Bay of Plenty and Lakes Rheumatic Fever Prevention Plan:

Transcription

1 Bay of Plenty and Lakes Rheumatic Fever Prevention Plan: Bay of Plenty DHB (refreshed as at 20 October 2015) Summary version 1

2 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

3 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 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

4 List of Abbreviations ARF BAU BOP BOPDHB BPS CHW CME/CNE CoBoP DNS EECA EBOP EBPHA GAS GP HNZ ICD codes INR MoH MOH NHF NMO Ltd PHN PHO PoPAG RAPHS RHD Toi Te Ora WBOP WBOPPHO WISH Acute Rheumatic Fever Business as Usual Bay of Plenty Bay of Plenty District Health Board Better Public Services Community Health Worker Continuing Medical Education/Continuing Nursing Education Collaboration Bay of Plenty District Nursing Service Energy Efficiency and Conservation Authority Eastern Bay of Plenty Eastern Bay Primary Health Alliance Group A Streptococcus General Practice / Practitioner Housing New Zealand International Classification of Disease codes International Normalisation Ratio (for use of warfarin anticoagulant) Ministry of Health Medical Officer of Health National Heart Foundation Nga Mataapuna Oranga Primary Health Organisation Public Health Nurse Primary Health Organisation Population Health Professional Advisory Group Rotorua Area Primary Health Services Rheumatic Heart Disease Toi Te Ora Public Health Service Western Bay of Plenty Western Bay of Plenty Primary Health Organisation Whakatohea Iwi Social and Health Services 4

5 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 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 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 schoolbased 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

6 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 The plan also signals the level of continuing preventive services to be provided from 1 July 2017 until June 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 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

7 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/ / / / / / /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 Bay of Plenty New Zealand 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/ /12 Baseline numbers (3-year average rate) 2012/13 Target: Remain at baseline level 2013/14 Target: 10% reduction from baseline level 2014/15 Target: 40% reduction from baseline level 2015 /16 Target: 55% reduction from baseline level 2016/17 Target: 2/3 reduction from baseline level Lakes Bay of Plenty New Zealand 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 Bay of Plenty New Zealand Total New Zealand Maori New Zealand Pacific

8 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 and 4 were <5 or >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 coordinate actions in each DHB plan to achieve DHB targets 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 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

9 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) 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

10 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 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 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

11 2.1 BOP and Lakes shared priorities 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

12 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 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 $ 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 preintervention period from 2000 to 2010, Maori children aged 5-14 had a ARF rate of 128.7/100,000 (95%CI ), and in the intervention period from 2011 to 2014, the rate was 50.7/100,000 (95%CI ). 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

13 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

14 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 swabs No of +ve swabs Positivity rate No of swabs No of +ve swabs Positivity rate No of swabs No of +ve swabs Positivity rate , % 7,095 1, % % , % 9,301 1, % % , % 6,017 1, % % ,734 1, % 13,104 1, % 1, % ,579 1, % 16,422 2, % 1, % 2015 to Sept 10, % 14,283 1, % 1, % 2010 to date 57,190 5, % 66,222 10, % 5,727 1, % The following graphs present the same data for the general practice swab testing results. 14

15 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

16 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 127 systems failure analysis reports completed 69 remembered having a sore throat 42 saw a health professional 31 got antibiotics 6 did not get right antibiotic (Intervention: more health professional education) 11 did not get antibiotics (Intervention: more health professional education) 27 did not see a health professional (Interventions: individual, whanau and community awareness raising/ improved access to primary care including rapid response clinics) 58 did not remember having a sore throat (Intervention: improving housing programme, echocardiographic screening?) 16

17 Analysis of BOP case review forms 2014/15 Unknown if completed course? did not complete course (intervention: improved adherence education) 1 got right antibiotic 7 (6 initial ARF and 1 recurrent) Case review reports completed 3 remembered having a sore throat (includes recurrent case) 1 saw a health professional (recurrent case) 1 got antibiotics 0 did not get right antibiotic (Intervention: more health professional education) 0 did not get antibiotics (Intervention: more health professional education) 2 did not see a health professional (Interventions: individual, whanau and community awareness raising/ improved access to primary care including rapid response clinics) 4 did not remember having a sore throat (Intervention: improving housing programme, echocardiographic screening?) 17

18 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/ / /18 + out years DHB funding (contracted) 851, , ,520 MoH funding (contracted) 430,375 98,875 0 Additional MoH funding (not contracted) 100,000# 331, ,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

19 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) Kawerau - EBPHA (expires 30/6/17) Murupara - Te Ika Whenua Hauora (expires 31/12/15) Tuhoe area# Tuhoe Hauora (expires 31/12/15) Tauranga area NMO Ltd (expires 30/6/16) 126, ,945 44, ,000* 75,713 75,75,71 #reassignment from Tuhoe Matauranga Trust to Tuhoe Hauora on 12 Oct 2015 *$65,000 from MoH to 31/12/1531/12/15 Community awareness raising Whakatane NASH (expires 30/6/16) 50,475 Rapid response clinics EBPHA (expires 30/6/16) WBOPPHO (expires 30/6/16) NMO Ltd (expires 30/6/16) 107, ,000 35,000 All providers funded by MoH to 30/06/16 Housing improvement initiatives Smart Energy Solutions Ltd (expires 30/6/16) Sustainability Options Ltd (expires 31/12/16) Tauranga Community Housing Trust (expires 31/12/16) 50,000 77,687# 77,688# Laboratory testing Laboratory costs (Part of PathLab bulk funding agreement) 185,000 P #Providers funded by MoH to 31/12/16 MoH 31 /12/1 Coordination and governance Additional funding to Toi Te Ora-Public Health Service through PV Schedule 85,000 Clinical quality assurance of swabbing programmes EBPHA (expires 30/6/17) Funded by DHB to provide quality assurance across all school-based throat swabbing programmes. Funded by DHB through EBPHA to provide quality assurance across all throat swabbing programme.50 Register ongoing costs Rotorua Area Primary Health Services (expires 30/6/16) 40, ,000 Funded Ff.50 District nursing support BOPDNS through PV Schedule 60,409 Total 1,381, 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

20 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

21 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 Kawerau area EBPHA Murupara area Te Ika Whenua Hauora Tuhoe area# Tuhoe Hauora Tauranga area NMO Ltd 126, ,945 44, ,000 75,713 75,75,71 No change from 2015/16 other than any cost efficiencies /12/15 Community awareness raising Whakatane- NASH 50,475 No change from 2015/16 Rapid response clinics Revamp of services towards Business as Usual within primary and community care 135,123 Costs reduced from $245,000 in 2015/16 Housing improvement initiatives Smart Energy Solutions Ltd Sustainability Options Ltd Tauranga Community Housing Trust Healthy home programme coordination service 50,000 49,437# 49,437# 40,000,00077,6871 Laboratory testing Laboratory costs 185,000 #Providers funded by MoH to 31/12/16 at $49,437 each for 6 mths. Development of new service from 1/01/17 Development of new service from 1/01/1evelopm service from 1/01/17$98,875at $MoH 31 /12/1 No change from 2015/16, although savings will be sought if swabbing numbers reduce. Coordination and governance Additional funding to regional PHU (excludes associated skin and respiratory disease funding) 85,000 No change from 2015/16 Clinical quality assurance of swabbing programmes EBPHA.50 40, Register ongoing costs Rotorua Area Primary Health Services 14,000 No change from 2015/16.50 No change from 2015/16 District nursing support BOPDNS 60,409 No change from 2015/16 Total 1,255, 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

22 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

23 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 Kawerau area EBPHA Murupara area Te Ika Whenua Hauora Tuhoe area# Tuhoe Hauora Tauranga area NMO Ltd 126, ,945 44, ,000 75,713 75,75,71 No change from 2016/17 other than any cost efficiencies /12/15 Revamped Business as Usual sore throat management services within primary and community care 135,123 No change from 2016/17 Housing improvement initiatives Home insulation provider Healthy home programme coordination service 50,000 80, ,6871 Laboratory testing Laboratory costs 185,000 Register ongoing costs Rotorua Area Primary Health Services 14,000 No change from 2016/17 Development of new service from 1/01/17 Development of new98,875at $MoH 31 /12/1 No change from 2016/17, although savings will be sought if swabbing numbers reduce. No change from 2015/16 District nursing support BOPDNS 60,409 No change from 2015/16 Total 1,020, 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

24 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: 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 socioeconomic 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 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 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

25 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 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

26 The Ministry of Health Healthy Homes Initiative programme ceases at 31 December 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 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 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

27 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

28 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. Ongoing implementation of advocacy plan. Toi Te Ora Public Health Service Q /16 and ongoing Housing report to be published on Toi Te Ora website Toi Te Ora Public Health Service Q3 2015/16 Qualitative housing research report completed. Information used for advocacy. Toi Te Ora Public Health Q3 2015/16 and ongoing 28

29 Service Housing workshop completed. Scope the potential to establish a wider BOP housing forum Toi Te Ora Public Health Service Planning and Funding, BOPDHB Q4 2015/16 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 Programme to continue beyond 1 January 2017, but in modified form. Planning and Funding, BOPDHB Q2 2016/17 MoH/HPA Key tips for a warmer, drier home toolkit promoted and distributed to RF sector team and RF housing teams. Toolkit includes messages for crowded whanau. Planning and Funding, BOPDHB Sustainability Options Ltd Tauranga Community Housing Trust Q1 2015/16 and ongoing 29

30 Toi Te Ora Public Health Service Toi Te Ora and Pacific Islands Community (Tauranga) Trust/EBPHA to promote Pacific resources and information as part of the wider RF awareness campaigns. Toi Te Ora Public Health Service Q4 2015/16 Toi Te Ora undertaking a revision of the Our Home Our Responsibility calendar. The MoH/HPA Key tips for a warmer, drier home toolkit promoted and utilised. Toi Te Ora Public Health Service Q4 2015/16 New housing referral and assessment system in place from 1 January Planning and Funding BOPDHB Q2 2016/17 (Work with philanthropic sector, EECA, iwi Runanga, local authorities and insulation companies to develop community healthy housing projects.) Dependent on national government decisions on continuation of EECA funding from 1 July Likely to focus on private rental accommodation only. Continue to explore opportunities for working with iwi. Planning and Funding BOPDHB Q1 2015/16 and ongoing 30

31 4.2 Improving general hygiene in education settings Hygiene messages promoted by CHWs in the throat swabbing schools Throat swabbing project providers Q1 2015/16 and ongoing Hand and general hygiene awareness raising and education in schools and ECEs. Toi Te Ora Public Health Service Q1 2015/16 and ongoing 4.3 Reducing skin infections in schools, community and home settings Healthy skin / skin infection information promoted via website, CHWs, newsletters Toi Te Ora Public Health Service Q1 2015/16 and ongoing 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 PoPAG and skin infection reports. Toi Te Ora Public Health Service Annual trend monitoring of skin infections Toi Te Ora Public Health Service Q3 2015/16 and annually in 2017 onwards 31

32 4.4 Throat swabbing programmes Ongoing funding of BOPDHB programmes will continue in (2015/16 and 2016/17. BOPDHB to pick up funding for Tuhoe programme from 1 Planning and Funding BOPDHB Q1 2015/16 Q1 2016/17 January 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 demonstrates benefit. Planning and Funding BOPDHB 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

33 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 more accessible and affordable e.g. drop in clinics, primary PHOs care clinics attached to EDs, extended and weekend hours. Develop a new programme to optimise access to free primary care for sore throat management. 4.5 Awareness raising of sore throats, Rheumatic Fever and its presentations, and Rheumatic Heart Disease Yearly review and re-release (of a Rheumatic Fever awareness raising communication plan). The 2015/16 campaign to complement national awareness campaigns, messages and resources. Campaign to include a focus on local Pacific Island communities. Toi Te Ora Public Health Service Q2 2015/16 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

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

35 Introduce analgesia utilisation to help comfort and adherence in western BOP. Clinical Nurse Manager District Nursing Services Q4 2015/16 BOPDHB Rheumatic Fever Clinical Champion Fully functioning RF clinical register across Lakes/ BOP. Continued funding and use of same. Register review to support cardiac care INR for cardiac and echo appointments. Planning and Funding BOPDHB Rotorua Area Primary Health Services BOPDHB Rheumatic Fever Clinical Champion Q1 2015/16 Ongoing quality improvement in DNS services. Ongoing use of register to improve timeliness of secondary prophylaxis. Clinical Nurse Manager District Nursing Services Q3 2015/16 and ongoing 35

36 4.7 Notification of ARF cases to the Medical Officer of Health (MOH) Any exceptions are followed up with notifying doctor Toi Te Ora analyst to compare hospitalisation figures with notifications. Toi Te Ora Public Health Service Q1 2015/16 and ongoing 4.8. Review of cases to identify known risk factors and system failure points Root cause analysis reports completed for all notified ARF patients. Feedback provided if required. Toi Te Ora Public Health Service Q1 2015/16 and ongoing 4.9 Other actions to facilitate the effective Review and improvements to pathway. BOPDHB Rheumatic Fever Clinical Champion Q4 2015/16 and ongoing follow-up of identified RF cases Toi Te Ora Public Health 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

37 4.10 Interventions for patients who do not have established RHD Implementation and review of a treatment plan for patients who do not have established (or documented) rheumatic heart disease. BOPDHB Rheumatic Fever Clinical Champion Q4 2015/16 and ongoing 4.11 Interventions for patients who do have established RHD Incorporation of NHF guideline on follow up to Bay Navigator pathway development. Register use of this. BOPDHB Rheumatic Fever Clinical Champion Q4 2015/16 and ongoing 37

38 Appendix 1 - Stakeholders Stakeholders BOP/ Lakes Rheumatic Fever Steering Group BOPDHB Planning and Funding and paediatrics teams Lakes DHB Planning and Funding and paediatrics teams BOPDHB Māori Health Planning and Funding team Lakes DHB Māori Health team Toi Te Ora - Public Health Service Eastern Bay Primary Health Alliance Korowai Aroha Rotorua Ngati Awa Social and Health Services Rotorua Area Primary Health Services (RAPHS), Te Ika Whenua Hauora Tuhoe Hauora Te Manu Toroa (Nga Mataapuna Oranga PHO) Whakatohea Iwi Social and Health Services BOP/ Lakes Rheumatic Fever Sector Group Eastern Bay PHA Toi Te Ora - Public Health Service Korowai Aroha Rotorua Ngati Awa Social and Health Services Te Ika Whenua Hauora Tuhoe Hauora Te Manu Toroa (Nga Mataapuna Oranga PHO) Whakatohea Iwi Social and Health Services Māori Health Services Lakes DHB Māori Health team BOPDHB Māori Health Planning and Funding team BOPDHB Regional Māori Health Services Te Puni Kokiri Housing Sector Smart Energy Solutions Ltd Sustainability Options Ltd Tauranga Community Housing Trust Eastern Bay Energy Trust Tauranga Electricity Community Trust BayTrust Ministry of Health Ministry of Social Development Housing New Zealand Population Health Professional Advisory Group (PoPAG) BOP Child and Youth Strategic Alliance BOPDHB and Lakes DHB cardiologists and echocardiography services 38

39 Appendix 2 Logic model for Toi Te Ora Goal 1: Reduce childhood admissions from ARF, respiratory and skin infections, each by 2/3rds in 5 years 39