Bay of Plenty and Lakes Rheumatic Fever Prevention Plan: Bay of Plenty DHB 2013 - 2017 (refreshed as at 20 October 2015) Summary version - Toi ...

 
Bay of Plenty and Lakes Rheumatic Fever Prevention Plan: Bay of Plenty DHB 2013 - 2017 (refreshed as at 20 October 2015) Summary version - Toi ...
Bay of Plenty and Lakes Rheumatic
      Fever Prevention Plan:

         Bay of Plenty DHB
            2013 – 2017
 (refreshed as at 20 October 2015)
         Summary version
                                     1
Bay of Plenty and Lakes Rheumatic Fever Prevention Plan: Bay of Plenty DHB 2013 - 2017 (refreshed as at 20 October 2015) Summary version - Toi ...
Foreword
In most of the developed world rheumatic fever is thought of as one of those diseases that
people used to get. Here in New Zealand it is still very much a problem. It is a particularly
cruel illness, often snatching away a child’s or teenager’s potential, just when they should be
gaining their confidence and independence. A complication of a seemingly minor throat
infection can lead to heart disease, disability and years of treatment. This scenario plays out
month after month; the number of cases still unacceptably high and unequally affecting
Māori, Pacific and deprived communities.

From 2009, Bay of Plenty and Lakes DHBs have led and funded a comprehensive approach
to reduce rheumatic fever, working closely with affected communities. As national
awareness of the issue grew, local initiatives have been absorbed into a national drive to
prevent rheumatic fever.

The additional focus and funding that has flowed from the national campaign, has had an
impact. Data on cases and their management has never been so complete. There is greater
awareness of rheumatic fever and its importance among professionals and communities,
established school-based services, a register of cases to make sure secondary cases are
prevented, and a core of dedicated staff and community leaders. Television advertising has
for the first time alerted the public right across the country to the issue. Efforts to address the
underlying determinants of this illness, in particular poor housing conditions, are now
benefiting from a clear health service focus, and cross agency approach.

Despite best endeavours, cases of acute rheumatic fever have continued to occur locally
and nationally, and rates have remained stubbornly high. There are, however, some
encouraging signs of change. The early part of 2015 saw a fall in rates of hospital
admissions, and preliminary evaluation of school based services at the national level,
showed modest effectiveness in preventing cases. The detailed findings are awaited, as are
the results of other research into rheumatic fever that have been commissioned as part of
the national programme.

The structure of a comprehensive approach to preventing rheumatic fever has at last been
put in place across NZ, and there are now belated, but welcome signs that a difference may
be emerging.

Continuing to accept a small but steady number of ill children every year is, as I said in the
foreword to the first version of this plan, not an option.

Now is not the time to lose our nerve. Rheumatic fever doesn’t happen in modern,
developed countries. It shouldn’t be happening here.

Dr Jim Miller

Medical Officer of Health

Chairperson

Lakes/BOP Rheumatic Fever Steering Group

                                                                                                 2
Bay of Plenty DHB Rheumatic Fever Prevention Plan (refreshed version) sign-off

This document has been reviewed and accepted as the refreshed Bay of Plenty DHB Rheumatic
Fever Prevention Plan from 1 January 2016 and beyond 30 June 2017.

 Name: Phil Cammish
 Chief Executive
 Bay of Plenty DHB
                                                   ___________________       20/10/2015
                                                   Signature

Name: Punohu McCausland

Chairperson, Maori Health Runanga

Bay of Plenty DHB

                                                  ____________________       20/10/2015

                                                  Signature

                                                                                       3
List of Abbreviations
ARF                     Acute Rheumatic Fever

BAU                     Business as Usual

BOP                     Bay of Plenty

BOPDHB                  Bay of Plenty District Health Board

BPS                     Better Public Services

CHW                     Community Health Worker

CME/CNE                 Continuing Medical Education/Continuing Nursing Education

CoBoP                   Collaboration Bay of Plenty

DNS                     District Nursing Service

EECA                    Energy Efficiency and Conservation Authority

EBOP                    Eastern Bay of Plenty

EBPHA                   Eastern Bay Primary Health Alliance

GAS                     Group A Streptococcus

GP                      General Practice / Practitioner

HNZ                     Housing New Zealand

ICD codes               International Classification of Disease codes

INR                     International Normalisation Ratio (for use of warfarin anticoagulant)

MoH                     Ministry of Health

MOH                     Medical Officer of Health

NHF                     National Heart Foundation

NMO Ltd                 Nga Mataapuna Oranga Primary Health Organisation

PHN                     Public Health Nurse

PHO                     Primary Health Organisation

PoPAG                   Population Health Professional Advisory Group

RAPHS                   Rotorua Area Primary Health Services

RHD                     Rheumatic Heart Disease

Toi Te Ora              Toi Te Ora – Public Health Service

WBOP                    Western Bay of Plenty

WBOPPHO                 Western Bay of Plenty Primary Health Organisation

WISH                    Whakatohea Iwi Social and Health Services

                                                                                                4
Section 1: Overview of rheumatic fever in Bay Of Plenty and Lakes District
Health Boards (DHBs)

1.0 Background
Acute rheumatic fever (ARF) has been clearly recognised as a significant problem in New
Zealand which needs to be addressed. Bay of Plenty DHB (BOPDHB) and Lakes DHB
recognised ARF as a priority issue in 2008. In 2009 a joint steering group was established to
lead a range of DHB-funded initiatives to address rheumatic fever which are now operating
largely as business as usual. Ministry of Health (MoH) funded projects were introduced in
2012, with further MoH-funded programmes introduced in 2015.

The approach taken so far has been based firmly on the Heart Foundation rheumatic fever
guidelines, taking into account the local epidemiology and community wishes.

Programmes are now in place in the following areas:

   1. raising public awareness that ‘sore throats matter’
   2. continuing professional development for health professionals and Community Health
       Workers (CHWs)
   3. school-based throat swabbing campaigns, with linked activity in reducing skin
       diseases
   4. improved notification of new cases to the Medical Officer of Health (MOH)
   5. implementation of rapid-response clinics in medium-risk areas not covered by school-
       based programmes
   6. housing improvement and assistance to “live well together” to reduce structural and
       functional crowding
   7. improving case management, including development of a rheumatic fever register
       across Lakes and BOP DHBs
   8. enhanced surveillance and root-cause analysis of cases

A range of positive results have been demonstrated to date. These include raised
awareness of rheumatic fever in higher risk communities and the general public; increased
awareness of the sore throat guidelines among GPs; the establishment of a register in
BOPDHB district; school-based throat swabbing programmes in 30 decile 1-3 schools that
are operating to agreed protocols, having gained the support of local communities. To date
though, there is no clear evidence of a sustained trend to reduced rates of ARF in the BOP.

                                                                                              5
1.1 Purpose of the plan
The purpose of this refreshed plan is firstly to enable BOPDHB, Lakes DHB and their partner
organisations to co-ordinate services and prioritise initiatives to achieve the national Better
Public Services (BPS) target to reduce the incidence of rheumatic fever by two thirds to 1.3
cases per 100,000 people by June 2017. The plan also signals the level of continuing
preventive services to be provided from 1 July 2017 until June 2022. The BOPDHB
refreshed plan goes beyond the reduction of ARF, by also focusing on minimizing the impact
of rheumatic heart disease (RHD) in the population served by BOP and Lakes DHBs through
coordinated secondary service provision. About 80% of children and young people develop
Rheumatic Heart Disease (RHD) following Acute Rheumatic Fever. A Maori man with RHD
lives 12 years and a Maori woman lives 17 years less than Maori without RHD. Acute
Rheumatic Fever’s long shadow is RHD.

While some limited evidence is emerging nationally and locally on which services are most
likely to achieve the BPS target, it is likely that more evidence will be produced from
evaluations undertaken in the future. This refreshed plan therefore will need to be reviewed
regularly to ensure that practice is aligned to the most recent at hand.

1.2 BOP and Lakes DHBs – a shared approach
In order to achieve the Better Public Services target to reduce rheumatic fever, a shared
approach has been taken by BOP and Lakes DHBs, as there is significant regional work that
is common to both. This includes the development of a single rheumatic fever register,
awareness raising, clinical and peer support for the school-based programmes and
continuing professional development for health professionals.              There is a shared
commitment to continue to work together to meet this challenging target.

However, it is also recognised that in some areas, different approaches are warranted. This
is reflected in the development of two separate plans, one for Lakes DHB and one for
BOPDHB, which share a common overview but provide DHB-specific interventions.

1.3 Commitment to reducing rheumatic fever in the BOP and Lakes DHBs

1.3.1. Target data
Lakes and BOP DHBs are committed to reducing the incidence of rheumatic fever to levels
set by the Better Public Services targets. The specific targets for each DHB are summarised
in Tables 1 and 2 along with the National targets.

                                                                                             6
Table 1: Acute rheumatic fever initial hospitalisation target rates per year for Lakes and BOPDHBs (per 100,000
total population), 2012/13 to 2016/17

District Health Board       2009/10–            2012/13          2013/14             2014/15         2015 /16           2016/17
                            2011/12             Target:          Target:             Target:         Target:            Target:
                            Baseline            Remain      at   10%                 40%             55%                2/3
                            rate                baseline level   reduction           reduction       reduction          reduction
                            (3-year                              from                from            from               from
                            average                              baseline            baseline        baseline           baseline
                            rate)                                level               level           level              level

Lakes                       7.8                 7.8              7.0                 4.7             3.5                2.6
Bay of Plenty               3.8                 3.8              3.4                 2.3             1.7                1.3
New Zealand                 4.0                 4.0              3.6                 2.4             1.8                1.3

Table 2: Acute rheumatic fever initial hospitalisation target numbers per year for Lakes and BOP DHBs (total
population), 2012/13 to 2016/17

District Health Board       2009/10–            2012/13          2013/14             2014/15         2015 /16           2016/17
                            2011/12                                                                                     Target:
                                                Target:          Target:             Target:         Target:
                            Baseline                                                                                    2/3 reduction
                                                Remain at        10%                 40%             55%
                            numbers                                                                                     from baseline
                                                baseline level   reduction           reduction       reduction
                                                                                                                        level
                            (3-year                              from                from            from
                            average                              baseline            baseline        baseline
                            rate)                                level               level           level

Lakes                               8                  8                 7                   5               4                      3

Bay of Plenty                       8                  8                 7                   5               4                      3

New Zealand                        177                177                162                 109             83                     62

1.3.2 Performance data
The actual performance against these targets for the years 2012/13, 2013/14 and 2014/15 is
shown in Table 3:
Table 3: Actual acute rheumatic fever hospitalisation rates and numbers per year for Lakes and BOP DHBs (total
population), 2012/13 to 2014/15 (data provided by Ministry of Health)

District Health Board                      2012/13 actual                        2013/14 actual                   2014/15 actual
                                    Rates        Numbers                     Rates     Numbers               Rates      Numbers

Lakes                                6.8              7                        3.9               4            5.8               6
Bay of Plenty                       3.3               7                      4.6              10              3.2              7

New Zealand Total                    4.0              179                      3.9           175              3.0             135
New Zealand Maori                   12.7                                     10.6                             8.8
New Zealand Pacific                 25.9                                     31.6                            22.5

                                                                                                                                         7
A brief summary of the demographics of the 44 cases of first episode AFRF notifications to
the Medical Officer of Health from 1 January 2010 to 30 September 2015 shows that:
      A total of 31 cases were in the eastern BOP and 13 in the western BOP
      A total of 21 cases came from geographical areas where full school-based throat
       swabbing programmes are currently in place, 18 resided in areas where there is
       reasonable access to current rapid response clinics, and 3 were in areas that are
       outside of sore throat management programmes other than routine general practice.
      Of the 44 cases, 39 were Maori, 3 Pacific, one NZE and one Unknown using the
       prioritised ethnicity classification system
       A total of 36 cases were aged 5-14, 4 were aged 15-19 and 4 were 20 years
       of age.

1.4 Rheumatic fever champions
The BOP and Lakes rheumatic fever champions have been nominated by their respective
DHBs and all are members of the BOP and Lakes rheumatic fever steering group. One of
the key tasks of the champions is to act as the main point of contact for rheumatic fever
issues in each DHB. The Lakes and BOP DHBs Rheumatic Fever Champions will work
within the two DHBs and with equivalent champions across other DHBs, to drive and co-
ordinate actions in each DHB plan to achieve DHB targets.

1.4.1 Lakes DHB
Dr Johan Morreau (Community Paediatrician) and Dr Neil Poskitt (General Practitioner and
Clinical Leader of Child Health for RAPHS) are the rheumatic fever champions for Lakes
DHB. One of the key tasks of the champions is to act as the main point of contact for
rheumatic fever issues in Lakes. Dr Poskitt, in conjunction with RAPHS, has been key to the
development of the Rheumatic Fever Register. This provides the capability to audit current
rates, trends, adherence rates and review of patient care.

Elise Pope (rheumatic fever co-ordinator) is the champion for continuous monitoring and
performance of prophylaxis care, interlinking primary and secondary health care services
and assisting in the transition from child to adult care for rheumatic fever patients throughout
Lakes DHB.

1.4.2 BOPDHB
Dr John Malcolm (Paediatrician, Whakatane Hospital) and Pamela Barke (Nurse Leader
Regional Community Services) are the rheumatic fever champions for the BOPDHB. John’s
appointment provides paediatric medical oversight for programmes, and draws on his
considerable expertise and interest in rheumatic fever issues over many years.

                                                                                              8
Pamela Barke is the champion for monitoring performance of the delivery of Benzathine
Penicillin prophylaxis. This work is also linked to the steering group priority goals to develop
a regional rheumatic fever register and audit Bi-cillin delivery. The district nurses also
provide education and facilitate follow up care for patients with a diagnosis of acute
rheumatic fever and/or rheumatic heart disease (RHD).

1.4.3 Future Governance provisions
To date, the governance of the BOP Rheumatic Fever Prevention Plan has been through the
BOP and Lakes DHBs Rheumatic Fever Steering Group. This Group has included all the key
stakeholders, but at a senior clinical and portfolio manager, Planning and Funding level. This
group will continue to provide immediate oversight for the refreshed BOP Rheumatic Fever
Prevention Plan.

The BOPDHB is currently entering into early discussions on possible new governance
arrangements across the wider central government sector as part of strategic thinking to
better integrate the health and social sectors. This new governance body will include the
Ministries of Education and Social Development, and Te Puni Kokiri as a minimum. The role
of this new Governance Group is to provide strategic oversight of a range of intersectoral
activities, including most likely:

       Social Sector Trial sites in Whakatane and Kawerau;

       Community Response Forum;

       Better Public Service targets, including rheumatic fever prevention;

       BOPDHB’s Child and Youth Strategy, which is jointly signed off by MSD, MoE and
        BOPDHB;

       MBIE contract streamlining and accountability/audit processes.

Membership of the Governance Group will be at senior Executive levels in each
organisation.

                                                                                              9
Section 2: Overarching actions to reduce the incidence of rheumatic fever in
the BOP and Lakes districts

2.0 Overview of the prevention of ARF and RHD
The overarching goal for BOP and Lakes DHBs is to reduce the incidence of rheumatic fever
amongst the total population (but primarily Māori and Pacific peoples) by two thirds by June
2017. In order to achieve this, there are a number of critical prevention stages:

Primordial prevention: Broad social, economic and environmental initiatives undertaken to
prevent or limit the impact of GAS infection in a population. BOP and Lakes DHBs will
undertake interventions aimed at preventing the transmission of Group A streptococcal
throat infections in crowded housing situations through the continuation of the Healthy
Homes Initiative funded by the Ministry until 31 December 2016. DHBs have less direct
influence on child poverty and other social issues, but will work with local government and
other central governments agencies where possible, including through cross sector
programmes such as Children’s Action Team, Social Sector Trials and Whanau Ora, to
improve living standards for vulnerable children and young people.

Primary prevention: Reducing GAS transmission, acquisition, colonisation and carriage or
treating GAS infection effectively to prevent the development of ARF in individuals. BOP and
Lakes interventions will be aimed at school, community and primary health care level
through appropriate detection and management of GAS pharyngitis. Primary prevention also
includes community awareness raising initiatives and continuing professional development
for health professionals.

Secondary prevention: Administering regular prophylactic antibiotics to individuals who
have had an episode of ARF to prevent the development of RHD or to individuals who have
established RHD to prevent the progression of the disease. In the BOP and Lakes,
secondary prevention is closely linked to the implementation of a regional register, with
monitoring and auditing capabilities. Care pathways and Bi-cillin prophylaxis protocols are
also aimed at preventing further recurrence of ARF and RHD.

Tertiary prevention: Intervention in individuals with RHD to reduce symptoms and disability
and prevent premature death. BOP and Lakes DHBs acknowledge the need to ensure
excellent clinical follow up of patients with an existing diagnosis of ARF and RHD. The BOP
and Lakes rheumatic fever register operated by RAPHS will support this work.

                                                                                         10
2.1 BOP and Lakes shared priorities 2013-2017
There is significant regional work that is common to both DHBs to achieve the goal of
reducing rheumatic fever. Since 2009, efforts to address rheumatic fever have been led by
the Lakes/BOP Rheumatic Fever Steering Group. A multifaceted approach was adopted
including the revision of priorities from year to year, with a focus on primary, secondary and
to a lesser extent tertiary prevention. With the adoption of a challenging national target for
the reduction of rheumatic fever rates and confirmation that health is to take the lead across
sectors, primordial prevention will be a new and significant area of work. The steering group
agreed broad priorities for action across both DHBs from 2013 to 2017, these being:

      addressing the determinants of health, in particular poor housing conditions and
       crowding;
      establishment of a rheumatic fever register across BOP and Lakes districts;
      community awareness raising;
      continuing professional development for health professionals;
      easier access to primary care;
      ensuring the delivery of high quality school-based programmes in high risk areas to
       ensure that children have access to prompt treatment, to ensure that services are
       operating safely, and to contribute to national evaluations of effectiveness;
      meaningful monitoring – process and outcome evaluation.

                                                                                           11
2.2 What does this mean for BOPDHB and the BOP school based sore throat
swabbing programme?
The national interim evaluation has provided some useful insights. While unfortunately not
achieving statistical significance, there is encouragement that the programmes have been
partially successful in reducing the incidence of RF, and may be an important component of
a DHB's programme to achieve the RF target. In regards to BOPDHB, our population, and
our school based programme, there are some aspects which limit direct comparison
between the national evaluation and the potential effectiveness or cost effectiveness of the
service in our region.

The cost of delivering the school based programmes in BOPDHB is considered to be lower
than figures used in the interim evaluation:
      The total school rolls of the 29 schools in the programme is 4,551 as at July 2014.
       Based on an approximate 98% consent rate to throat swabbing, then there are 4,460
       children able to access the programme.
      The total cost of the school-based throat swabbing programme is $721,667 per
       annum, including the agreement prices for all providers, laboratory testing costs, and
       the costs of the nursing clinical assurance oversight.
      Therefore the costs per child per annum are $161.81 c.f. Counties-Manukau DHB
       costs used in the economic analysis of $200 per child per annum.

Further to the national evaluation, a local audit and evaluation on preliminary data reported a
non-statistically significant decrease in RF rates for Māori children (aged 5-14) in eastern
BOP intervention schools – Opotiki, Kawerau and Tuhoe programmes. In the pre-
intervention period from 2000 to 2010, Maori children aged 5-14 had a ARF rate of
128.7/100,000 (95%CI 60.6-177.4), and in the intervention period from 2011 to 2014, the
rate was 50.7/100,000 (95%CI 16.3-118.3). This data is to be updated for the 2014/15 year
and the inclusion of the Murupara programme. This unpublished audit and evaluation may
provide some broad indication that RF rates may be reducing in the Eastern BOP. However,
because of small numbers, we are unsure how robust this observation is and to what we
should attribute any changes.

The reduced costs of the BOPDHB school-based throat swabbing programme would have
an effect on the cost per QALY gained for the programme. The BOPDHB programme is also

                                                                                            12
not limited to solely the prevention of RF, with linked activities to reduce skin diseases and
highlight the importance of good hygiene practices.

It is appreciated that school based sore throat swabbing programmes are not likely to allow
DHBs to reach RF targets on their own, rather they are seen as a interim approach while
other initiatives increase primary care access. In BOPDHB school based programmes are
one component of the RFPP, with further initiatives detailed elswhere in this Plan.

When school based sore throat swabbing commenced in BOPDHB (in 2009), it was
acknowledged the programme would continue beyond the period funded by MOH.
Stakeholder and community engagement has shown us that the school based programmes
are valued and well received in communities, and act to increase awareness of RF and the
importance of sore throat management in whanau. The interim national evaluation of school
based sore throat programmes does not have a sufficient number of cases to demonstrate a
statistically significant effectiveness in reducing ARF, however it does suggest that the
programme is likely to reduce the number of cases, and act as a useful adjunct to the other
initiatives BOPDHB is employing in order to reach the BPS target of rheumatic fever
incidence reduction. It is interesting to note that an evaluation undertaken by Dr Janine
Stevens of Hawke’s Bay DHBs Say Ahh programme in Flaxmere, also recommended that
the programme should continue. While recognising the challenges in continuing the
programme, such as increasing costs due to increased service utilisation, concens about
over-use of antibiotics, and opportunity costs for other health service priorities, the
recommendation supported continuation of the programme unless conclusive evidence
showed that the programme’s benefits were less than these costs.

2.3 Laboratory data
Data supplied by Path Lab for Group A streptococcus swab tests from January 2010 to
September 2015 shows a steady increase in the number of swabs taken in:
     the school-based throat swabbing programme, as additional schools have been
        included;
       in general practice, as community awareness increases and health practitioners are
        more familiar with accepted best pactice;
       in hospital emergencency departments, as community awareness increases.
Positivity rates have trended downwards in general practice, with positivity rates being lower
in the 2013 to 2015 to date period in comparison with the 2010 to 2011 period. Overall the
percentage of swabs which tested positive taken in A&E was significantly higher than those

                                                                                             13
taken in general practice, which in turn was higher than swabs from the school programme.
        That is likely to reflect the severity of symptoms in the people presenting to the different
        services.

        Table 4 shows the data from the school-based throat swabbing programme, general
        practice, and hospital emergency departments.

        Table 4: Path Lab data for GAS swab testing – BOPDHB district

   Year                  School-based                         General practice            Hospital Emergency Department
                 No of     No of +ve    Positivity    No of      No of +ve   Positivity    No of    No of +ve    Positivity
                swabs        swabs        rate       swabs        swabs          rate     swabs      swabs           rate
   2010          2,040        206        10.1%        7,095        1,336         18.8%      619       116            18.7%
   2011          5,954        600        10.1%        9,301        1,800         19.4%      664       138            20.8%
   2012          9,659        988        10.2%        6,017        1,732         28.8%      943       193            20.5%
   2013         13,734       1,300        9.5%       13,104        1,888         14.4%     1,123      211            18.8%
   2014         15,579       1,276        8.2%       16,422        2,031         12.4%     1,285      192            14.9%
2015 to Sept    10,224        987         9.7%       14,283        1,487         15.1%     1,093      169            15.5%
2010 to date    57,190       5,357        9.4%       66,222       10,274         15.5%     5,727      1,019          17.8%

        The following graphs present the same data for the general practice swab testing results.

                                                                                                                14
2.4 Root cause analysis data
The following flow diagrams showing the outcomes of the national and local system failure
analysis reports disclose that not much more than half of diagnosed cases of rheumatic
fever had any memory of a sore throat throat. Dr S Schulman noted this also as the ARF
programme in Baltimore, USA took effect. Of those that did note a sore throat, about a third
saw a health professional and were prescribed the right antibiotics, although strict adherence
to taking the antibiotics is not known. This supports that:
      reliance cannot be placed on sore throat management as a means to achieve a
       target of two-thirds reduction.
      Improvements can be made in the sore throat management pathway, which if
       achieved would potentiallly reduce the risk of acute rheumatic fever in children
       identified with sore throats.
      echocardiographic screening needs further consideration and the outcome of 2013
       Heart Foundation, MOH, Te Puni Kokiri and HRC funded evaluation research may
       have a bearing.

                                                                                           15
Analysis of national system failure analysis reports 2014/15

                                             ± ⅔ completed course         ± ⅓ did not complete course
                                                                          (intervention: improved adherence education)

                                                                                                25   got right antibiotic

                                                                        31
                                                                     got antibiotics
                                                                                                6 did not get right antibiotic
                                                                                            (Intervention: more health
                                                                                              professional education)
                                               42
                                              saw a health
                                              professional
                                                                        11   did not get antibiotics
                                                                             (Intervention: more health professional education)
                        69
                      remembered
                   having a sore throat
                                               27    did not see a health professional
                                                    (Interventions: individual, whanau and community awareness raising/
                                                     improved access to primary care including
                                                     rapid response clinics)
127
systems failure
analysis reports
completed                                    58   did not remember having a sore throat
                                                   (Intervention: improving housing programme, echocardiographic screening?)

                                                                                                                                  16
Analysis of BOP case review forms 2014/15

                                                  Unknown if completed course?         did not complete course
                                                                             (intervention: improved adherence education)

                                                                                                        1   got right antibiotic

                                                                               1
                                                                            got antibiotics
                                                                                                        0 did not get right antibiotic
                                                                                                    (Intervention: more health
                                                                                                      professional education)
                                                      1
                                                    saw a health
                                                    professional
                                                  (recurrent case)
                                                                               0   did not get antibiotics
                                                                                    (Intervention: more health professional education)
                            3
                         remembered
                      having a sore throat
                  (includes recurrent case)
                                                      2   did not see a health professional
                                                           (Interventions: individual, whanau and community awareness raising/
                                                            improved access to primary care including
                                                            rapid response clinics)
7
(6 initial ARF and 1 recurrent)
Case review reports
completed                                         4   did not remember having a sore throat
                                                         (Intervention: improving housing programme, echocardiographic screening?)

                                                                                                                                         17
Section 3: Investment to reduce ARF incidence and RHD

Section 3.0 Introduction
This section outlines the service and funding decisions over the next few years. The overall
strategy is to make every effort to achieve the target by 30 June 2017, while keeping DHB
funding levels constant as the Ministry contribution decreases. From 2017/18 onwards, the
DHB funding levels may be able to be reduced, depending on outcomes against the national
and DHB target, and evidence of the most effective and cost-efficient services. The following
summary in Table 5 outlines budgets for the next three years and beyond.
Table 5: Summary of Budgets 2015/16 to 2017/18 and beyond

                                       2015/16      2016/17     2017/18 + out years

DHB funding (contracted)               851,551      825,423       836,520

MoH funding (contracted)               430,375       98,875            0

Additional MoH funding (not contracted) 100,000#    331,250+     183,743α

Total expenditure                    1,381,926     1,255,548   1,020,263

# MoH funding (not contracted) available in 2015/16 to be used for meeting costs of Tuhoe
programme for 6 mths ($65,000) and Rapid response clinic services delivered by NMO Ltd
($35,000)

+ MoH funding (not contracted) available in 2016/17 to be used for meeting costs of Tuhoe
programme for 12 months ($130,000), Healthy Homes programme coordination service
($40,000), revamped rapid response clinics ($135,123), and offset part of Ngati Awa
programme in Whakatane area ($26,127).

Α MoH funding (not contracted) available in 2017/18 to be used for meeting costs of Tuhoe
programme for 12 months ($130,000), and part of the revamped Business as Usual sore
throat management services within primary and community care ($53,743).

3.1 BOPDHB resources committed to reducing rheumatic fever 2015/16
The BOPDHB has planned for the following investment to be made in reducing rheumatic
fever in 2015/16 (GST exclusive). Most of this resource is already committed in provider
agreements – Table 6 refers.

                                                                                          18
Table 6: BOPDHB resources committed to reducing rheumatic fever 2015/16

                       Initiatives                        Cost $              Comment
  School-based throat swabbing programmes
  Opotiki-Whakatohea Iwi Social & Health(expires
  30/6/17)                                                126,171
  Kawerau - EBPHA (expires 30/6/17)                       118,945   #reassignment from Tuhoe
  Murupara - Te Ika Whenua Hauora (expires                44,902    Matauranga Trust to Tuhoe
  31/12/15)                                              130,000*   Hauora on 12 Oct 2015
  Tuhoe area# Tuhoe Hauora (expires 31/12/15)             75,713    *$65,000 from MoH to
  Tauranga area NMO Ltd (expires 30/6/16)               75,75,71    31/12/1531/12/15

  Community awareness raising
  Whakatane – NASH (expires 30/6/16)                      50,475

  Rapid response clinics
  EBPHA (expires 30/6/16)                                107,000
                                                                        All providers funded by
  WBOPPHO (expires 30/6/16)                              103,000
                                                                            MoH to 30/06/16
  NMO Ltd (expires 30/6/16)                               35,000

  Housing improvement initiatives
  Smart Energy Solutions Ltd (expires 30/6/16)          50,000
  Sustainability Options Ltd (expires 31/12/16)
  Tauranga Community Housing Trust (expires             77,687#     #Providers funded by MoH
  31/12/16)                                              77,688#    to 31/12/16 MoH 31 /12/1
  Laboratory testing
  Laboratory costs (Part of PathLab bulk funding
  agreement)                                            185,000     P

  Coordination and governance
  Additional funding to Toi Te Ora-Public Health          85,000
  Service through PV Schedule

  Clinical quality assurance of swabbing
  programmes
  EBPHA (expires 30/6/17) Funded by DHB to
  provide quality assurance across all school-based       40,936             Funded Ff.50
  throat swabbing programmes.                              404
  Funded by DHB through EBPHA to provide quality
  assurance across all throat swabbing programme.50
  Register ongoing costs
  Rotorua Area Primary Health Services (expires
                                                          14,000
  30/6/16)

  District nursing support
                                                          60,409
  BOPDNS through PV Schedule
  Total                                                 1,381,926                  .175

Footnote:
The table does not include investment where services are provided in kind. These include:
Planning and Funding portfolio manager, contracts management, finance and overhead costs; PHO
data analysis and evaluation costs; Paediatrics and Nursing contributions within Rh Fever Steering
group. Also Toi Te Ora - Public Health Services Medical Officer of Health time and Communicable
Diseases Nurse time in actual case management; costs within general practice, or routine District
Nursing Services Bi-cillin management programme. This footnote applies also to Tables 7 and 8.

                                                                                                  19
3.2 BOPDHB investment for 2016/17, including new initiatives
The BOPDHB’s strategy for the 2016/17 year is to make every reasonable endeavour to
achieve the target, maintaining services at current levels as much as possible within funding
constraints. The Ministry has reduced its funding from 2015/16 levels by $100,250. The DHB
will also reduce its investment into programmes by $26,128 while maintaining core services.

The intention is to continue funding the following programmes during the 2016/17 year at the
same level as in 2015/16.

   Opotiki, Kawerau, Murupara, Tuhoe and Tauranga South school-based throat swabbing
    programmes, considering any cost efficiencies that are practicable.
   The community awareness raising programme delivered by NASH in eastern BOP.
   Clinical quality assurance agreement with EBPHA.
   Coordination and governance through Toi Te Ora - Public Health Service
   Laboratory costs (ensuring that the block amount being paid currently aligns with the
    volume of swabs being sent to PathLab, so that the price per swab remains competitive)
   Register ongoing costs
   District nursing support for a Rheumatic Fever Coordinator
   BOPDHB third party funding for all housing projects across the BOP, including those
    specifically for rheumatic fever prevention whanau.
The DHB will continue to fund Ministry-initiated projects but with reduced funding and
changes to the service delivery model.
   Housing Insulation Initiative scheme, with the pathway, referral criteria and processes be
    streamlined from 1 January 2017, and be dependent on subsidy levels and criteria set by
    EECA and other third party funding contributions.
   A revamped Business as Usual primary and community-based service for rapid
    response assessment and treatment of sore throats.

                                                                                           20
Table 7: BOPDHB resources committed to reducing rheumatic fever 2016/17

                     Initiatives                         Cost $             Comment
  School-based throat swabbing programmes
  Opotiki area Whakatohea Iwi Social and Health         126,171
  Kawerau area EBPHA                                    118,945    No change from 2015/16
  Murupara area Te Ika Whenua Hauora                     44,902    other than any cost
  Tuhoe area# Tuhoe Hauora                              130,000    efficiencies
  Tauranga area NMO Ltd                                  75,713    /12/15
                                                     75,75,71

  Community awareness raising
  Whakatane- NASH                                        50,475     No change from 2015/16

  Rapid response clinics
                                                                      Costs reduced from
  Revamp of services towards Business as Usual          135,123
                                                                      $245,000 in 2015/16
  within primary and community care

  Housing improvement initiatives
  Smart Energy Solutions Ltd                             50,000    #Providers funded by MoH
  Sustainability Options Ltd                             49,437#   to 31/12/16 at $49,437
  Tauranga Community Housing Trust                                 each     for    6     mths.
                                                         49,437#   Development      of    new
  Healthy home programme coordination service
                                                         40,000    service    from     1/01/17
                                                     ,00077,6871   Development of new service
                                                                   from 1/01/1evelopm service
                                                                   from 1/01/17$98,875at $MoH
                                                                   31 /12/1
                                                                    No change from 2015/16,
  Laboratory testing                                                 although savings will be
  Laboratory costs                                      185,000         sought if swabbing
                                                                         numbers reduce.

  Coordination and governance
  Additional funding to regional PHU (excludes           85,000     No change from 2015/16
  associated skin and respiratory disease funding)

  Clinical quality assurance of swabbing
  programmes                                                        No change from 2015/16
  EBPHA                                                  40,936                .50
                                                          404
                        .50
  Register ongoing costs                                            No change from 2015/16
  Rotorua Area Primary Health Services                   14,000

  District nursing support                                          No change from 2015/16
                                                         60,409
  BOPDNS
  Total                                                1,255,548                .175

Footnote:
The BOPDHB will consider each funding line separately in this plan when agreements
expire, as part of its annual budget planning process from 2016/17 onwards, in light of wider
budget drivers and national and local priorities. It will also actively seek additional revenue
streams from Ministry of Health and philanthropic trusts which align with this overall plan.

                                                                                                21
3.3 BOPDHB investment for 2017/18 and later out years to 2021/22
The question of when school-based throat swabbing programmes should cease has not yet
been satisfactorily resolved nationally. Continuation of school-based throat swabbing in high
risk communities will largely be determined by their local success and all contributions to the
success in achieving the BPS target, and national evaluations and cost-efficiency analyses.
The BOPDHB’s strategy for the 2017/18 year and later out years to 2021/22 is to shift into a
maintenance mode, retaining a core of specific rheumatic fever prevention services as much
as possible within funding constraints, and building up Business as Usual primary and
community-based services. The shortfall in funding between 2015/16 programme costs, and
funding available from the DHB and MoH is $232,889 in 2017/18 and beyond if all services
delivered in 2016/17 were to continue, and the BOPDHB were to maintain existing
investment levels. Neither proviso is likely, although this will be dependent on whether the
DHB achieves the target by 2016/17. The DHB will therefore reduce the total costs of all
programmes from the 2016/17 figure of $1,255,548 to a maximum of $1,020,263. Of this
$1,020,263, $183,743 will be met by the Ministry of Health, with the balance met by the
BOPDHB. Further savings may occur once national evaluations provide clearer indications
of the effectiveness of different services.

The DHB intends to continue funding the following programmes during the 2017/18 year and
beyond at the same level as in 2015/16.

   Opotiki, Kawerau, Murupara, Tuhoe and Tauranga South school-based throat swabbing
    programmes, considering national evaluative evidence of effectiveness and cost -
    efficiency.
   Laboratory costs (ensuring that the block amount being paid currently aligns with the
    volume of swabs being sent to PathLab, so that the price per swab remains competitive)
   Register ongoing costs
   District nursing support for a Rheumatic Fever Coordinator
   BOPDHB third party funding for all housing projects across the BOP, including those
    specifically for rheumatic fever prevention whanau.
   Housing Insulation Initiative scheme, although the pathway, referral criteria and
    processes will be streamlined from 1 January 2017, and be dependent on subsidy levels
    and criteria set by EECA and other third party funding contributions.
   Revamped Business as Usual sore throat management services within primary and
    community care.
In 2017/18 and out years, it is intended that the BOPDHB will cease contracting specifically
for the clinical quality assurance agreement with EBPHA, and the coordination and

                                                                                            22
governance through Toi Te Ora - Public Health Service. These activities will be embedded
as Business as Usual into the continuing school-based swabbing programme agreements,
and Toi Te Ora’s core Public Health Services agreement with the Ministry of Health
respectively. This will allow these services two years to plan for this change.

Table 8: BOPDHB resources committed to reducing rheumatic fever 2017/18 and out
years

                     Initiatives                       Cost $               Comment
  School-based throat swabbing programmes
  Opotiki area Whakatohea Iwi Social and Health       126,171
  Kawerau area EBPHA                                  118,945      No change from 2016/17
  Murupara area Te Ika Whenua Hauora                   44,902      other than any cost
  Tuhoe area# Tuhoe Hauora                            130,000      efficiencies
  Tauranga area NMO Ltd                                75,713      /12/15
                                                   75,75,71

  Revamped Business as Usual sore throat
  management services within primary and              135,123        No change from 2016/17
  community care

  Housing improvement initiatives
  Home insulation provider                             50,000      No change from 2016/17
  Healthy home programme coordination service                      Development      of  new
                                                       80,000      service from 1/01/17
                                                                   Development             of
                                                   501177,6871     new98,875at $MoH 31 /12/1
                                                                    No change from 2016/17,
  Laboratory testing                                                 although savings will be
  Laboratory costs                                    185,000           sought if swabbing
                                                                         numbers reduce.

  Register ongoing costs                                             No change from 2015/16
  Rotorua Area Primary Health Services                 14,000

  District nursing support                                           No change from 2015/16
                                                       60,409
  BOPDNS
  Total                                              1,020,263                    .175

Footnote:
The BOPDHB will consider each funding line separately in this plan when agreements
expire, as part of its annual budget planning process from 2017/18 onwards, in light of wider
budget drivers and national and local priorities. It will also actively seek additional revenue
streams from Ministry of Health and philanthropic trusts which align with this overall plan.

                                                                                                23
3.4 Co-benefits
While the focus of this plan remains the prevention of Acute Rheumatic fever and Rheumatic
Heart Disease, there are a number of co-benefits associated with the work undertaken.
These include:

3.4.1 Prevention, early assessment and treatment of skin infections
Up until recently, in New Zealand there has not been a demonstrated causal association
between streptococcal skin infections and rheumatic fever. However the same socio-
economic factors that result in skin infections are linked to rheumatic fever e.g. crowded
housing conditions, poverty and barriers to effective early primary health care. Therefore the
preventive actions taken for acute rheumatic fever would be expected to impact on the
incidence of skin infections and vice versa. Indeed, skin infections and cellulitis prevention
are delivered under the same agreement and by the same staff in the Kawerau programme,
with declining throat GAS, ARF and skin infections, and resources have been shared with all
other school-based throat swabbing and community awareness programmes in the BOP.

3.4.2 Respiratory infections in children
Similarly to skin infections, the underlying factors causing respiratory infections in young
children are the same as for rheumatic fever i.e. crowded housing conditions, poverty and
barriers to effective early primary health care. Respiratory disease make up three of the top
six ASH conditions for 0-4 year olds (with skin infections a fourth condition). There are on
average 1,100 admissions of BOPDHB children aged 0-14 every year from respiratory
infections, with 89% being bronchiolitis, upper respiratory infections, pneumonia and lower
respiratory infections. In Whakatane 1 in 6 infants are admitted with bronchiolitis. A
childhood respiratory management pathway is being developed under Bay Navigator which
should include information around referral processes for home insulation and other
improvements.

3.4.3 Enrolment and ongoing engagement with primary health care
With free primary care and access to prescriptions for all under 13 year olds in the BOP,
some (but not all) of the barriers to accessing primary health care have been removed.
There is still a need to increase engagement with primary health care for adolescents aged
13-19, who traditionally have low utilisation rates, particularly for conditions not associated
with injury or sexual and reproductive health. Needing to access primary care for sore throat
management, including pharmacy for antibiotics, will help to normalise routine primary care
consultations.
The enrolment rate for BOP residents in general practice and PHOs is generally high at
98+%, although those not enrolled will tend to be in those populations at risk of rheumatic

                                                                                            24
fever. Staff working in school-based and community rheumatic fever programmes check the
enrolment of all families they engage with.

These co-benefits illustrate there would be value in taking a more comprehensive approach
to well child health care to encompass a number of common issues as part of an integrated
service within communities. Community Health Workers can contribute local knowledge and
credibility. This wider approach within families could include as appropriate to the age of the
child:
        Housing improvements;
        Immunisation outreach;
        Skin infections and cellulitis;
        Sore throat management;
        Oral health;
        SUDI prevention;
        Breastfeeding promotion;
        Smoking cessation.

3.5 Re-designed Healthy Homes Initiative from January 2017
The BOPDHB has been involved in home insulation and broader home improvement
projects for many years. In conjunction with philanthropic trusts, private home insulation
providers, NGOs and Hauora services, it has developed expertise and experience in this
field, which has been strengthened with the Ministry of Health funded Healthy Homes
Initiative. The current situation in the BOP is as follows:
        There are existing community-based projects in Maketu and surrounding areas, and
         Kawerau, with the potential for a new project in Murupara township in 2016.
        Philanthropic trusts e.g. BayTrust are funding home assessments, project
         management, DIY workshops and community development as part of a long term
         strategic direction.
        The two energy trusts, Tauranga Electricity Community Trust and Eastern Bay
         Energy Trust, are acting as third party funders to support government funding
         available through EECA. The DHB is contributing an additional $50,000 per annum
         for home insulation funding.
        A comprehensive set of interventions alongside home insulation are now available
         across most of the BOPDHB district. These include curtains, heaters, firewood,
         clothing, bedding and blankets, budget advice, and Work and Income benefit
         reviews, and are currently exploring ways to deliver free or low cost home
         maintenance services.

                                                                                            25
   The Ministry of Health Healthy Homes Initiative programme ceases at 31 December
       2016. Through this programme, effective relationships have been developed with
       MSD and HNZ.

The DHB is looking to establish a sustainable service across its district from 1 January 2017.
One of the problems at the moment is that there are a number of eligibility criteria for funding
of home insulations, set by EECA, the Ministry of Health, and third party funders. This has
resulted in a number of referral processes being in place, which leads to confusion amongst
health practitioners who are engaged with families who would benefit from home
improvements.

The intention is to simplify referral processes for all health practitioners by having a common
referral form that would be sent to a single clearing house. Having only one initial referral
form will allow the DHB to widen the sources of referrals to include general practice, public
health nurses and other health professional not currently involved in making referrals. This
organisation would be funded by the DHB to undertake healthy homes assessments; refer
for interventions to reduce crowding and make home improvements; provide home energy
awareness and healthy living together education; and report back to the DHB on
assessment and intervention outcomes. The assessments would be funded by the
philanthropic sector and home insulations would be funded by EECA and local funders
according to their criteria. It is likely that in future the government’s funding will be limited to
rental property, but that is the sector where the most uninsulated homes are.

The BOPDHB in conjunction with Lakes DHB and through Toi Te Ora-Public Health Service
will hold a workshop on healthy housing in about April 2016. This workshop will provide an
opportunity for existing projects to showcase their work, for key stakeholders to outline their
roles, and for discussion on future pathways for home insulation and other home
improvements. There may be opportunities to involve landlord and rental management
groups. The workshop may lead to the development of a permanent cross-agency forum for
health and housing issues, if that is the collective wish of the key stakeholders.

3.6 Revamped Business as Usual sore throat management services in primary and
community care
Although it is early days yet, the current rapid response clinic service may prove to be cost
ineffective in its current form. The service is more effective in the eastern BOP where it is
reaching into smaller communities that are medium to high risk through schools and general

                                                                                                 26
practice. The western BOP service is for a large population and geographical area, and is
still relying on families to access a centralised service in Tauranga city, even if free and out
of normal hours, which is unlikely to overcome the usual barriers to accessing primary health
care. A revamp of the rapid response clinic service is likely to be required, particularly in the
western BOP, based on services that are more accessible to at-risk populations. This could
include greater use of school nurses in primary, intermediate and secondary schools, and
pharmacies. Further work is required with PHOs and others to refine this service. The
intention is to establish this new service no later than 1 July 2016, and earlier if necessary.

                                                                                                  27
Section 4: Action plan for 2015/16 and subsequent years

4.0 Introduction
This section identifies detailed actions that BOPDHB will undertake to prevent the transmission of Group A streptococcal throat infections in
children and young people. Primordial prevention interventions will address housing conditions, general hygiene and skin infections. These
actions also fit with Toi Te Ora’s Goal 1: To reduce childhood admissions from ARF, respiratory and skin infections, each by 2/3rds in 5 years.
Please refer to the logic model diagram in Appendix 2.
N.B. This section is based on the content that was included in the original RFPP. Through the refresh progress, new or expanded actions
have then been developed for the 2015/16 and 2016/17 years leading up to the target assessment at 30 June 2017, and to 2017/18 and
beyond following that date. A lead person, agency or agencies are identified for each action, and a timeframe set for completion of that action.
This section can then be the basis for action reporting to the Ministry of Health.

        Section                                      Action                                      Lead agency                 Timeframe

4.1 Housing               Housing advocacy plan to be finalised and implemented.       Toi Te Ora Public Health       Q3-4 2015/16 and ongoing

                          Ongoing implementation of advocacy plan.                     Service

                          Housing report to be published on Toi Te Ora website         Toi Te Ora Public Health       Q3 2015/16
                                                                                       Service

                          Qualitative housing research report completed. Information   Toi Te Ora Public Health       Q3 2015/16 and ongoing

                          used for advocacy.

                                                                                                                                               28
Service

Housing workshop completed. Scope the potential to establish   Toi Te Ora Public Health       Q4 2015/16

a wider BOP housing forum                                      Service

                                                               Planning and Funding, BOPDHB

Ongoing review and monitoring of Healthy Homes Initiative      Planning and Funding, BOPDHB   Q1 2015/16 and ongoing

                                                               Sustainability Options Ltd

                                                               Tauranga Community Housing
                                                               Trust

MoH-funded programme continues until 31 December 2016.         Planning and Funding, BOPDHB   Q2 2016/17

Programme to continue beyond 1 January 2017, but in
modified form.

MoH/HPA ‘Key tips for a warmer, drier home’ toolkit promoted   Planning and Funding, BOPDHB   Q1 2015/16 and ongoing
and distributed to RF sector team and RF housing teams.
                                                               Sustainability Options Ltd
Toolkit includes messages for crowded whanau.
                                                               Tauranga Community Housing
                                                               Trust

                                                                                                                       29
Toi Te Ora Public Health
                                                              Service

Toi Te Ora and Pacific Islands Community (Tauranga)           Toi Te Ora Public Health      Q4 2015/16
Trust/EBPHA to promote Pacific resources and information as   Service
part of the wider RF awareness campaigns.

Toi Te Ora undertaking a revision of the ‘Our Home Our        Toi Te Ora Public Health      Q4 2015/16

Responsibility’ calendar.                                     Service

The MoH/HPA ‘Key tips for a warmer, drier home toolkit’
promoted and utilised.

New housing referral and assessment system in place from 1    Planning and Funding BOPDHB   Q2 2016/17

January 2017.

(Work with philanthropic sector, EECA, iwi Runanga, local     Planning and Funding BOPDHB   Q1 2015/16 and ongoing

authorities and insulation companies to develop community
healthy housing projects.) Dependent on national government
decisions on continuation of EECA funding from 1 July 2016.
Likely to focus on private rental accommodation only.

Continue to explore opportunities for working with iwi.

                                                                                                                     30
Hygiene messages promoted by CHWs in the throat swabbing          Throat swabbing project       Q1 2015/16 and ongoing
4.2 Improving general
hygiene in education     schools                                                           providers
settings

                         Hand and general hygiene awareness raising and education in       Toi Te Ora Public Health      Q1 2015/16 and ongoing

                         schools and ECEs.                                                 Service

                         Healthy skin / skin infection information promoted via website,   Toi Te Ora Public Health      Q1 2015/16 and ongoing
4.3 Reducing skin
infections in schools,   CHWs, newsletters                                                 Service
community and home
settings

                         Ongoing awareness raising via the rheumatic fever                 Toi Te Ora Public Health      Q3 2015/16 and ongoing
                         programme.                                                        Service

                                                                                           Throat swabbing project
                                                                                           providers

                         Finalise and disseminate skin infection report and implement      Planning and Funding BOPDHB   Q2 2015/16 and ongoing

                         the recommendations. Implement the recommendations of the
                                                                                           Toi Te Ora Public Health
                         PoPAG and skin infection reports.
                                                                                           Service

                         Annual trend monitoring of skin infections                        Toi Te Ora Public Health      Q3 2015/16 and annually in
                                                                                           Service                       2017 onwards

                                                                                                                                                  31
Ongoing funding of BOPDHB programmes will continue in           Planning and Funding BOPDHB   Q1 2015/16
4.4 Throat swabbing
programmes            (2015/16 and 2016/17.
                                                                                                                    Q1 2016/17
                      BOPDHB to pick up funding for Tuhoe programme from 1
                      January 2016.

                                                                                      Planning and Funding BOPDHB   Q3 2015/16

                      Ongoing funding of all school-based programmes will continue    Ministry of Health            Q1 2017/18
                      as long as evaluations and cost efficiency analysis
                                                                                      Planning and Funding BOPDHB
                      demonstrates benefit.

                      Feed back findings of MoH evaluations and analysis to primary   Planning and Funding BOPDHB   Q2 2015/16 and ongoing
                      and secondary care.

                      Promote and utilise MoH on-line tools and best practice         Toi Te Ora Public Health      Q3 2015/16
                      outlined in the New Zealand Primary Care Handbook.              Service

                      Rheumatic fever e-learning course promoted. CHWs to             EBPHA Rheumatic Fever Nurse
                      complete course as part of ongoing training.                    Coordinator

                                                                                      BOPDHB Rheumatic Fever
                                                                                      Clinical Champion

                      Support school-based swabbing programmes.                       EBPHA Rheumatic Fever Nurse   Q1 2015/16 and ongoing
                                                                                      Coordinator

                                                                                                                                             32
Review of first rapid response clinic initiatives, and seek quality   Planning and Funding BOPDHB   Q3 2015/16 and ongoing
                         improvements. Explore further options to make primary care
                                                                                               PHOs
                         more accessible and affordable e.g. drop in clinics, primary
                         care clinics attached to EDs, extended and weekend hours.

                         Develop a new programme to optimise access to free primary
                         care for sore throat management.

                         Yearly review and re-release (of a Rheumatic Fever                    Toi Te Ora Public Health      Q2 2015/16
4.5 Awareness raising
of sore throats,         awareness raising communication plan).                                Service
Rheumatic Fever and
its presentations, and   The 2015/16 campaign to complement national awareness
Rheumatic Heart          campaigns, messages and resources. Campaign to include a
Disease
                         focus on local Pacific Island communities.

                         Presentations and discussions with ED, Orthopaedics, adult            BOPDHB Rheumatic Fever        Q3 2015/16
                         medicine, primary care re 2014 NHF Guidelines.                        Clinical Champion

                         Incorporate 2014 RHD benchmarks from NHF into Bay                     BOPDHB Rheumatic Fever        Q2 2015/16
                         Navigator.                                                            Clinical Champion

                         The 2016/17 campaign to complement national awareness                 Toi Te Ora Public Health      Q4 2016/17
                         campaigns (if held), messages and resources. Campaign to              Service
                         include a focus on local Pacific Island communities.

                         Dissemination across BOP disciplines.

                                                                                                                                                      33
Development of early arthritis part of pathway to identify Septic   BOPDHB Rheumatic Fever            Q4 2015/16
                           Arthritis Acute Rheumatic Fever.                                    Clinical Champion

                           Dissemination across BOP disciplines

4.6 Delivery and           Register will be utilised by BOP DNS, paediatricians,               Planning and Funding BOPDHB       Q2 2015/16
monitoring of              cardiologists, physicians, Toi Te Ora.
                                                                                               Rotorua Area Primary Health
prophylactic antibiotics
                           Register implementation and utilisation for primary Bi-cillin       Services
                           purposes; note facility supporting cardiac care INR for cardiac
                           and echo appointments.                                              BOPDHB Rheumatic Fever
                                                                                               Clinical Champion

                                                                                               Clinical Nurse Manager District
                                                                                               Nursing Services

                           Handovers for Bi-cillin recipients of both Bi-cillin delivery and   Clinical Nurse Manager District   Q2 2015/16
                           cardiac care when moving between DHBs.                              Nursing Services

                           More frequent auditing to be undertaken once register is fully      Clinical Nurse Manager District   Q4 2015/16
                           functional.                                                         Nursing Services

                                                                                               Planning and Funding BOPDHB

                                                                                                                                              34
Introduce analgesia utilisation to help comfort and adherence   Clinical Nurse Manager District   Q4 2015/16
in western BOP.                                                 Nursing Services

                                                                BOPDHB Rheumatic Fever
                                                                Clinical Champion

Fully functioning RF clinical register across Lakes/ BOP.       Planning and Funding BOPDHB       Q1 2015/16

Continued funding and use of same.
                                                                Rotorua Area Primary Health
Register review to support cardiac care INR for cardiac and     Services
echo appointments.
                                                                BOPDHB Rheumatic Fever
                                                                Clinical Champion

Ongoing quality improvement in DNS services. Ongoing use of     Clinical Nurse Manager District   Q3 2015/16 and ongoing

register to improve timeliness of secondary prophylaxis.        Nursing Services

                                                                                                                           35
Any exceptions are followed up with notifying doctor                Toi Te Ora Public Health   Q1 2015/16 and ongoing
4.7 Notification of ARF
cases to the Medical                                                                           Service
                           Toi Te Ora analyst to compare hospitalisation figures with
Officer of Health (MOH)
                           notifications.

                           Root cause analysis reports completed for all notified ARF          Toi Te Ora Public Health   Q1 2015/16 and ongoing
4.8. Review of cases to
identify known risk        patients. Feedback provided if required.                            Service
factors and system
failure points

4.9 Other actions to       Review and improvements to pathway.                                 BOPDHB Rheumatic Fever     Q4 2015/16 and ongoing
facilitate the effective                                                                       Clinical Champion
follow-up of identified
                                                                                               Toi Te Ora Public Health
RF cases
                                                                                               Service

                           Distribution of dental pack to all Bicillin patients and selected   Toi Te Ora Public Health   Q3 2015/16 and ongoing
                           other priority risk groups through throat swabbing schools and      Service
                           rapid response clinics to be undertaken as funding allows for
                           replacement packs and packs for new patients.

                                                                                                                                                   36
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