResponsivenessTo Individual &Family/WhaanauNeed

6. Improve the Capacity of theHealth Sector toDeliver QualityServices

Increase Accessto primary carefor the mostdeprived

EthnicityRecording andoutcomes

Reduce avoidablehospitalisationsparticularly forMaaori andPacific peoples

Reduce Smoking rates in Maaoriand PacificHouseholds

Improve Breast Feeding for allmothers but particularly forMaaori.

Supported Self Care

The Development of After Hourscare

The delivery of culturally competent care

Clinical Quality Improvement inPrimary Care

WorkforceDevelopment

Maintain the proportion of Maaori, Pacific and Deprivationquintile 5 population in Counties Manukau that areenrolled in a PHO

Maintain and improve ratio of Maaori, Pacific andDeprivation quintile 5 population’s utilisation of generalpractice services to “other” populations at > 1.1

PHOs to maintain or improve on accurate ethnicityrecording for all enrolled patients

All indicators to be reported by Maaori, Pacific and Other,.Targets for Maaori and Pacific to be the same or betterthan the global target unless otherwise stated

Reduce the ASH Rate per 1000 population (with focusunder 5 years, 45-64 and 0 -74 yrs) (It is agreed the best way to achieve this is by reducing theincidence of Cardiovascular Disease and better managingthose at high risk of CVD in addition to specific interventionssuch as POAC, FAMA, After Hours Access)

Percentage of enrolees with smoking status recordedwithin last 3 years in patients aged >=14 years.

Increase the proportion of infants exclusively and fully breastfed at:

6 weeks3 months6 months

Each PHO offers access to a Self Management Education(SME) programme

All newly diagnosed diabetics are offered group SME

Increase capacity of formal enrolments self managementprogrammes to enable 1,000 participants per year

All PHOs after-hours plans are fully implemented providing a network of affordable and accessible after hours primarycare services across Counties-Manukau.

Practices with greater than 10% Maaori and/or Pacific populations will have attended Tikanga best practice andPacific cultural competency training programmes

Achieve targets set in the PHO Performance ManagementProgramme

FTE Reporting of all practice/PHO staff by type (Doctors,Nurses and Community Health Workers) and FTEAchieving all the targets in the "Investing in our Primary &Community Health Care Workforce - Counties Manukau.A Workforce Development Plan 2007-2011"

99%

>1.1

90%

10%

80%

100%

100%

90%

90%

100%

The CMDHB Primary Health Care Plan defines a 5year health strategy supported by a 3 year work pro-gramme. It proactively seeks to progress sectorresponsiveness to the needs of the population inorder to realise improved health for all and identifiesthe contribution Counties Manukau DHB PrimaryCare will make to developing healthy futures for thepopulation served over the next 3-4 years.

It builds upon the achievements of the initial 2002CMDHB Primary Care Plan; Moving ForwardTogether, that was a first response to theGovernment’s New Zealand Primary Care Strategy2001. The work of the initial plan realised the devel-opment of sector change in the roles, functions andstructures of the primary care.

It has paved the way for the 2007-2010 plan whichnow seeks to realise the full intent of the nationalPrimary Health Care Strategy. The national strategyset out a ten year vision and we are half way throughthat timeframe. The sector has come a long way sincethat strategy was published but we have a long way togo in order to fully realise the vision expressed in thestrategy. It is hoped that plan sets out the work pro-gramme and pathway to fully realise the goals andaspirations of the Primary Health Care Strategy.

Key areas for further development include:

• Community involvement in health service planning and delivery

• Primary Care (under the umbrella of PHOs) will be the first and usual means that people interact with health services

• people will have easy access to comprehensive services that improve, maintain and restore their health

• having people understand and adopt a supportedself care approach to foster wellness, empoweringthem to understand the links between lifestyle choices, environment and health status

• a stronger emphasis on prevention, screening and wellness in order to improve population health and reduce health inequalities

• CMDHB and PHOs will work in partnership with their community, the wider health sector and with inter-sectoral agencies to coordinate care and achieve improved health for the population

• using systems and information to continuously improve the quality of care and accountability for health outcomes

• workforce development including building capacity and growing skills of a multidisciplinary team


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6.0 Summary

The population of Counties Manukau DHB includes theterritorial local authorities of Franklin, Papakura andManukau. The population growth and composition is:The population is growing at 2-3 % per year. The popu-lation over 65 years old is projected to double from33,800 in 2001 to 76,000 in 2021.Total Maaori andpacific populations are growing and ageing. Counties

Manukau has a higher 45-64 year old mortality ratethan all of the rest of New Zealand.The high proportion of Counties Manukau populationliving in deprivation has a significant impact on healthand health service provision. For example the high rateof illness related to overcrowded housing and the con-sequent high hospitalisations for treatment.

The success of the Plan will be assessed in 2011 and will ultimately be reflected in any change in the health statusof the community.

7.0 Appendices

Table Six: Projected Population Growth by Age Group, Statistics NZYear 0 - 14 15 - 44 45 – 64 65 + Total200120062011201620212026

% change 2001-2026

104,480113,300117,160119,700122,400127,700

22%

174,410191,750203,590211,100222,000232,000

33%

81,03096,980

112,940124,700132,900137,200

69%

33,79041,14050,39063,20076,40092,000172%

393,710443,170484,080518,700553,800589,000

50%

Table Seven: Counties Manukau Projected Population Growth by EthnicityEthnicity

OtherAsianPacificMaaori

% change 2001-2026

2001198,23047,70078,55069,230Other

9%

2006203,05073,70090,41076,010Asian162%

20011211,04088,300102,10082,640Pacific

81%

20016213,930100,600114,47089,700Maaori

52%

2021215,670113,000127,79097,320Total50%

2026216,140125,000142,290105,570

Source: MoH Ethnic-Specificprojections June 2004

Source: MoH Ethnic-Specificprojections June 2004

7.1 Appendix One: Population Composition

Maaori in Counties Manukau12% of New Zealand’s Maaori lived in CountiesManukau (including Otahuhu). Some key populationfigures relating to Maaori in Counties Manukau:

• Maaori make up about 18% of the total district population

• Within Counties Manukau, relatively few Maaori live in the areas of Howick Pakuranga (5%) and Beachlands Maraetai (7%). Maaori are over-represented in the less affluent areas of Manukau Manurewa (26%), Otara (25%) and Takanini Papakura (24%) but equitably represented in Mangere Papatoetoe Otahuhu (19%) and South Rural (16%)

• The projected total fertility rate for a Counties Manukau Maaori woman is 2.8 children Life expectancy at birth is 71 years for males and 74 years for female. This far behind European and others (76.6 and 81.8 respectively)

• Maaori living in Counties Manukau have a high level of deprivation – 66% live in areas with an NZDep96 decile of 8 to 10

Pacific people in Counties Manukau36% of New Zealand’s Pacific people lived inCounties Manukau (including Otahuhu). About halfthese people identified as Samoan, with Cook Island(21%) and Tongan (16%) being the next largestgroups. These proportions are very similar to thosefor all New Zealand.

Some key population dynamics relating to Pacificpeople:

• Pacific people make up approximately 19% of the total district population

• Migration to New Zealand was encouraged by New Zealand’s post-war growth in secondary industry, with many Pacific people settling in Counties Manukau’s dormitory suburbs – 46% of Counties Manukau’s Pacific people reside in Mangere or Papatoetoe or Otahuhu, 28% in Otara and 19% in Manukau or Manurewa

• The projected total fertility rate for a Counties Manukau Pacific woman is 3.5 children, well above that for European and

others of 1.9. The rate is expected to decrease to 2.4 by 2021

• Life expectancy at birth is 75 years for males and 79 years for females, compared with European and others (80 and 85 respectively)

• Pacific people are over-represented in hospital admissions, the causes of many of which are preventable

• Pacific people living in Counties Manukau have a high level of deprivation – 84% live in areas with an NZDep96 decile of 8 to 10

Asian people in Counties Manukau27% of New Zealand’s Asian people lived inCounties Manukau. (Here ‘Asian’ refers to people ofPakistani and Indian ethnicity, through to South EastAsia and East Asia, including the Philippines,Indonesia and Japan).The Counties Manukau Asianpopulation are a demographically diverse group.Along with Others (non Maaori, non-Pacific), theAsian community on the whole can be classifiedsocioeconomically as “least deprived”.

In terms of life expectancy and potentially avoidablemortality, the Asian population health status is simi-lar to or better than that of the Others.While theAsian population has a slightly greater number ofhospital discharges that are classified as potentiallyavoidable compared to Others. However this groupis over represented in health statistics with regardto childhood obesity and diabetes in the generalpopulation. Cultural responsiveness to the needs ofAsians is also a significant barrier to access and util-isation.

Some key population dynamics relating to Asianpeople:

• Asian people make up approximately 15% of the total district population

• Life expectancy at birth was 80 years for males and 85 years for females

• Asian people living in Counties Manukau on the whole have a low level of deprivation – with less than 30% living in areas with a NZDep96 decile of 8 to 10

• The total fertility rate is 1.9

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Primary Health Organisations (PHO’s) are accountable for thehealth gains of their enrolled populations and are responsible fororganising and delivering primary health care to them.

Non Government Organisations (NGO’s) are generally non-profit, voluntary community groups which are organized on a local,national or international level.Task-oriented and driven by peoplewith a common interest, NGOs perform a variety of services in per-sonal health, disability and mental health within the primary caresector. Examples are: the Stroke Foundation,The Mental HealthEducation & Resource Centre, Family Planning, Plunket Society,Kaupapa Maaori services, etc.

General Practitioners mostly now work as part of a PrimaryHealth Organisation. The estimated 247 fulltime equivalent (FTE)Primary Care Doctors practising in Counties Manukau equates toaround 1,600 people per GP. GP’s are accountable for the health ofthose registered with them.The 2005 national survey highlightedthat 30% of GPs were planning to have left practice by 2010 and in2006 the analysis of CMDHB Community NGO & Primary HealthWorkforce Survey highlighted 282 new GPs are needed inCounties Manukau by 2021 of which 101 are additional and 181 arerequired to replace existing practitioners just to maintain the cur-rent GP to population ratio without taking into account the addi-tional workload from aging of the population and increased burdenof disease from obesity and other lifestyle factors.

It should be noted that while there is a relative shortage of GeneralPractitioners in Counties Manukau, the development of the multi-disciplinary Primary Health Care Teams (together with increasedemployment of Nurses and Community Health Workers), shouldresult in General Practitioners realigning their workload so thatsome of their traditional role can be divested to others.This willassist in maintaining a viable workforce to meet future needs butrequires new ways of working and building the skills of the multidis-ciplinary team.

Primary Health Care Nurses have an evolving role in responseto the Primary Health Care Strategy. Primary Health Care Nurseswork autonomously and collaboratively to promote, improve, main-tain and restore health. Primary care nursing encompasses popula-tion health, health promotion, disease prevention, wellness care, firstpoint of contact care and disease management across a lifespan.Primary Health Care Nurses work in wide range of roles – schools,public health nurses, well-child nurses, practice nurses, nurse special-ists, case managers, rest homes,ACC, Community organisations etc.Career pathways development is seeing nursing roles develop andbuild on a broader scope of practice to incorporate a populationhealth approach.The challenge is to build on these roles to advancedNurse Practitioner level while ensuring sustainability in the sector

Community Pharmacy There are over 80 community pharmaciesin Counties Manukau which dispense prescribed medicines andrelated products including medicines that are bought by patients i.e.over the counter medicines. Many community pharmacies also pro-vide a range of clinical services including patient counselling andadvice on the optimal use of their medication. This may includehelping people to keep taking their medication as prescribed espe-cially for those with chronic conditions. This also means liaisingwith prescribers. There is a growing role for pharmacy in assistingpeople to adhere to medications prescribed and in supporting selfcare. The pharmacist role will change in emphasis away from pre-dominantly dispensing to other clinically focused services that assistspeople particularly those with long term conditions to optimise

their health and work with the rest of the primary care team toavoid harm from medications.This latter area has traditionally beencarried out more by Clinical Pharmacists.

Clinical Pharmacists have a somewhat extended role and tend tohave further qualifications at the post-graduate level. Historicallythese more specialised pharmacists worked in hospitals but increas-ingly can be found working in community pharmacies or employedby primary care organisations.They undertake a range of activities toencourage safe, effective, and cost efficient prescribing and medicineadministration. The clinical pharmacist will be involved in more pop-ulation health activities including research (clinical trials), review ofthose on multiple medicines, reconciling what medications areintended with what is actually taken, and evaluation etc.

Laboratories contract with the DHB to carry out a range of labo-ratory tests ordered by health professionals, particularly generalpractitioners.There are two types of tests, Schedule and non-Schedule. Schedule tests are provided free of charge to patientswhile non-Schedule tests are usually free from hospital based servic-es only. The demand for laboratory services by Counties Manukaugeneral practitioners is growing rapidly – at a rate well above popu-lation growth.This leads to significant financial pressure on the DHB,but does not necessarily reflect inappropriate use of laboratoryservices, given the health needs of our population.Therefore theDHB needs to support a dual focus on quality and cost containment.

Dental Services are provided by private providers, some of whomreceive public funding for care of children and relief of pain services.Auckland Regional Dental Service (ARDS) contracted throughWaitemata DHB provides a regional service predominantly focusingon child oral health and the school dental service.

Allied Health Services are services that are delivered by alliedhealth professionals – health care practitioners with formal qualifica-tions (education and clinical training). This includes such professionsas physiotherapy, occupational therapy, speech language therapy,dietetics and social work etc. They work collaboratively withDoctors, Nurses and other members of the health care team todeliver services in the community. The role and functions of alliedhealth in primary care are a central theme of workforce develop-ment with the establishment of interdisciplinary teams in the sector.

Community Workers work in a supported and supervised waywith health professionals to deliver a range of services to the com-munity ranging form one to one patient contact to work withgroups. Community Health Workers play a vital role in assistingpatients and whaanau to engage with the “wider system” includinghealth providers and intersectoral agencies to get the most benefitfrom the system. They will have an increasing role in assisting peopleto better manage their own health in the future.

Carer Support workers are non-regulated and assist disabled peo-ple to live independently in the community or in the residential dis-ability sector. Health Care Assistants are often specifically trainedto fulfil this role.

New Roles will be developed and become an increasing part of thehealth landscape of the future. Positions such as Clinical Assistants(Medical, or Nurse Assistants) should result in health professionalsbeing able to review and refocus workloads with some more tradi-tional, less specialised work being delegated.This will assist in main-taining a viable workforce to meet future needs.


17

7.2 Appendix Two: Wider Primary Health Stakeholders and Workforce

The success of many of these related plans is depend-ent on the relationship their targeted populationshave with the Primary Health Sector. To make refer-ence to only a few:

The Disability Strategy with its intent of maximis-ing visibility, function and potential within the main-stream for those with disability is a prime example.

The Health of Older Peoples Strategy, with itsstrong focus on providing and maintaining healthrelated opportunities and choices for the elderly toremain valued members of their communities, remain-ing at home in their community for as long as possi-ble.

The plan for Primary Mental Health is to take astructured approach to the management of mild tomoderate mental health conditions within the com-munity as opposed to hospital services and signal therelationship with the general primary sector as beingkey to success. The plan integrates well with thePrimary Health Care Plan as it is underpinned by awellness philosophy and strengths based supportedself care approach to conditions such as depressionand anxiety.

The Well Child Plan(s) with the intent of reducingchildhood disease and maximising wellbeing in chil-dren through such targeted programmes as nationalimmunisation, maternity services, screening pro-grammes, nutrition programmes and access to oralhealth. Although this plan is for increased interactionfor the whole community there is particular emphasison Maaori and Pacific children due to the level ofhealth disparities amongst these groups.

The Youth and Sexual Health Plan(s) are target-ed toward the youth population, aged under 22 years,with a particular focus on Maaori and Pacific popula-tions who are over represented in these areas ofhealth need.

The overall goal is to provide a consistent model ofservices for under 22 year olds that is free for sexualhealth. This would result in near universal access forthis target group regardless of which locality, PHO orPractice they belonged too.

Work is concentrated on achieving consistency inareas such as access to services, sexual health educa-tion, interventions that reduce risk taking behaviours,unwanted pregnancy, teenage pregnancy and sexuallytransmitted disease. The success of this is dependenton relationships with this population at a primarycare level.

Activity covered within the local plans is not repeatedhere. However, there are some specific aspects ofwork that have a more immediately explicit relation-ship with the Primary Health Care Plan due to thescope and timing of the projects that underpin them.These are in the areas of Let’s Beat Diabetes (LBD),Maaori Health, and Pacific Health.

Let’s Beat Diabetes is a five year plan aimed atlong-term structural changes to prevent and/or delaythe onset of diabetes, slow disease progression, andincrease the quality of life for people with diabetes.It recognises the significant activity that alreadyexists to prevent and manage diabetes, and creates along-term vision to align existing activity and a con-text for new investment, based on evidence and bestpractice. This is a whole of society programme withten action areas involving multiple agencies and is aplan for Counties Manukau not just the DHB. Whileit is branded for diabetes it is hoped the resultantwork programme and interventions will deliverhealthier lifestyles that will impact on global healthsignificantly impacting on the incidence of obesityand its sequels, cancer and cardiovascular disease aswell. Primary Care initiatives such as Diabetes GetChecked, CCM and the continued development ofaccessible retinal screening and monitoring via com-munity services (as a complication of diabetes)directly support the intent of LBD. The alignmentand co dependency for success between LBD andprimary care is further evident in that both plansrecognise the importance of working in partnershipthe wider sector. LBD is also leading the way withregard to innovative models of care and finding newways to design and deliver services to the popula-tion – a key focus of the primary health care Plan.Last, both share a philosophy of community engage-ment and empowerment for health gain whichdrives the work streams that support the Plans.

The CMDHB Whaanau Ora Plan has six over-arching Maaori Health priority areas:

1. Lifestyle risk factors,2. Chronic disease,3. Tamariki and Rangatahi health,4. Kaumatua, Kuia and disability support

services,5. Mental health,6. Infrastructure development.

Areas of alignment which mutually support the suc-cess of both Plans to achieve improved health statusfor the population are to be realised in workstreams such as CCM, where enhancement initia-tives such as He Puna Oranga and Heart GuideAotearoa look to improve both health outcomesand overall quality of life with a particular focus onMaaori.The former is a Maaori nurse-led service whichfocuses on improving the quality of life and struc-tured care for those with chronic disease(s). Thelatter is a self management tool designed to helppatients in the home by focusing on changing andimproving lifestyle behaviours through goal setting.This service has particular emphasis on reducinginequalities, targeting clients who have unequalaccess to cardiac rehabilitation and low completionrates.

Community initiatives such as Hauora Whaanau andWhare Oraanga, look to combine a whole family


18

7.3 Appendix Three: Key Linkages with Local Plans

approach the current advances in primary healthcare development, with the Maaori iconic feature ofMarae, as a Maaori-centric venue for Maaori healthgain aspiration in a traditional Maaori health con-text.Whare Oraanga seeks to implement culturalchange management, with the development andimplementation of healthy lifestyle activities.

CMDHB’s Maaori Responsiveness Programme wasdeveloped to specify the overall direction of anorganisation-wide approach to the application ofTikanga Maaori to the work practices of the DHB.It also provides the framework within which theapplication of Tikanga Maaori can be applied tomainstream as well as Kaupapa Maaori services. It isa KPI for the Primary Health Care Plan that thisprogramme is rolled out in the primary sector.

Supporting the development of sustainable Maaoriproviders, who are “fit for purpose” and are there-fore enabled to contribute to improved Maaorihealth outcomes in Counties Manukau is a priorityfor Whare Oranga and this along with culturalresponsiveness in the mainstream is supported inthe Primary Health Care Plan.

Through targeted funding of initiatives that involvehealth promotion and/or services that increaseaccess, the attainment of a low fees environment forquality services and the development of structuredcare programmes for the management of long termconditions the Primary Health Care Plan is wellaligned to achieve a reduction in inequalities andimproved health status for Maaori who are over-rep-resented in the statistics which involve the burdenof disease and the links of socio-economic status onoverall health.

Therefore it is evident that the Primary Health CarePlan and the Whaanau Ora Plan are closely alignedas a key focus of both is to remove barriers toaccess, reduce inequalities and increase responsive-ness to individual and whaanau need. Initiatives thatsupport community engagement, improve providerunderstanding of the community and the goal ofachieving culturally appropriate delivery in the main-stream as well as kaupapa Maaori services shouldsecure improved relationships with and understand-ing of the sector in order that it can be used formaximum health gain by Maaori.

The relationship between CMDHB PrimaryHealth Care Plan and The Tupu, Ola, Moui -Pacific Health and Disability Action Planshares some similarities with the above.Theseinclude: increasing access to first point of contactservices, reducing inequalities in health and reducingthe impact of disease and incidence of avoidablecomplications for the Pacific population who arealso overrepresented in statistics relating to diseaseand poor health.

A driving theme of the Tupu, Ola, Moui is to ensure

that health service provision reflects a coordinatedand responsiveness approach to Pacific peoples by:

1. Acknowledgment that Pacific patients and their families have important social relationship that have a bearing on their health status

2. Pacific people’s community settings and environment reinforce those relationships(i.e. extended family, church, ethnic-specific contexts)

3. Health professionals ensure quality interactions with their Pacific patients and that they provide an environment that is supportive and effective in addressing health need

4. The Primary Health Care Plan 2007-2010 is particularly aligned with Tupu,Ola, Moui - Pacific Health and Disability Action Plan through the following activitiesor programmes which are primary care driven:

5. Community Engagement via the support of Lotu Moui church activities which aim to increase knowledge of disease, prevalence and prevention strategies for Pacific communities. Lotu Moui is a crucial way for the

6. Increasing access and reducing barriers via supporting the implementation of innovative models targeted at Pacific Youth

7. Supporting cultural competency skills in mainstream providers

With all of these relationships taken into account,the CMDHB Primary Health Care Plan 2007-2010has work programmes that are predominantly (withthe exception of Well Child Immunisation Rates)focussed on the needs of the general adult popula-tion. The reason for this is that it has been identi-fied (taking all information into account from com-munity consultation through to international evi-dence in primary health care provision), that this iswhere the most significant gains in the health of theoverall community can be made within the scopeand time frames the Plan encompasses. However,other inter-sectoral work is occurring with the edu-cation sector (Health Promoting Schools,Aim Hi,Lets Beat Diabetes, etc) to ensure that the futuregeneration are being educated in a way to promotehealth lifestyle choices, including prevention andscreening activities for early intervention.

The work programmes are targeted at the wholepopulation. However there is particular emphasison Maaori and Pacific peoples due to the significanthealth inequalities present in these groups comparedto the mainstream.


19

The Primary Care Plan 2007-2010 was informed byfeedback from various groups throughout the com-munity of Counties Manukau. During the months ofFebruary and June 2007 a total of 14 consultationopportunities were offered by the DHB spanning

� 2 0 / 0 2 / 0 7 - A n g l i c a n C h u r c h H a l l , P a p a k u r a

� 2 1 / 0 2 / 0 7 – M a n g e r e C e n t r a l C o m m u n i t y H a l l , M a n g e r e

� 2 3 / 0 2 / 0 7 – H o w i c k L i b r a r y , H o w i c k & To w n H a l l , P a p a t o e t o e

� 2 8 / 0 2 / 0 7 – C o n c e r t C h a m b e r s , P u k e k o h e

� 0 1 / 0 3 / 0 7 – P r i m a r y C a r e F o c u s G r o u p

� 0 2 / 0 3 / 0 7 – C o m m u n i t y P a n e l

� 0 5 / 0 3 / 0 7 – M a n u k a u C i t y C o u n c i l , ( P r o v i d e r s )

� 1 3 / 0 3 / 0 7 – L a m b i e D r i v e C h i l d h o o d D i s a b i l i t y G r o u p

� 1 5 / 0 3 / 0 7 – D i s a b i l i t y S e r v i c e s , Te R o o p u W a i o r a x 2 a m / p m

� 1 9 / 0 3 / 0 7 – M a n a w h e n u a F o r u m

� 1 8 / 0 5 / 0 7 - C o m m u n i t y P a n e l

� 2 2 / 0 6 / 0 7 – C o m m u n i t y P a n e l

general public meetings, Maaori specific meetings, andhealth provider meetings. Approximately 350 peopleprovided feedback.The venues and dates of meetings are listed below:


20

7.4 Appendix Four: KPIs for 2002 Plan

7.5 Appendix Five: Messages from Community Consultation

Table Eight:

Achieved Partially Achieved Little Progress orNot Achieved

Increased proportion of funding to Primary & Community

Embedding of basic systems>90% NHI on claims, prescriptions and lab orders; Ethnicity recording;National Systems e.g. Capitation Based Funding;Enrolment.

>90% of Population enrolled with a PHO

Community involvement in PHO Governance

Widespread uptake of Chronic Care Management

>90% GPs using POAC

PHC Workforce Plan completed

90% e-Discharge Summaries

Measuring Provider Satisfaction withCMDHB

Indicators of Community Participationin PHOs’ Service Planning

90% Kids immunized by age 2y (NIR)

90% of eligible patients enrolled inCCM Diabetes Module

90% of practices with QualityImprovement Plan

Referred Services(laboratory & pharmaceutical)Management (but now part of thePHO PerformanceManagementProgramme)

e-Referrals toCMDHB services


21

The tables do not representeach and every verbatimcomment but they do cap-ture key themes and pointsraised. It is this feedbackwhich has informed ourplan and developed thestrategic direction of thework programme for thecoming years.

Table Nine: General Community FeedbackTheme Feedback

Barriers to AccessingPrimary &Community HealthServices

Understanding theLinks BetweenHealth, Lifestyle &Environment

Coordination ofCare

Receiving care

Other

• The biggest barrier to using GPs well is the lack of relationship feel viewed as “a transaction not a person”

• Care outside of normal working hours, holidays and late night is difficult to access

• Services to rural areas are needed and wanted

• Cost is a significant barrier to access – “affordability of services versus free hospitals”

• Communication and language barriers need to be addressed

• Cultural insensitivities prevail and the cultural psyche is not well understood

• Being able to identify a health issue before it escalates is a hurdle

• Need education and information that makes sense

• Want to talk with real people not leaflets and phone answering machines

• Need to talks about health issues all the time not just one off approaches to things

• Get into the schools and centres and start raising awareness of everyday health issues

• Lack of coordination and communication

• Inter agency links – why don’t you guys all talk to each other, why do I give information over and over, why don’t you all work together

• Happy to see a health professional or representative does not have to be a doctor every time

• Very open to group sessions, group consultation and group learning

• Use knowledgeable patients who live well to teach others, do the same with families

• One stop shop is desired – everything linked up in the one place

• Inter agency links – why don’t you guys all talk to each other, why do I give information over and over, why don’t you all work together

• Value Complimentary medicine and support access to it

• Get us involved in managing our own care

• Laissez faire to PHOs – don’t understand them and what they do

• Don’t understand the primary secondary tertiary approach – health is just health

Table Ten: Community ProvidersTheme Feedback

Improved PopulationHealth Outcomes

Relationships andResponsibilities

Quality ofRelationships in theSector

Other

• Focus on screening & prevention

• Structured and resourced to be the fence at the top of the cliff not the ambulance at the bottom

• Understand who is at risk and have a joint approach

• Get services to where people work

• Understand ethnic cultural differences

• Understand gender cultural difference and modify approach accordingly

• Improving access and compliance

• Not just a focus on outcomes but also quality processes and structures

• Understand what drives behaviours and reinforce messages of change

• Get the community involved

• Transparency

• Buy in

• Involvement

• Sharing Information v Privacy Issues

• Funding for after hours is a key issue

• Focus on children as the future of the community

• Can we all share our business plans and priorities and really plan and work together especially for the most complex and high

• Laissez faire to PHOs

• High needs areas

7.6.1 Community Participation Community participation at many levels is essential tothe success of the Plan which states that improved pop-ulation health will be attained by encouraging people toaccess community-based services early; to understandand adopt, where possible, a supported self careapproach; to empower the community to foster well-ness; and to understand the links between lifestyle choic-es and environment with health status. The aim is forexpert patients and families to develop within communi-ties for certain diseases and conditions and that sup-ported self care becomes the “norm”.

However community participation also needs to occurat a much more strategic level. Ultimately the communi-ty should own its collective health status and understandthe continuum of health from health promotion, well-ness and wellbeing through health events to chronic dis-ease management. In doing so the community will beenabled to fully participate in health service planning forthe population and community members being part ofgovernance and decision making will become the norm.

7.6.2 Increasing Access and Reducing HealthInequalitiesThe high proportion of Counties Manukau populationliving in deprivation has a significant impact on healthand health service provision. Maaori and Pacific Peoplesparticularly are over-represented in almost every healthstatistic. Supporting primary care as the first and usualway for people to access and use health services is thekey to reducing the health inequalities. The DHB andPHOs will work collaboratively on programmes andservices such as provision of after-hours care, innovativemodels of care, Services for Increased Access and HealthPromotion activities, and the funding of populationscreening and structured care programmes to make

access to health care easier, and to work to reducehealth inequalities. In line with the CMDHB Vision theprimary care sector will work in partnership with ourcommunities to improve the health status of all, withparticular emphasis on Maaori and Pacific Peoples andother Communities with health disparities.

7.6.3 Innovative Model of Primary Care CMDHB’s District Strategic Plan is based on a founda-tion of effective primary care services, particularly withrespect to reducing health inequalities and populationhealth gain generally. While we have made someprogress in closing the gap of disparities between ourpopulation groups there is still substantial room forimprovement. Given that today’s inequalities exist as aresult of the current system, be that complexly interre-lated with social systems, there is a need to achieve theparadigm shift described in the Primary Health CareStrategy with a much greater focus on health promotionand prevention in addition to providing acute medicalservices.

Other countries have grappled with this issue and alsodescribe the need for similar reorientation of healthservices and attempted reform , , , , .

Inequality in access to health services is a key determi-nant of disparity in outcomes. There is evidence that theincreased access to general practitioners improveshealth outcomes. Over recent years investment inPrimary Care and lowering of patient co-payments hasresulted in improved access, particularly for the mostdeprived. Starfield clearly describes the benefits thatarise from health systems that have a strong primarycare orientation both in terms of improved health out-comes and overall cost. Improving access to services isvital to making a difference, and locally based primary


22

7.6 Appendix Six Elaborating on Priorities

290

280

260

240

220

200

Number of CMDHB GP FTEs and numberof GP FTEs per 100,00 population

270

250

230

210

2001 2002 2003 2004 2005 2006

300

80

70

60

50

85

75

65

55

GP FTEFTE per 100,000population

Source: MedicalCouncil of NZ(2001-2005), PHOreporting (2006)

Figure 1:

and community services are the key to better access.

Despite some gains there is real concern that this will notbe sustainable because there has been no real growth ingeneral practitioner numbers in Counties Manukau forover five years (see Fig. 1). This is on the backdrop ofalready being approximately 50 GPs short of the nationalaverage. Add to this the obesity epidemic, aging (fore-cast 172% growth in >65 year olds over the next 20years) and 50% growth in the total population with theresultant increase in the burden of disease, clearly this sit-uation cannot be sustained.

These issues are global as evidenced by the following listfrom the Central and North Adelaide Health Service’sstrategy document9. Their proposed solution is to lookat GP Plus health centres and networks which are basedaround 100,000 population groupings along similar lines toour proposed Primary and Community Health Centres:

• ageing of our population;• increasing prevalence of chronic disease;• increasing community expectations about

access to health care;• known and forecast workforce and skill

shortages across all clinical; specialities;• emerging technological improvements with a

resultant increase in demand for health services;

• requirement to upgrade the physical infrastructure of hospitals and primary health centres;

• continued rising cost of health care that is increasing at a rate faster than the State revenue base.

Given that these drivers will place demands on the healthsystem that specialist and hospital services will simply notbe able to address, early intervention and effective man-agement by primary care teams is fundamental.

Projections clearly show that growth in the primary careworkforce will not match this increase in demand. Henceprimary and community health services are going to haveto be structured differently and operate differently inorder to meet the demand in addition to delivering betteroutcomes for all, but particularly the most deprived.

CMDHB will work with the sector and the community tojointly develop innovative models of primary care withinPrimary and Community Health Services that support cli-nicians in facing this challenge. We see that services in thefuture will be locality based with greater co-location tofacilitate teamwork, efficiency and convenience for theconsumers. This represents a significant opportunity forthe community and primary health care providers todesign a future system that will best meet the healthneeds of the population. Further investment in primarycare will be required to achieve this.

This work is an integral part of the DHB’s HealthService’s Plan that takes a long term view of service con-figuration. It is envisaged that there will be between six toeight centres developed that will deliver Primary andCommunity Health Services on a locality basis to catch-ment populations of between 50,000 to 120,000. Taking along term approach means existing primary care struc-tures will align with these services over time to ensure

that primary health care and other community servicesare configured in the most sensible fashion to meet localpopulation health needs as well as interact effectively withthe rest of the health system, in particular DHB providerarm services and intersectoral agencies.

The first such centre will be in Mangere and is referred toas the Mangere Integrated Community Health Care(MICH) Project. This project aims to deliver a detailedbusiness case for a centre to be established that will be anincubator for an exemplar model of care that delivers fullyintegrated health services to the people of Mangere.Implementation will be informed by the available evidenceand with this in mind CMDHB has had a literature reviewcommissioned through the Health Services ResearchCentre of Victoria University . The idea is a hub whereservices will be co-located and integrated to improveconvenience, accessibility, quality of care and efficiency ofoperation. This model is still being developed but a high-level description is contained within the CMDHB’s HealthServices Plan’2

It is recognised that the model of care will vary betweencentres reflecting the needs of each suburb’s communitybut the following services are likely to be included:

� General practice� Primary care nursing, including practice and district

nursing and nurse practitioners� GPs with special interests (GPSI) and Specialist

Nurses (especially in management of long term conditions)

� Dispensing and clinical pharmacy � Midwifery clinics (maternity care)� Community mental health� Medical and surgical specialist clinics (where these

do not require specialised equipment)� Dental� Physiotherapy and other allied health therapies� Radiology� Laboratory specimen collection and potentially

some on-site processing� Minor surgery and other procedures in specially

designed treatment or procedure rooms � Extended hours Accident & Medical services (and, in

some cases, overnight services) � Observation facilities,with some centres having

short-stay beds and others having a direct relationship with nearby residential care facilities.

� Social and other intersectoral services such as Work and Income, budgeting advice etc.

The centres also provide a base for outreach workers,including community health workers, clinical and supportservices delivered in people’s homes, public health nursing,community rehabilitation, and needs assessment and serv-ice co-ordination (NASC). In high needs localities, othergovernment agencies may also have customer serviceoffices co-located.

Mangere, being the first centre,will not only be an incuba-tor for integrated care but will also be a hub for work-force development. The need for evaluation of such amodel means we will be working in partnership with theSouth Auckland Clinical School and the School ofPopulation Health to monitor and improve on the serviceas it progresses using a participatory action researchmethodology.


23

7.6.4 Chronic Care Management and SelfCareCMDHB has a reputation for being an early adopterof integrated care and in particular chronic caremanagement (CCM). We have also invested heavilyin other integrated initiatives such as PrimaryOptions for Acute Care (POAC), a programme thatprovides GPs with simple alternatives to admittingpeople to hospital . This service is focused onreducing acute demand at Middlemore Hospital andbecause previous evaluation has demonstrated apositive return on investment continued investmentin this programme is planned to continue into theforeseeable future. A formal audit of POAC isunderway with results expected in August 2007.

A number of integrated care initiatives were evaluat-ed by CBG Health Research , , with positive results.Many were formally written up for publication in theNZMJ , , , , , , Some of these, particularly Maaoriand Pacific Provider Development continue as partof the Primary Health Care Strategy roll-out underPHO funding. Others were developed from pilotsinto what we now know as our Chronic CareManagement (CCM) Programme. This programme isbased on the Wagner model and, as evidenced bythe references above, has been extensively evaluatedand reported on. Investment in this programme wasbased on a positive return on investment (ROI)analysis undertaken by Deloitte in 2001.14 This ROI

made assumptions based on best practice from clini-cal trials which were then extrapolated to provide atheoretical savings on marginal costs should thesame level of outcomes be achieved. We are updat-ing this ROI analysis using actual performance datawhere possible but this is proving very difficultbecause there is no control group and one does notknow what the rates of admission would be had theCCM intervention not occurred. Updating themodel using current costs and latest evidence sug-gests that the ROI should be even more favourablebut we know that in actual practice this is not likely,as we have only seen a significant reduction in bedday use (from baseline) for those enrolled in thecongestive heart failure module [data yet to be pub-lished]. Therefore, despite encouraging results, actu-al practice has not achieved the reductions predict-ed from earlier pilots particularly the success seenin COPD . While further analysis is required, actionis being directed to improve the programme’s imple-mentation and close the gap to achieving best possi-ble outcomes.

Clinical outcomes for the CCM programme werereviewed in 2005 by Tracey and this interim evalua-tion demonstrated some positive gains and somelearning about how things could be done better. Animprovement action plan was put in place as a resultand we are now awaiting the publication of the for-mal evaluation undertaken by the School of


24

1.0

0.5

-1.5

CCM DiabetesChange in HbA1c with time in Programme

0

-0.5

-1.0

Start Year1 Year2 Year3 Year4 Year5

Cha

nge

in H

bA1c

(%

)

1 year cohort n = 44032 year cohort n = 29823 year cohort n = 1996

4 year cohort n = 11815 year cohort n = 260UKPDSProgramme Overall

Years in Programme

This equates to the systems based approach to model the impact of best practice interventions for those with chronicdisease presented by Homer et al that demonstrates the theoretical benefits that can be achieved .

Figure 2:CCM DiabetesAchievedGlycaemicControl &counterfactual(based onUKPDS)

Population Health. We are achieving outcomes forpeople with diabetes with average drop in HBA1Cmaintained at 0.6% over five years. Evidence fromsystematic reviews, suggests that this is as good orbetter than international practice would expectalthough there are isolated examples of more inten-sive programmes achieving better results so weknow that we can always do better. From UKPDSstudy we know that HBA1C, which is an indicator ofcontrol of diabetes, is likely to deteriorate at 0.2%per annum in settings of usual care. Illustratedbelow (Figure 2.) is a graphical way to present theresults for people with diabetes in CCM. The netreduction in HBA1C represents the benefit from theintervention and we know this surrogate outcomemeasure will result in real benefits in reduced mor-bidity, mortality and costs.

Systems are being developed that enable accurateidentification of those most of risk of hospitalisation.The PARR tool is one such example. CMDHB hasfor a long time looked at its most high users of hos-pital services with a particular emphasis on adultmedicine. There are consistently approximately1500 patients per annum who meet the criteria ofhaving had two or more medical admissions withgreater than five bed days. In 2002 CMDHB in col-laboration with the primary sector piloted aFrequent Adult Medical Admissions (FAMA) pro-gramme targeting these frequent users. Thisachieved a 48% savings in bed days by using careplanning and close follow-up . The funding for thisprogramme was stopped before the evaluation wascompleted. While the mechanism still exists thereare very low numbers of people enrolled in FAMAas it has never been formally re-launched. We planto re-launch this programme with additional supportfrom hospital clinicians to promote uptake with agreater focus on nurse case management to supportself care in the community. While there is mixed

evidence for the effectiveness of case management ,there will be a greater focus on managing these veryhigh users of hospital services within the context ofthe CCM Programme.

What is clear from international literature are thesuccessful components of systems that support peo-ple with long term conditions. It is known that selfmanagement programmes deliver better results.

Self-care support is defined as the systematic provi-sion of support, self management education and sup-portive interventions by health care staff to increasepatients’ skills and confidence in managing theirhealth problems, share in decision-making, monitorand respond to their health condition appropriately,and the adoption of a healthier lifestyle.Evaluation of the Expert Patient Programme in theUnited Kingdom has been completed for the first sixmonth pilot, which was constructed as a randomisedcontrolled trial . This concluded that lay-led selfcare skills training courses are moderately effectiveand showed:

• Moderate gains in self-efficacy• Improved quality of life, wellbeing and better

relationships with health professionals• High satisfaction with the course• No impacts on routine primary health care

utilisation• Reductions in costs of hospital use such that

the programme was cost effective and could be implemented without overall increase in costs,even taking into account increased out of pocket expenses for patients

CMDHB has a new initiative on self managementeducation (SME) that will be formally evaluated aspart of the ‘Lets Beat Diabetes’ initiative. This is avery small scale programme and is early in its imple-


25

300

200

0

Deaths from Diabetic Complications

100

0 2 4 6 8 10 12 14 16 18 20 Year (0-2001)

Status Quo (SQ)Full programme adoption (FA)Partial adoption (PA)Full adoption, desease mgmt only (FADM)Full adoption, full drug coverage (FADC)Full adoption, poor execution (FAPE)

(PA)

(FA)

(SQ)

(FADM)

(FADC)

(FAPE)

Figure 3:

mentation. We will learn from the Expert PatientProgramme evaluation to expand the SME pro-gramme accordingly. We have an excellent platformto do so with the infrastructure created in primarycare through the CCM Programme but may need tocentralise the training programme for self manage-ment to ensure an efficient and standardisedapproach. This will be critical to the success of thisplan delivering to its aims set out in the missionstatement

In summary the CCM Programme is being effective.There is room to further develop the supported selfcare components of the programme. Whether theoriginal projected cost savings are being realised isdebatable and requires further analysis. This work isbeing undertaken. While we know there is room forimprovement in some of the clinical indicators, par-ticularly relating to smoking cessation and bloodpressure reduction in other areas we are achievingworld class results particularly for such a ‘highneeds’ population group. This would suggest that weshould build on the CCM programme to improve itsimplementation and that further investment will berequired to achieve this. This plan recommends thatthe CCM programme continues to be supported toreach a target of 20,000 enrolments by June 2011.

7.6.5 Clinical Quality Improvement We have made good progress in establishing embry-onic clinical governance systems across PHOs. ThePHO Performance Management Programme (PMP)and the CMDHB Clinical Governance Forum haveassisted with this. All Counties Manukau PHOs par-ticipate in the PMP and as such have in place ‘per-formance improvement plans’. Population healthindicators such as immunisation rates, cervicalscreening and cardiovascular risk assessment suggestthere is room for much improvement. It is criticalfor PHOs to be able to demonstrate that theincreased investment that has occurred in primaryhealth care is value for money. Without demonstra-tion of this further investment of the scale seen todate will not be forthcoming. As evidenced by com-ments regarding access to primary health servicesabove we can have confidence that this investmentshould result in positive gains but it is importantthat the DHB is able to measure and report on this.

PHO performance is a key focus. Over timeCMDHB will move to outcome frameworks formeasuring performance and these will also bereflected in the PHO Performance ManagementProgramme.

Population health and clinical indicators will bephased-in with financial benefits for improvement inthe enrolled population. The PHO PerformanceManagement Programme will need to be integratedinto individual PHO Quality and ServiceProgrammes and have clinical oversight from thePHO Clinical Governance Forum.

The PMP is being extended to include cardiovascularrisk assessment as a key indicator and will be fur-ther developed to assist with measurement of vitalpopulation health indicators. In addition to PMPindicators CMDHB additionally reports to PHOslocal indicators such as the KPIs in the CCMProgramme, Utilisation of hospital services includingEC and Ambulatory Sensitive Hospitalisation.Through the Clinical Governance Forum we willhave a greater focus on clinical outcomes and sup-port PHOs to take a quality improvement approachwith their practices. We will also support PHOs toimplement benchmarking systems which will initialremain confidential to the PHOs concerned but intime will be shared with the public.

Clinical quality will also focus on the best use ofresources, particular community pharmacy andlaboratory services. These services are generalistfirst level community health services where thecommunity should expect good and easy access.

Pharmacists are an integral part of the health work-force and have a key role in ensuring patientsachieve the optimal benefits of prescribed and overthe counter medicines particularly for those personswith chronic conditions. In addition, pharmacistshave a key role in medicines information and providean easily accessible avenue for health education andpromotion. These opportunities will be developedover the course of the strategy for example, thedevelopment of Community Pharmacist role inChronic Care Management (CCM) to improve indi-vidual patient outcomes as part of the primaryhealthcare team.

While parts of the CMDHB population are histori-cally low users of medicines and laboratory testswhen compared to the rest of the NZ Population.As the Primary Health Care Plan is focussed on awellness philosophy, early detection, screening andappropriate intervention will promote heavy growthin the use of these services.This must be both man-ageable and affordable. The PHO PerformanceManagement Programme will ensure monitoring andbest use of these resources.

Ongoing development of clinical governance at astrategic level is crucial for the execution of thePHC Strategy. Multidisciplinary membership alongwith consumer representation needs to bestrengthened.

7.6.6 Workforce Development An ageing population, increasing rates of chronic dis-ease and health workforce shortages are straining ourhealth system. Without change, we will spend moreand more to achieve less and less. A wealth of inter-national evidence shows that health systems oriented


26

towards primary care achieve better health outcomesfor a lower overall cost than systems focussed onhospital care. A strong primary health care system iscentral to improving the health of the communityand, in particular, tackling health inequalities.

The Counties Manukau Primary Health Care Plan isfundamentally linked with Counties ManukauWorkforce Development Plans. Over the last fewyears the Primary Health Care WorkforceDevelopment and Action Plan (2004) has beenfocused on:

• General Practitioners recruitment & retention• Nursing recruitment & retention including a

career pathway for nurses • Specific Nursing projects• Development of a framework to support

Community Health Workers including a level 4 training course

• Broadening Pharmacy services to consider value added aspects of clinical pharmacy

• Rural workforce retention and support

Since the 2004 plan successful achievements in theseareas have been:• Level 4 Certificate in Community Health Work

implemented at Manukau Institute of Technology (MIT). 16 Trainees (75% Maaori) completing with high degree of satisfaction (>85% very satisfied)

• FTE Reporting by PHOs commenced (GP,Nursing and CHW numbers) to enable trackingthe impact of our initiatives

• Learning and Development Training courses offered to PHOs, NGOs and general practice staff

• Sponsored DHBNZ LAMP Leadership Development programme places for primary care

• The School Careers Programme won a DHBNZ Workforce Innovation Award. This consists of a set of resources, including a DVD entitled “What ya gonna do?” This DVD and accompanying posters promote primary health care as a career option for year 9 & 10 students in addition to a package of informationfor senior students wishing to consider a career in health. The programme includes visiting health professionals and attendance at expos as well as placements in work experienceoptions in health. The programme targets School Health Careers advisors to consider health as an option to recommend to students.

• Attendance and promotion at various youth careers expos and sponsorship for students to attend programmes such as the Sci-Tech Experience, a 3-day hands-on programme for Year 11 (Form 5) students to learn about scienceand related career pathways.

• In the last year 56 new Health Scholarships were awarded in partnership with The South Auckland Health Foundation.

• Completion of the “Community, NGO & Primary Care Workforce Census” and subsequent analysis and paper by NZIER.

• Establishment of the PHC Nursing team and

subsidising the appointment of PHC nurse leaders for Maaori and Pacific PHOs as well as for the DHB.

• Appointment of an Infection Control Nurse to work across PHOs and practices in primary care

• New graduate programme established for primary care nursing with 5 positions available annually.

• Working with national groups on development of the nursing career pathway but also specific support for nurses to complete Nursing councilrequirements for “Professional Development Portfolios”

• Report commissioned on how Pharmacists might be involved in wider primary care team and linking community pharmacy involvement inaspects of the chronic care managementprogramme for value added clinical components

• Support for retention of the GP workforce in Waiuku.

The 2004 plan is currently being reviewed and thedraft due in August 2007 – “Counties ManukauWorkforce Development Plan : Investing in ourPrimary & Community Health Care Workforce2007-2011” is focused more on the explicit role ofworkforce in improving the health of the wholepopulation, where education and disease preventionare equally as important as treatment, self-care issupported and there is a wide range of health pro-fessionals working together to provide primaryhealth care services to the community. This changein approach has significant implications for the pri-mary and community health care workforce, withnew roles needing to be developed and new skillsneeded for these roles.This plan recognises that while we need more peo-ple working in primary and community health care,particularly more Maaori and Pacific peoples andothers with high health needs, it is also recognisedthat more people alone will not address the futurehealth needs of our community. In addition to need-ing more people working in primary and communityhealth care, there is a need for the workforce to beconfigured differently.

This change in approach has significant implicationsfor the primary and community health care work-force, with new roles and skills needing to be devel-oped. A priority will be development of new rolessuch as ‘Clinical Assistants’ and more autonomy fornurses working within teams, greater use of commu-nity health workers and health promotion. Ongoingfocus will be maintained around skills developmentfor managing long term conditions particularly fornurses and a greater focus on lifestyle behaviourmodification and the competencies to encouragepatient self care including the development of lay-trainers to lead this work. Further, the developmentof health promotion skills and competencies, lookingat the role that allied health professionals can play inprimary care in expanding the multidisciplinary teamare also priorities.

Valuing our workforce and providing better supportfor the multidisciplinary team will be key enablers toachieve the goals of this plan.


27

7. 7. Appendix Seven: Outline of the Work Programme Target Area


28

Table Eleven:

DSP Outcome Primary Health Care Clinical, Service or Link Plan Target Area Development Programme

Community representation and election on BoardsCommunity panelCommunity consultationWorking with “expert patients and families” to support others

Upholding the intent of the Treaty of Waitangi in our workImplementation of Tikanga Best practiceComplaints Incidents Management System for Primary CarePatient & family service feedback

Health Promotion InitiativesServices to Increase Access InitiativesCulturally competent service provisionThe Development of Clinical PharmacyMore outreach services into the community

Progression of Chronic Care Management Programmes including: Cardio-vascular disease, ChronicHeart Failure, Diabetes, Chronic Obstructive Pulmonary Disease; Renal Disease, and Depression

ImmunisationCardiovascular Disease & Diabetes Screening & ManagementRetinal ScreeningSexual HealthChronic Care Management

As part of the Chronic Care Management Programme - Patient and Family Self ManagementEducation Training across general health areas e.g. nutrition and obesity initial focus on Diabetes butextending to generic areas including mental health

Management of cardiovascular riskPrimary Options for Acute CareFrequent Adult Medical Admissions Supporting the residential care sectorManagement of Acute Demand Initiatives including alternatives to Emergency Care & Structured after-hours care (see below)PharmacyValuing Patient Choices – Advanced Care Planning

District wide coordinated after hours access to affordable GP and Nursing services

Primary Community Health Service (as integrated co-located services)Nursing Rural OutreachMultidisciplinary Models of service delivery

Recruitment and Retention of General Practitioner and Nursing workforceFurther development of new roles (Community Health Workers and Health Care assistants)Broaden the range of health professionals involved in the management, and co-ordination of a person’s care.Progressing the role of the non-regulated workforce eg community health workersWorking with groups of expert patients and families to educate and support othersThe role of clinical pharmacy

Definition of Service Scope for PHOsPHO Fit for Purpose & configurationPrimary Community Health Services configuration

PHO Board structures and configurationAppropriate community representation Appropriate community engagement in service developmentRole definition for DHBs and PHOs

Transparency, openness, and measurable performanceContinuous Quality Improvement - Clinical Audit & User feedbackFunding for OutcomesPHO Performance Management ProgrammeHigh Quality performance (reliable, cost effective, quality services)

The action here is to develop an Primary Care Information Strategy for Counties Manukau. Thistheme is of critical importance to the integration and coordination of care. It is inherent in the PHOPerformance Management Programme changes as well as a significant component of the innovativemodel of care within a Primary & Community Health Service.

1 Community Well Being5 Sector Responsiveness

1 Community Well Being4 Health Inequalities5 Sector Responsiveness

4 Health Inequalities5 Sector Responsiveness6 Sector capacity & Quality

3 Priority Conditions4 Health Inequalities5 Sector Responsiveness

1 Community Well Being2 Child & Youth3 Priority Conditions4 Health Inequalities6 Capacity & Quality

1 Community Well Being3 Priority Conditions4 Health Inequalities5 Sector Responsiveness

3 Priority Conditions4 Health Inequalities6 Capacity & Quality

4 Health Inequalities5 Sector Responsiveness

1 Community Well Being2 Child & Youth4 Health Inequalities5 Sector Responsiveness6 Capacity & Quality

5 Sector Responsiveness6 Capacity & Quality





Community engagement (the community partici-pates at all levels and providers build understand-ing of our community and relationships of mutualtrust, respect and unconditional positive regard)

The delivery of culturally competent care withinthe mainstream (building relationships of mutualtrust, respect and unconditional positive regard)

Increased access to primary care through reducingbarriers

Management of Long Term Conditions

Increased development of Risk ScreeningProgrammes, Prevention and Early Detection

Patient Self Care

The Management of Avoidable Hospital Admissions

The Development of After Hours Care

The Development of Innovative Models of Care

Workforce Development

The Development of PHOs – Role, Purpose andStructure

Sector Relationships and Governance

Clinical Governance

Integrated InformationTechnology


29

7.8 Appendix Eight: Work Programme Action Plans

Table Twelve:

THEME ACTION DETAIL 2007-08 2008-09 2009-10 TotalAREA

Community consultation & Focus Groups as part of PCHCs

Community participation including representation on PHO Boards

Development of the CMDHB Community panel

Working with groups of “expert patients” and families to educate and support others (CNP, & Whaanau Ora)

Assist PHOs to develop patient & family service feedback (Consumer Satisfaction)

Improve Immunisation Coverage to 95% of children aged under 2 year old

Implementing Well Child framework

Sexual Health

Initiatives to identify and reduce substance abuse

Patient and Family Self Management Education Training initial focus on diabetes but extendingto generic areas including mental health

Cardiovascular Disease & Diabetes Screening

Diabetes Get Checked Detection

Retinal Screening

Mammography Screening

Cervical Cancer Screening

Colon Cancer Screening?

Early Detection of Renal Disease

Progression of Chronic Care Management Programmes including structured management for:

• Cardio-vascular disease

• Chronic Heart Failure

• Diabetes

• Chronic Obstructive Pulmonary Disease

• Renal Disease

• Depression

Diabetes Get Checked Management

Roll out of Heart Guide Aotearoa (Cardiac Rehab)

Coordinated Care Programme (link to MoH PCHS Work Programme)

Management of cardiovascular risk – introduce new annual review for all people with CVD risk >15%

Frequent Adult Medical Admissions

Respecting Patient Choices/Advanced Care Planning

Upholding the intent of the Treaty of Waitangi

Implementation of Tikanga Best practice

Pacific Cultural Competency Training

PHO Health Promotion Plans

PHO Services to Increase Access Initiatives

More outreach services into the community (PCHS &Rural Nursing Outreach initiative)

- - -

- - -

- - -

-

PHOs to fund

Assumed PHOs will prioritise with any additional resources to be supplied through

Child Health Plan

No additional resources other than as provided via Youth & Sexual Health

& SIA Plans

PHOs to fund using SIA/PMP incentives(New National funding expected for Colon

Cancer Screening)

Expected national funding

Included in CCM above

Expected resourcing from PHOs and MaaoriHealth Plan

Expected resourcing from PHOs & PacificHealth Plan

PHO funding streams

The communityparticipates at alllevels andproviders buildunderstanding ofour communityand positive rela-tionships

Increased development ofRisk ScreeningProgrammes,Prevention andEarly Detection

Patient Self Care

Increased development ofRisk ScreeningProgrammes,Prevention andEarly Detection

Management ofLong TermConditions

The Managementof AvoidableHospitalAdmissions Care

The delivery of culturally competent care within the mainstream

Increased accessto primary carethrough reducingbarriers

CommunityEngagement

BestPractice

CommunityEngagement/ Life style

BestPractice

ReducingBarriers

Outcome 1: Community Wellbeing

Outcome 2: Child & Youth Health

Outcome 3: Priority Conditions

Outcome 4: Health Inequalities


30

(Table Twelve continued):

THEME ACTION DETAIL 2007-08 2008-09 2009-10 TotalAREA

Winter Demand Publicity Campaigns

Primary Options for Acute Care

Management of Acute Demand Initiatives including alternatives to Emergency Care

Structured after-hours care:District wide coordinated after hours access to affordable GP and Nursing services

A mobile team to support Rest Home residents and long stay private hospital patients toavoid hospitalisation (? linked to POAC)

The Development of Clinical Pharmacy

Primary Community Health Service (as integrated co-located services)

Multidisciplinary Models of service delivery

Pilot & evaluate Nursing Case Management

PHO Board structures and PHO configuration

Role definition of DHBs and PHOs

Definition of Service Scope for PHOs

Defining “Fit for Purpose” and growing PHO Capabilities

Progress the Re-configuration of PHOs

PHO Performance Management Programme & future indicators

Complaints Incidents Management System for Primary Care

High Quality performance (measurable with transparency & openness, reliable, cost effective, encourage practice accreditation)

Continuous Quality Improvement:- User feedback - Clinical Audit

Funding for Outcomes

Demonstrating Value for Money: evaluating what we do

Awards ceremony for innovation and outcomes in reducing health inequalities (with an initial focus on clinical indicators for chronic conditions – in particular CVD Risk)

Recruitment and Retention of Nursing workforce:

• Extension of new Graduate Programme

• Nurse Leader position for PHOs

• Scoping & development of walk-in centre

Recruitment and Retention of General Practitioner workforce

Further development of new roles (Community Health Workers and Health Care assistants)

Framework for CHW career development, support & supervision

Broaden the range of health professionals involved in the management, and co-ordinationof a person’s care

Changing role of pharmacy – clinical pharmacist

Developing skills re working with groups & individuals for lifestyle behaviour change

Develop a Primary Care Information Strategy for Counties Manukau. Additional infrastruc-ture is resourced throughout the various initiatives and activity. This is a critical elementfor us to be able to measure success, PHO Performance, value for money, and theInnovative Model of Care (MICH).

PHOs expected to fund including SIA

Resourced by national PMP

Expected PHO Funding (though some connection with DHB CIMS would require

additional resource)

The Managementof AvoidableHospitalAdmissions

The Developmentof InnovativeModels of Care

SectorRelationships andGovernance

The Developmentof PHOs – Role,Purpose andStructure

TheDevelopment ofPHOs – Role,Purpose andStructure

Development ofClinicalGovernance

CelebrateSuccess


IntegratedInformationTechnology

CommunityEngagementReducingBarriers

SectorChange

SectorChange

SectorChange

Performance


I.T. &Integration

Outcome 5: Sector Responsiveness

Outcome 6: Capacity & Quality


31

7.9 Appendix Nine: Health Target Areas New Zealand2007 Director General of Health

Table Eight:TARGET AREA INDICATOR

Childhood Immunisation

Oral Health

Cancer Treatment Waiting Times

Ambulatory Sensitive Admissions

Diabetes Screening

Diabetes Management

Retinal Screening

Mental Health Services

Electives

Tobacco Harm Reduction

Nutrition/Physical Activity/Obesity

Expenditures

Proportion of 2 year olds that are fully immunised95%

Proportion of adolescents utilising oral health services85% utilisation

Proportion of patients waiting less than 8 weeks between first specialist assessment and start of radiation oncology treatment (Excluding Category D)

Rate of hospital admissions per 1000 population that are ambulatory sensitive(focus on Under 5 years and 65-74 yrs)

Proportion of estimated number of people with diabetes receiving annual screen

Proportion of those on Diabetes register who have an HBA1C of 8.0 or less

Proportion of those on Diabetes register who have had retinal screening in the last 2 years

Proportion of long term mental health clients who have an up-to-date relapse prevention plan

100%

Achieve all ESPI targets and achieve an increase in the absolute number of elec-tive discharges in specified areas (agreed with each DHB)

Continue to increase the prevalence of never smokers amongst 14 and 15 yearolds by 7% and increase the proportion of smoke free homes where

there was one or more smokers 75%

Increase the proportion of infants exclusively and fully breastfed and increaseadult fruit and vegetable consumption

Reduce the percentage of the health budget spent on the Ministry of health

10State Government of Tasmania, Department ofHealth and Human Services, A Primary HealthStrategy for Tasmania – Discussion paper. October2006

11Hill J., GP Plus Health Care Strategy,Government of South Australia, Department ofHealth, May 2007.

12Government of South Australia, CentralNorthern Adelaide Health Service, Primary HealthCare: BUILDING THE CAPACITY - FINAL REPORT,Feb 2007 http://www.health.sa.gov.au/cnahs

13Gravelle H., Morris S., Sutton M. Are GeneralPractitioners Good for You? Endogenous Supplyand Health; CHE Research Paper 20; October2006, University of York, et al.

14Starfield, B. (1998), Primary Care: Balancinghealth needs, services and technology. New York:Oxford University Press, 1998.

1Doggett, J.,“A New approach to Primary HealthCare for Australia” Centre for Policy Development,June 2007. http://cpd.org.au/paper/new-approach-primary-health-care-australia

2King A., (February 2001), The Primary HealthCare Strategy; N.Z. Ministry of Health.

3CMDHB Health Services Plan, July2006

4CMDHB Community NGO & Primary HealthWorkforce Surveyhttp://www.cmdhb.org.nz/Counties/About_CMDHB/Planning/Workforce/NGO-Primary-Workforce-surveyresponses.pdf

5Counties Manukau District Health Board, HealthyFutures – a Strategic Plan for Counties ManukauDistrict Health Board.http://www.cmhb.org.nz/Counties/About_CMDHB/Planning/Planning-documents.html#DSP

6Counties Manukau District Health Board,CMDHB Progress 2001-2006hhttp://www.cmhb.org.nz/Counties/FundedServices/ Public-Health/reports/CMDHB-progress2001-2006-v3.pdf

7Department of Health, Primary Care, GeneralPractice and the NHS Plan: information for generalpractitioners, nurses and other health professionalsand staff working in Primary Care in England.January 2001

8Reid J., NHS Improvement Plan: Putting people atthe heart of public service, Department of Health,National Health Service, England, June 2004.

9Institute of Medicine Committee on Quality ofHealth Care in America (IoM). Crossing the QualityChasm:A New Health System for the 21stCentury. National Academy Press:Washington, DC.2001 http://www.iom.edu/CMS/8089/5432.aspx

8.0 References


32

8.0 References (continued)

41Singh D., Transforming chronic care. Evidenceabout improving care for people with long-termconditions. University of Birmingham HealthServices Management Centre, 2005.http://www.hsmc.bham.ac.uk/news/Transforming%20Chronic%20Care%20JAN%202005).pdf

42Singh D, Ham C. Improving Care for People withLong Term Conditions:A review of UK andInternational Frameworks. HSMC. . Birmingham:HSMC, University of Birmingham & NHS Institutefor Innovation and Improvement, 2006.

43World Health Organisation Innovative Care forChronic Conditions: Building Blocks for Action:Global Report 2002 WHO document no.WHO/NMC/CCH/02.01.

44National Health Committee. Meeting the Needsof People with Chronic Conditions, Wellington:National Health Committee, 2007.http://www.nhc.health.govt.nz/moh.nsf/pagescm/666/$File/meeting-needs-chronic-conditions-feb07.pdf

45Department of Health, NHS. Supporting Peoplewith Long Term Conditions – Improving CareImproving Lives. An NHS and Social Care Modelto support local innovation and integration. 5 Jan2005

46Lorig K., Sobel D., Stewart A., Brown B., BanduraA., Ritter P., Gonzalez V., Laurent D., Holman H.(1999). Evidence suggesting that a Chronic DiseaseSelf-Management Program can improve health sta-tus while reducing hospitalization. Medical Care,37(1), 5 – 14.

47Lorig K., Holman H. Self Management Education:History, Definition, Outcomes and MechanismsAnn Behav. Med 2003; 26:1-7

48Flinders Model of Self Management SupportAccessed July 2006http://som.flinders.edu.au/FUSA/CCTU/

49Department of Health, NHS. Supporting Peoplewith long term conditions to self care – a guide todeveloping local strategies and good practice 24February 2006

50The Expert Patient: a new approach to chronicdisease management for the 21st centuryDepartment of Health 2001.http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4006801&chk=UQCoh9

51Rogers,A., Bower P., Gardner C., Gately C.,Kennedy A., Lee V., Middleton D., Reeves D.,Ricahrdson G., The National Evlaution of the PilotPhase of the Expert Patient Programme – FinalReport. National Primary Care Research &Development Centre, December 2006.

15Smith J., Ovenden C., Developing integrated pri-mary and community health services: what can welearn from the research evidence. A report forCounties Manukau District Health Board,August2007; Health Services Research Centre,VictoriaUniversity of Wellington.http://www.cmdhb.org.nz/Counties/Funded-Services/PrimaryCare/documents/literaturere-viewreport.pdf

16Aish H., Didsbury P., Cressey P., Grigor J.Gribben B., Primary Options for Acute Care:general practitioners using their skills to man-age “avoidable admission” patients in the com-munity NZMJ 116(1169): 9 pp. 21 February 2003.URL: http://www.nzma.org.nz/journal/116-1169/326/

17Deloitte Touche Tohmatsu, Counties ManukauDistrict Health Board integrated Care ProjectReturn on Investment Analysis, 2001.

18Clarke D, Howells J,Wellingham J, Gribben B.Integrating healthcare: the Counties Manukauexperience. NZMJ 2003;116. URL:http://www.nzma.org.nz/journal/116-1169/325/

19Gribben B., Counties Manukau District HealthBoard Integrated Care Evaluation 2000 – 2001Diabetes Disease Management, December 2001.

20Gribben B., Counties Manukau District HealthBoard Integrated Care Evaluation 2000 – 2001Integrated Care Project for Patients with CHF,December 2001.

21Gribben B., Counties Manukau District HealthBoard Integrated Care Evaluation 2000 – 2001Overview and Summaries, December 2001.

22Gribben B. (February 2003),ImplementingIntegrated Care in Counties Manukau NZMJ,116(1169): 3 pp. URL: http://www.nzma.org.nz/jour-nal/116-1169/323/

23Wellingham J.,Tracey J., Rea H., Gribben B.;Thedevelopment and implementation of the ChronicCare Management Programme in CountiesManukau NZMJ, 116 (1169): 21 Feb 2003 URL:http://www.nzma.org.nz/journal/116-1169/327/ 8pp

24Rowe I., Brimacombe B., Integrated care infor-mation technology NZMJ, 116: (1169) 11 pp. URL:http://www.nzma.org.nz/journal/116-1169/330/ , 21February 2003.

25Maniapoto T., Gribben B.; Establishing a Maoricase management clinic NZMJ: 116(1169); 8 pp.URL: http://www.nzma.org.nz/journal/116-1169/328/, 21 February 2003.

26Tracey J., Bramley D.; The acceptability ofchronic disease management programmes topatients, general practitioners and practicenurses NZMJ 21 Feb 2003; 116 (1169): 11 pp.URL: http://www.nzma.org.nz/journal/116-1169/331/

27Rea H., Kenealy T.,Wellingham J., Moffitt A.,Sinclair G., McAuley S., Goodman M.,Arcus K.;Chronic Care Management evolves towardsIntegrated Care in Counties Manukau, NewZealand; NZMJ 2007, 120: 1252.

28Wagner EH. Chronic disease management:Whatwill it take to improve care for chronic illness?Effective Clinical Practice. 1998;1:2-4.

29Rea H., McAuley S., Stewart A., Lamont C.,Roseman P., Didsury P.,A chronic disease manage-ment programme can reduce days in hospital forpatients with chronic obstructive pulmonary dis-ease. Internal Medicine Journal 2004; 34: 608–614

30Tracey J., et al Chronic Care ManagementProgramme: Interim Programme Evaluation ReportCounties Manukau DHB,April 2005http://www.cmdhb.org.nz/Counties/Funded-Services/CCM/docs/evaluation/CCM-interim-evalu-ationreport.pdf

31Kenealy T., Carswell P., Clinton J., Mahoney F.,Chronic Care Management – External Evaluation –DRAFT Report. School of Population Health,University of Auckland. 30 April 2007 [interimreport being finalised for publication].

32Knight et al.A systematic review of diabetes DMProgrammes Am J Managed Care 2005; 11:242-50

33Norris et al.The effectiveness of disease andcase management for people with diabetes. Am JPrev Med 2002; 22(4s);15-38.

34UKPDS Group, Intensive blood glucose controlwith sulphonylureas or insulin compared with con-ventional treatment and risk of complications inpeople with type 2 diabetes. Lancet (1998);352:837-853, 1998.

35Homer J., Hirsch G., Minniti M., Pierson M.,Models for Collaboration: How System DynamicsHelped a Community Organize Cost-Effective Carefor Chronic Illness Washington

36R:\PCD Primary Care Development\01 ChronicCare Management (CCM)\100 PARR CaseManagement Tool\case_managing.htm

37Roseman P., Frequent Adult Medical AdmissionsFinal Report. Counties Manukau DHB. July 2003 http://www.cmdhb.org.nz/Counties/Funded-Services/CCM/docs/reports/FAMAreport.pdf

38Sidorov, J., Shull, R.,Tomcavage, J., Girolami, S.,Lawton, N., & Harris, R.. Does diabetes diseasemanagement save money and improve outcomes?Diabetes Care, 25, 684-689. 2002.

39Webb M., Howson H., Overview of the evidenceon effective service models in chronic disease man-agement. (Abridged) National Public Health Servicefor Wales,Welsh Assembly Government. December2005.

40Ham C., Developing integrated care in the NHS:adapting lessons from Kaiser HSMC, University ofBirmingham. http://www.hsmc.bham.ac.uk

CMDHB wishes to acknowledge the many

people who have contributed to the

development of this plan. This includes:

PHO management and clinical leaders,

other health providers, Manawhenua, the

community at large and CMDHB staff

members.

In particular, CMDHB wishes to acknowl-

edge the effort of Tina McCafferty,

Programme Manager Primary Care

Development, for her role in authoring

the document and compiling feedback.

For communication please contact:

Tina McCafferty

Programme Manager, Primary Care

Development

Counties Manukau District Health Board

Private Bag 94-052

S.A.M.C.

Manukau City

Ph: +64 9 262 9572

[email protected]

© Counties Manukau District Health Board

March 2007

Components of this document may be

reproduced without permission providing

the source is acknowledged

Acknowledgement:

P r i m a r y H e a l t h C a r e P l a n 2 0 0 7 - 2 0 1 0

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