Bay of Plenty and Lakes Rheumatic Fever Prevention Plan:

Transcription

1 Bay of Plenty and Lakes Rheumatic Fever Prevention Plan: Bay of Plenty DHB

2 It is our attitude at the beginning of a difficult undertaking which, more than anything else, will determine its successful outcome. William James (American psychologist, philosopher and physician) 2

3 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. This has not gone unnoticed, and there have been many voices calling for change and initiative to reduce the rates. In the past few years there has been a growing consensus that a national approach is needed. Led by the Heart Foundation, there has been a pulling together of the literature, development of guidelines and now a clear cross-departmental Government target. Bay of Plenty and Lakes DHBs have led and funded a programme to reduce rheumatic fever, working closely with affected communities. There is greater awareness, established school-based services, and a core of committed staff and community leaders. There are, however still far too many children affected: we need to see a step change in addressing this illness. The Health sector is now firmly in the lead, and will need to both build on existing endeavours, and encourage entirely new approaches to reach our goal. There is now wide determination to see fewer children and young people damaged by this preventable disease. The Better Public Services target for acute rheumatic fever reduction will be very difficult to achieve, but that very challenge will drive new approaches, new partnerships among agencies and communities, and changes to services. I am encouraged to see the beginning of this change outlined in this plan. Continuing to accept a small but steady number of ill children every year is not an option. Dr Jim Miller Chair Bay of Plenty and Lakes Rheumatic Fever Steering Group. 3

4 Bay of Plenty DHB rheumatic fever prevention plan sign-off This document has been reviewed and accepted as the formal Bay of Plenty DHB Rheumatic Fever Prevention Plan for implementation in terms of content and sign off by: Name: Phil Cammish Chief Executive Bay of Plenty DHB 07/10/2013 Signature 4

5 Table of Contents Foreword... 3 Table of Contents... 5 List of Abbreviations... 9 Section 1: Overview of rheumatic fever in Bay Of Plenty and Lakes District Health Boards (DHBs) Background Purpose of the plan BOP and Lakes DHBs a shared approach Structure of the plan Commitment to reducing rheumatic fever in the BOP and Lakes DHBs Table 1: Acute rheumatic fever initial hospitalisation target rates per year for Lakes and BOPDHBs (per 100,000 total population), 2012/13 to 2016/ Table 2: Acute rheumatic fever initial hospitalisation target numbers per year for Lakes and BOP DHBs (total population), 2012/13 to 2016/ Stakeholder input and engagement Local stakeholders Local Māori communities Rheumatic fever champions Lakes DHB BOPDHB Section 2: Overarching actions to reduce the incidence of rheumatic fever in the BOP and Lakes districts Overview of the prevention of ARF and RHD

6 2.1 BOP and Lakes shared priorities Section 3: Investment in reducing rheumatic fever BOPDHB resources committed to reducing rheumatic fever 2013/ Table 3: BOPDHB resources committed to reducing rheumatic fever 2013/ BOPDHB investment beyond 2013/14, including new initiatives Table 4: Breakdown of targetted project costs over the period 2013/14 to 2016/17 and beyond BOPDHB sustainability beyond June Section 4: Actions to prevent the transmission of Group A streptococcal throat infections Introduction Housing Improving general hygiene in education settings Reducing skin infections in schools, community and home settings Section 5: Actions to treat Group A streptococcal throat infections quickly and effectively Introduction Throat swabbing programmes Primary care and sore throat management guidelines Awareness raising Section 6 : Actions to facilitate the effective follow-up of identified rheumatic fever cases Introduction Delivery and monitoring of prophylactic antibiotics

7 6.2 Notification of ARF cases to the Medical Officer of Health (MOH) Review of cases to identify known risk factors and system failure points Other actions to facilitate the effective follow-up of identified RF cases Section 7: Actions to facilitate the effective follow-up of patients with rheumatic heart disease Introduction Interventions for patients who do not have established RHD Interventions for patients who do have established RHD Section 8: Summary of the Rheumatic Fever Prevention Plan Table 5: Summary of Rheumatic Fever Prevention Plan Appendix 1- Rheumatic Fever Hospitalisation Rates Bay of Plenty and Lakes District Health Boards, Appendix 2 - Stakeholders Appendix 3 Logic model for Toi Te Ora Goal 1: Reduce childhood admissions from ARF, respiratory and skin infections, each by 2/3rdc in 5 years Appendix 4 Overview of BOP rheumatic fever agencies Appendix 5 - Lists of schools, decile rating and rolls in the BOPDHB funded throat swabbing programmes Appendix 6 - Lists of schools, decile rating and rolls in the Ministry of Health funded throat swabbing programmes Appendix 7 Reporting framework References

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9 List of Abbreviations ARF Acute Rheumatic Fever BAU BOP BOPDHB BPS CHW CME/CNE CoBoP DNS EECA EBOP EBPHA GAS GP HNZC HSL ICD codes MoH MOH PHN PHO PoPAG RAPHS RHD Toi Te Ora WBOP WISH 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 Corporation HealthShare Limited International Classification of Disease codes Ministry of Health Medical Officer of Health 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 Whakatohea Iwi Social and Health Services 9

10 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 at various stages of implementation. Ministry of Health funded projects were 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. Actions have been started in the following areas: 1. raising public awareness that sore throats matter 2. continuing professional development for health professionals 3. school-based swabbing campaigns 4. improving notification of new cases 5. improving case management, including developing a rheumatic fever register across Lakes and BOP DHBs 6. enhanced surveillance and analysis of cases A range of positive results have been demonstrated. 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 Lakes district; improved notification; and school-based throat swabbing programmes that are operating to agreed protocols, having gained the support of local communities. 1.1 Purpose of the plan The purpose of this plan is 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 The plan also aims to minimize the impact of rheumatic fever and rheumatic heart disease (RHD) in the population served by BOP and Lakes DHBs. 10

11 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 Structure of the plan The first two sections outline the shared approach taken by BOP and Lakes DHBs: Section 1: Presents the background, purpose and structure of the plan. This is followed by a commitment to reducing rheumatic fever, increasing stakeholder input and the role of the rheumatic fever champions. Section 2: Summarises the overarching actions to reduce the incidence of rheumatic fever. The following sections are BOPDHB specific: Section 3: Investment in reducing rheumatic fever Section 4: Actions to prevent the transmission of Group A streptococcal throat infections Section 5: Actions to treat Group A streptococcal throat infections quickly and effectively Section 6: Actions to facilitate the effective follow-up of identified rheumatic fever cases Section 7: Actions to facilitate the effective follow-up of patients with rheumatic heart disease Section 8: Summary of the Rheumatic Fever Prevention Plan 11

12 1.4 Commitment to reducing rheumatic fever in the BOP and Lakes DHBs 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 Midland and National targets. i 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/ / /13 Target: 2013/14 Target: 2014/15 Target: 2015 /16 Target: 2016/17 Target: Baseline Remain at 10% 40% 55% 2/3 rate (3-year average rate) baseline level reduction from baseline level reduction from baseline level reduction from baseline level reduction from baseline level Lakes Bay of Plenty Midland region 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 Midland region New Zealand For a detailed breakdown of the Rheumatic Fever Hospitalisation Rates in the Bay of Plenty and Lakes DHBs from , refer to Appendix 1. 12

13 1.5 Stakeholder input and engagement Local stakeholders Local stakeholders have had input to the plan primarily via the BOP and Lakes rheumatic fever steering group, which has met quarterly since The steering group members include representatives from BOPDHB and Lakes DHB Planning and Funding and paediatric teams, Toi Te Ora - Public Health Service (Toi Te Ora), Primary Health Organisations including Eastern Bay PHA (EBPHA), Rotorua Area Primary Health Services (RAPHS), and contracted providers Korowai Aroha, Whakatohea Iwi Social and Health Services (WISH), Te Ika Whenua Hauora, Te Kaokao o Takapau, Ngati Awa Social and Health Services (NASH) and Te Manu Toroa. Please refer to Appendix 3 for a full list of stakeholders. Toi Te Ora offered to co-ordinate the preparation of a shared plan for BOP and Lakes DHBs. This was discussed and agreed to at the rheumatic fever steering group meeting held on 22 February Draft versions of the plan have been sent to the steering group for comment and input. Iwi/Māori consultation is critical because of the over-representation of Māori in rheumatic fever incidence in the BOP and Lakes. Iwi/Māori input to this plan has been organised through the Lakes DHB Māori Health team, BOPDHB Māori Health Planning and Funding team, and BOPDHB Regional Māori Health Services. The Pacific population is relatively small in the Bay of Plenty, which is reflected in the small number of cases of ARF reported. The issue has been raised with the BOPDHB s Pacific Advisory Group, which has provided insight into how services can be best delivered to the Pacific population. A key aim of this plan is to reduce the health inequalities arising from the impact of ARF and RHD in the Bay of Plenty and Lakes DHBs. The BOPDHB Board is committed to implementing the plan Local Māori communities Experience has shown that driving change through community ownership requires active engagement and participation of iwi, hapu and whānau. Community presentations and lengthy discussions preceded the establishment of each of the DHB-funded school-based programmes. 13

14 Draft versions of this plan were sent to the rheumatic fever sector group this is comprised of the community health workers from each of the throat swabbing programmes in Opotiki, Kawerau, Murupara, Taneatua, Whakatane and Tauranga in the BOP and Rotorua in Lakes. The sector group s on-going engagement will be supported via active feedback into the plan, and by aiming to make the plan responsive and relevant to the work that they are undertaking. Whānau Ora will play a key role in raising community awareness, along with DHB contracts in aligning key social sector initiatives to improve housing and increase access to primary health services. A focus on health literacy with hapu and whānau/fanau in relation to rheumatic fever through a community engagement/response model is key if we are to contribute to the reduction in ARF rates in Māori and Pacific young people. Ongoing, active participation will be sought as the plan is implemented. 1.6 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 Midland DHBs, to drive and coordinate actions in each DHB plan and Midland Regional Services Plan to achieve DHB and Midland targets. HealthShare Limited (HSL), the Midland shared service agency, will bring together all the Midland Champions regionally 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. Sally Hutton (rheumatic fever co-ordinator) is the champion for continuous monitoring and performance of prophylaxis care, interlinking primary and secondary health care services 14

15 and assisting in the transition from child to adult care for rheumatic fever patients throughout Lakes DHB BOPDHB Jeff Hodson (General Manager Property Services) and Pamela Barke (Nurse Leader Regional Community Services) are the rheumatic fever champions for the BOPDHB. Jeff s appointment is seen as an innovative and complementary approach to other Midland DHBs as Jeff brings building expertise to help address housing issues. For example as part of the Warm Up NZ: Healthy Homes the BOPDHB will work with EECA, authorised home insulation providers and third party funders with an aim to insulate up to 1,000 homes in the BOP each year for the next three years. 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 and the Māori Health Action Plan targets. The district nurses also provide education and facilitate follow up care for patients with a diagnosis of rheumatic fever and/or rheumatic heart disease (RHD). 15

16 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 (primarily Māori and Pacific peoples) by two thirds by 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. ii BOP and Lakes DHBs will undertake interventions aimed at preventing the transmission of Group A streptococcal throat infections. Primary prevention: Reducing GAS transmission, acquisition, colonisation and carriage or treating GAS infection effectively to prevent the development of ARF in individuals. ii BOP and Lakes interventions will be aimed at 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. ii 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. 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 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 16

17 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 overcrowding 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 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. 17

18 Section 3: Investment in reducing rheumatic fever 3.1 BOPDHB resources committed to reducing rheumatic fever 2013/14 The BOPDHB has planned for the following investment to be made in reducing rheumatic fever in 2013/14 (GST exclusive). Table 3: BOPDHB resources committed to reducing rheumatic fever 2013/14 Initiatives Cost $ Staffing FTE School-based throat swabbing programmes Opotiki area Kawerau area Murupara area Tuhoe area# 119, ,340 44, , Community awareness raising/opportunistic swabbing Whakatane area# Tauranga area# 58,000 75, Housing insulation initiatives Agreement with Smart Energy Solutions Ltd 50, Laboratory testing Laboratory costs 187,100 Coordination and governance Additional funding to regional PHU (excludes associated skin and respiratory disease funding) 85,000 Clinical quality assurance of swabbing programmes Agreement with EBPHA.50 Register establishment and ongoing costs Agreement with Rotorua Area Primary Health Services (estimated) 40, , Total 932, # indicates Ministry of Health funding The BOPDHB has not included 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. Toi Te Ora Public Health Services Medical Officer of Health time, and Communicable Diseases Nurse time in actual case management. Also not included are costs within general practice, or District Nursing Services. 3.2 BOPDHB investment beyond 2013/14, including new initiatives The BOPDHB intends to continue funding the following programmes during the period from 2014/15 to 2016/17. 18

19 Opotiki, Kawerau, Murupara and Tuhoe school-based throat swabbing programmes Clinical quality assurance agreement with EBPHA Coordination and governance through Toi Te Ora - Public Health Service Laboratory costs (seeking to reduce these in 2013/14) Register ongoing costs Housing insulation initiative depending on other third party funding contributions The BOPDHB will need to enter into negotiations with the Ministry on the on-going funding of the two community awareness raising/opportunistic swabbing projects beyond June These programmes should be able to be scaled down over time as the community gains a better understanding of the key health messages around acute rheumatic fever prevention, and families access general practice more if their child has a sore throat. The timing of that reduction in direct service provision, and the development of a new service specification during that period, is critical. Consideration could also be given to focusing more on High School students (years 9-13). 19

20 Table 4: Breakdown of targetted project costs over the period 2013/14 to 2016/17 and beyond Service component 2013/ / / /17 Sustainable $ $ $ $ $ Four School-based throat swabbing programmes 397, , , , ,599 Community awareness raising programmes 133, , , ,000 50,000 Laboratory costs 187, , , , ,000 Quality assurance 40,180 40,180 40,180 30,000 20,000 Coordination and governance 104,000 85,000 75,000 75,000 30,000 Register establishment 40,000 30,000 30,000 30,000 30,000 Development of innovative 0 50, , ,000 50,000 approaches to improve access via routine general practice and child and youth health services Housing insulation / overcrowding programmes 50,000 50,000 50,000 50,000 TOTAL 951, , , , ,599 These costs (at 2013 $) reflect additional costs within the BOP for conducting a comprehensive and integrated rheumatic fever prevention programme on top of what has been traditional practice within Business As Usual (BAU). These costs do not therefore include: BOPDHB Planning and Funding commissioning costs, cost of antibiotics etc PHO data analysis and evaluation costs District nursing service secondary prevention prophylaxis costs Toi Te Ora Public Health Services Medical Officer of Health and Communicable Disease Nurses costs for follow up of newly notified cases Costs within general practice including associated laboratory costs. Any demographic growth or cost pressure funding in the future. Assumptions made: Existing school-based throat swabbing programmes continue until national criteria for ceasing them are determined. No further school-based throat swabbing programmes are initiated. Community awareness raising work outside of communities served by a full school-based swabbing programme continues but is reduced in scale as the community takes on the key messages, and more is done cost effectively at national level in terms of use of national media and resources. Laboratory costs are reduced, initially on a per test basis, and later as community carriage rates drop where school-based programmes have involved intensive use of antibiotics. Quality assurance costs drop as programmes become BAU and national consistency approach take effect. Coordination and governance costs drop as work becomes BAU. Register costs based on initial set-up costs plus ongoing annual fees. Where year-on-year savings are made, these are put into the development of innovative approaches to improve access via routine general practice and child and youth health services. 20

21 In addition a further $99,750 MoH funding is available for the period from 1 July 1013 to December Negotiations will be conducted with the Ministry of Health to determine how best to utilise this funding, For the purposes of this plan, the funding is shown as being used to continue community awareness raising programmes in the 2014/15 year. 3.3 BOPDHB sustainability beyond June 2017 The question of when school-based throat swabbing programmes should cease has not been resolved. The long-term programme at Whangaroa which began in February 2002 has not yet been stopped, eleven years later. The earliest programme in the BOP started in Opotiki in October 2009, and will have been operating for almost 8 years by June It is too early to say what the BOPDHB intends to do with sustainability funding for these programmes, as that will largely be determined by the success in achieving the BPS target, and national decisions on when such programmes should be ceased. However, when the BOPDHB started funding the programmes in Opotiki, Kawerau and Murupara, it acknowledged that it was in for the long haul, and this type of programme could not be ceased after a few years. 21

22 Section 4: Actions to prevent the transmission of Group A streptococcal throat infections 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 Housing Housing is recognised as a key determinant of health. iii Rheumatic fever is associated with exposure to household crowding. Although the evidence is not strong, the suggested mechanism is that overcrowding leads to an increased risk of GAS pharyngitis. iv Functional overcrowding often occurs in poorly insulated and heated homes where residents tend to occupy fewer and smaller rooms that are easier to heat. Key objective Intervention Actions Year /14 Year /15 Develop systems to ensure that families with children at high risk of ARF living in crowded housing are identified and appropriately Stocktake of housing in the Bay of Plenty and Lakes DHBs Toi Te Ora will undertake a scoping exercise to define and describe the size and extent of the housing situation in the BOP/ Lakes This will include an analysis of information on housing stock and overcrowding (both structural and functional), Use the information for action and advocacy on housing improvement Year /16 Year /17 Stakeholders Ongoing Ongoing Toi Te Ora, BOPDHB, Lakes DHB, District and Regional Councils HNZC EECA Insulation companies Measured by Stocktake results provide a benchmark to monitor effectiveness of interventions. 22

23 Key objective Intervention Actions Year /14 Year /15 referred to local housing and /or social services for follow-up & intervention The 2013 Census data will be used (available March 2014) to obtain information on housing in the BOP/ Lakes particularly in areas with high rates of rheumatic fever Year /16 Year /17 Stakeholders Measured by Develop referral pathways and systems The scoping exercise will provide information to help identify children at high risk of ARF and provide information for action and advocacy Develop referral pathways from health services to local housing and/or social services for follow up and intervention Effective relationships maintained with Collaboration Bay of Plenty (CoBOP), Work and Income and HNZC to facilitate referrals and prompt solutions to housing problems Identify appropriate providers (e.g. curtain banks) to refer families to. Work with the CHWs in RF programmes and their respective communities to identify at risk children and families. Referral pathways implemented and monitored to ensure both process and interventions are effective Ongoing review and monitoring Ongoing CoBOP partnerships including HNZC, Work and Income, Regional and District Councils. Bay of Plenty DHB Toi Te Ora CHWs and respective communities Numbers of families referred to HNZC, Work and Income and other agencies Referral pathways/pro tocols in place in primary and secondary care providers 23

24 Key objective Intervention Actions Year /14 Year /15 Develop effective healthy homes programmes Strengthen referral pathways in the school based sore throat swabbing programme Utilise Jeff Hodson (BOPDHB) as rheumatic fever champion to bring building expertise to housing interventions Warm Up NZ: Healthy Homes. BOPDHB to actively seek funding partners (on top of funding from the DHB itself) to insulate up to 1,000 homes in the BOP each year for the next 3 years. Eligibility includes householders with one or more children under 17 yrs who have specified health conditions Ongoing funding / insulation of houses under Warm Up NZ Healthy Homes Explore how to make services sustainable in the medium and long term Year /16 Ongoing Ongoing Year /17 Ongoing Ongoing Stakeholders BOPDHB, insulation and heating companies, third party funders including: private businesses, charitable trusts, energy trusts, District and Regional Councils, Toi Te Ora, HNZC, EECA. Measured by Presentations to potential funding partners Funding partners confirmed Number of homes retrofitted in the DHB district. Develop a generic proposal and presentation to be used to approach funders Liaise with national coordination, health promotion, communication, evaluation and research services. 24

25 Key objective Intervention Actions Year /14 Year /15 Work in partnership with Iwi Māori to improve housing Promote appropriate health messages for overcrowded whānau Identify key Iwi Runanga and Māori land trusts to engage and partner with and support awareness around rheumatic fever and improving housing Develop effective messages and utilise health literacy methods through a community engagement / response model Year /16 Year /17 Stakeholders Ongoing Ongoing Ongoing Iwi organisations, BOPDHB, Toi Te Ora Promote messages as part of awareness raising campaigns Ongoing Ongoing Toi Te Ora, Health Promotion Agency (national messaging), CHWs Measured by Number of meetings Iwi Runanga and Māori land trusts support for programmes Public awareness campaign reporting on quarterly basis Work alongside the Pacific Island community Evaluate the effectiveness of the Our Home Our Responsibility calendar used in the EBOP housing pilot Pacific Island utilise fono and Pacific Island workforce and community for raising awareness and improving housing Evaluation report completed by March 2014 Implement calendar as part of housing interventions if evaluation shows it to be effective and sustainable. Ongoing Ongoing Ongoing Pacific Island community organisations, e.g. Pacific Advisory Group, Pacific Island Community Tauranga Trust (PICTT) Pacific awareness campaign reporting on quarterly basis Implement plan Ongoing Ongoing Toi Te Ora Evaluation report Implementation of plan 25

26 4.2 Improving general hygiene in education settings The spread of Group A streptococcal throat infections can be reduced by promoting good hygiene practices in education settings. This combined with the early identification and treatment of Group A streptococcal throat infections is key to reducing the spread. Key objective Intervention Actions Year /14 Year /15 To reduce the spread of Group A streptococcal throat infections by promoting good hygiene practices Targeted communications on general and hand hygiene, cough/sneeze etiquette Identify primary schools with substandard hand washing facilities and develop a joint plan to improve hygiene in these schools Work with Ministry of Education at regional and DHB level to progressively improve hygiene conditions in schools Key hand hygiene messages will be promoted to schools and Early Childhood Education settings Hand hygiene resources will be available to reinforce key messages Relationship with Ministry of Education (MoE) developed at DHB regional level Joint plan completed with MoE to identify schools Include the use of the Ministry of Health hand washing guideline/protocols in higher priority schools, i.e. all schools with throat swabbing and community awareness programmes funded by BOPDHB or MoH Year /16 Year /17 Stakeholders Ongoing Ongoing Ongoing School and Early Childhood Education communities (staff, children, parents, whānau), Toi Te Ora, PHNs, CHWs Schools assessed and identified with substandard hand washing facilities Improvements are made in schools with substandard hand washing facilities Ongoing School communities (staff, children, parents, whānau), Toi Te Ora, MoE, PHNs Ongoing Ongoing Ongoing School communities (staff, children, parents, whānau), Toi Te Ora, MoE, PHNs Measured by Improving general hygiene report on a quarterly basis Number of schools assessed and referred to MoE Number of schools where improve-ments made Number of schools using hand washing guideline/ protocols Reduction in number of GAS positive siblings of positive cases 26

27 Key objective Intervention Actions Year /14 Year /15 Promote the cobenefits of hand hygiene in reducing other infectious illness e.g. gastroenteritis, colds and influenza and skin infections Promote healthy communal living habits in homes and schools Year /16 Year /17 Stakeholders Ongoing Ongoing Ongoing Well Child/Tamariki Ora providers, PHNs, Hauora providers, Pacific Islands Community (Tauranga) Trust, GPs, Accident and Emergency Departments in hospitals and community Measured by Reduction in relevant Ambulatory Sensitive Hospitalisation conditions 4.3 Reducing skin infections in schools, community and home settings Serious skin infections are a major cause of avoidable hospitalisations in New Zealand. Whilst ARF is most frequently associated with Group A streptococcal throat infections, there is some evidence that children with streptococcus pyogenes skin infections e.g. impetigo, may also be at risk of rheumatic fever. v Consequently, it may be beneficial to reduce the burden of bacterial skin infections in the Bay of Plenty. Key objective Intervention Actions Year /14 Year /15 Year /16 Year /17 Stakeholders Measured by To Increase awareness of the early detection, intervention and treatment of skin infections in the Bay of Plenty Undertake community awareness raising campaigns to increase understanding of skin infection prevention and management Develop skin infection communications plan Undertake awareness campaign Promote Toi Te Ora skin infection webpages and resources Ongoing Ongoing Ongoing Public Health Nurses, B4 School Nurses, whānau ora collectives Early Childhood Education centres, PoPAG, BOPDHB Planning and Funding, Toi Te Ora, EBPHA, paediatricians / secondary care services Campaign evaluation Number/rates of Skin infection admissions 27

28 Key objective Intervention Actions Year /14 Year /15 Year /16 Year /17 Stakeholders Measured by Improve responsiveness and effectiveness of primary and community health services in preventing and managing skin infections in the community Promote the Bay Navigator skin infection pathway to health professionals Support innovative projects e.g. the Kawerau cellulitis prevention/kiri Ora pilot project Ongoing Ongoing Ongoing PoPAG, BOPDHB GP Liaison, paediatricians/ secondary care services, Toi Te Ora, EBPHA, Audit of Bay Navigator pathway use Admission rates Support the joint BOP and Lakes Population Health Professional Advisory Group (PoPAG) to develop a five year plan to address skin infection prevention (including 2013/14 activity) Report to PoPAG to summarise previous interventions. Repeat the 2010/11 analysis of admissions to BOPDHB hospitals for skin infections using ICD coding to inform PoPAG plan Establish annual trend monitoring Annual trend monitoring of skin infections Annual trend monitoring of skin infections Ongoing PoPAG, BOP and Lakes DHBs Planning and Funding, Toi Te Ora, EBPHA, paediatricians / secondary care services PoPAG reports Annual trend monitoring 28

29 Section 5: Actions to treat Group A streptococcal throat infections quickly and effectively 5.0 Introduction This section will focus on primary prevention actions to treat Group A streptococcal throat infections quickly and effectively in the school-based throat swabbing programme areas and in primary care. Awareness raising will also be covered. 5.1 Throat swabbing programmes BOPDHB will continue to fund school based sore throat swabbing programmes in high risk areas to promote early identification and treatment of GAS amongst children. Please refer to Appendix 4 for summary of current rheumatic fever projects and service providers in the Bay of Plenty. Appendices 5 and 6 provide a list of the schools, decile ratings and rolls in the BOPDHB and MoH funded programmes. Of note, there are 18 decile 1 primary/intermediate schools in the BOPDHB district, and throat swabbing services are available to 15 of those schools. Key objective Intervention Actions Year /14 Year /15 Year /16 Year /17 Stakeholders Measured by Identify and treat Group A streptococcal throat infections quickly and effectively BOPDHB will continue to fund the following from 2013/14 to 2016/17: School-based throat swabbing programmes in Opotiki, Kawerau and Murupara Clinical quality assurance agreement with EBPHA Ongoing funding of BOPDHB programmes to identify and treat GAS infections in high risk areas Ongoing funding of BOPDHB programmes Ongoing funding of BOPDHB programmes BOPDHB to pick up funding for Tuhoe programme from 1 January 2016 Ongoing funding of all school-based programmes BOPDHB Planning and Funding, EBPHA, Whakatohea Iwi Social and Health Services, Te Ika Whenua Hauora, Te Kaokao o Takapau, School communities (staff, children, parents whānau) Quarterly reporting to BOPDHB from the DHB-funded projects. Number of schools in programme 29

30 Key objective Intervention Continue to monitor quality assurance of throat swabbing programmes Actions Year /14 Ensure teams are following quality manual and working effectively and mechanisms are in place to train staff Reporting to include visits to school, number of swabs taken, GAS positive results, sibling positivity rate, and repeat GAS infections from each team Year /15 Year /16 Year /17 Stakeholders Ongoing Ongoing Ongoing BOPDHB Planning and Funding, EBPHA, Whakatohea Iwi Social and Health Services, Te Ika Whenua Hauora, Te Kaokao o Takapau, CHWs, RF clinical lead, paediatricians, Toi Te Ora, GPs/primary care Measured by Quarterly reporting. Consent rates in schools Process audit evaluation BOPDHB, Toi Te Ora and the RF sector groups will continue to support the two MoH funded programmes in Tauranga (Te Manu Toroa) and Whakatane (Ngati Awa) Discussions to be held with the Ministry re the funding of the two community awareness raising / opportunistic swabbing projects beyond June 2014, including development of a new agreed service specification Delivery of programme in community Ongoing Ongoing Ministry of Health, Te Manu Toroa, Ngati Awa Social and Health Services, BOPDHB Planning and Funding Agreement on transition plan for projects 30

31 Key objective Ensure that children on the school based programmes with Group A streptococcal throat infections complete a full course of antibiotics Intervention Support Community Health Worker (CHW) initiatives to ensure compliance with antibiotic treatment e.g. Whānau Ora approach for hard to reach families. This includes follow-up phone calls to check children have completed antibiotics, sticker charts to monitor and reward adherence. Clear labelling of medication and clear instructions provided when antibiotics dispensed. Use of medicine cups Actions Year /14 Include the need to complete full course of antibiotics as a key message in awareness raising campaigns and health promotion initiatives On-going education of children, parents and whānau re the importance of completing antibiotics utilising appropriate health literacy approaches CHWs sharing ideas and successful methods of obtaining treatment adherence at quarterly RF sector meetings Year /15 Ongoing Explore expanding awareness raising and service provision to colleges e.g. by utilising existing college nurses Year /16 Year /17 Stakeholders Ongoing Ongoing CHWs from the school programmes, Toi Te Ora, paediatricians, primary and secondary care services Measured by Process audit evaluation Explore expanding awareness raising and service provision to colleges e.g. by utilising existing college nurses 31

32 5.2 Primary care and sore throat management guidelines BOPDHB will work with PHOs, GP practices and hauora to ensure that primary care health professionals who are likely to see high-risk children follow the most up-to-date sore throat management guidelines. Key objective Intervention Actions Year /14 Year /15 Year /16 Year /17 Stakeholders Measured by Ensure primary care health professionals likely to see high-risk children follow the most upto-date sore throat management guidelines Develop a rheumatic fever pathway on the BOPDHB Bay Navigator which will include the Heart Foundation Guidelines Work with BOPDHB GP Liaison to develop pathway. Promote awareness of and adherence to the sore throat management guidelines Ongoing update pathway as required Ongoing update pathway as required Ongoing update pathway as required BOPDHB GP Liaison, primary care, Toi Te Ora, BOPDHB paediatricians and secondary care services BOPDHB provider arm, clinical leaders Number of CME/CNE or other training opportunities undertaken. Analysis of Path Lab data to monitor the number of swabs taken for sore throats in children aged 5-15 years and the GAS positivity rate Education of health professionals particularly locum GPs Work towards making RF education a sustainable part of CME/CNE Build guidelines into existing technology (e.g. Medtech at a primary care level) and education systems e.g. inservice and induction Identify how GPs and PHOs can support efforts to meet the BPS targets RF education integrated in CME/CNE Utilise and adapt MoH online training packages currently under development Ongoing Ongoing BOPDHB GP Liaison, primary care providers, PHOs, BOPDHB, Toi Te Ora RF updates in induction programming RF guidelines in clinical support systems. 32

33 Key objective Intervention Actions Year /14 Identify and address barriers to primary care access Work with whānau and communities to identify barriers to accessing testing and treatment and work to remove these. Identify primary health approaches e.g. utilising practice nurses for accessible and affordable throat swabbing Explore options to make primary care more accessible and affordable e.g. drop in clinics attached to EDs Year /15 Pilot of new access approaches Year /16 Year /17 Stakeholders Review of pilot Ongoing BOPDHB GP Liaison, primary care, Toi Te Ora, BOPDHB provider arm, clinical leaders, children, parents, whānau Measured by Description and extent of new primary access routes Number of swabs tested from general practice 5.3 Awareness raising BOP and Lakes DHBs will work together to implement an awareness raising programme and provide clear, consistent messaging across the region Key objective Intervention Actions Year /14 Year /15 Develop and implement a RF awareness raising programme targeting high risk communities, the health sector and the public Develop a RF communications plan (both targeted and general awareness raising) Aim for clear, nationally consistent messaging and appropriate to the local context. Develop and implement RF communications plan Work in with national awareness campaigns, messages and resources provided by the Health Promotion Agency (HPA) and MoH Incorporate health literacy approaches to ensure messages are pitched correctly. Review of the campaign and its effectiveness Year /16 Yearly review and re-release Year /17 Ongoing Stakeholders BOP and Lakes DHBs, Toi Te Ora, CHWs, RF clinical lead, schools, children, whānau, HPA and MoH Measured by Communication campaign report 33

34 Key objective Intervention Actions Year /14 Year /15 Promote Kanohi ki te kanohi / face to face engagement and communication with children/ whānau and communities Year /16 Year /17 Stakeholders Measured by Awareness raising among health professionals Patient/whānau advocates to help educate others Refer to 5.2 above Ongoing Ongoing Ongoing BOPDHB GP Liaison, primary care, Toi Te Ora, BOPDHB provider arm, clinical leaders 34

35 Section 6 : Actions to facilitate the effective follow-up of identified rheumatic fever cases 6.0 Introduction This section outlines actions to facilitate effective follow up of identified RF cases to reduce the likelihood of recurrent ARF and associated cardiac valve damage (RHD). Key to achieving this is the establishment of a regional RF register, improved surveillance, review of cases and effective care pathways. 6.1 Delivery and monitoring of prophylactic antibiotics All patients with a diagnosis of acute rheumatic fever need secondary Benzathine Penicillin prophylaxis 3-4 weekly with the prescribed frequency determined by the consultant caring for them. Key objective Intervention Actions Year /14 Year /15 Ensure patients with a history of rheumatic fever receive antibiotics not more than 5 days after their due date Establish a fully functioning RF register across Lakes/ BOP Ensure full and up to date entry of RF patients Establish a register working group to address/resolve the contractual and IT barriers that prevented the roll out of the register across the BOP Fund the register and work with PHOs / providers to develop a contracting and clinical quality assurance framework Register established and fully functioning across BOP and Lakes Year /16 Year /17 Stakeholders Ongoing Ongoing BOP/ Lakes RF steering group, Rotorua Area Primary Health Services (RAPHS) BOPDHB District Nursing Service (DNS), paediatricians, cardiologists, physicians, BOPDHB IT services, GPs/PHOs, patients, whānau Measured by Annual report on register use Quarterly reports/ audits when register established Review of functions 35

36 Key objective Intervention Actions Year /14 Year /15 Audit of Bi-cillin delivery N.B. Improved achievement against this standard is one of the BOPDHB s local Māori Health Plan (MHP) targets. Quality assurance programmes are strengthened within District Nursing Services in order to meet this standard. Identify practices delivering Bi-cillin prophylaxis to RF patients. Identify risk factors for non- adherence to Bi-cillin BOPDHB champion to address performance against this standard for the MHP targets Ensure the RF register has full auditing function Collaboration between services to ensure that cases of acute rheumatic fever are actively followed up to achieve full secondary prevention antibiotic prophylaxis and appropriate, timely referral to care services such that no case is lost to follow up Bi-cillin delivery information is being collated quarterly by the BOPDHB District Nursing Annual audit undertaken by 30 June 2014 Link other Bi-cillin providers to the DNS and RF register (when implemented) Collect qualitative information from patients, whānau and DNS More frequent auditing to be undertaken once register is fully functional Assess effectiveness of new methods e.g. Buzzy Bee to improve adherence Year /16 More frequent auditing to be undertaken once register is fully functional Year /17 Stakeholders Ongoing DNS, BOPDHB Planning and Funding BOPDHB GP Liaison, PHOs, GPs and DNS Ongoing Ongoing DNS, community paediatricians Measured by Quarterly reporting Annual audit report and Qualitative information in quarterly reporting 36

37 Key objective Intervention Actions Year /14 Year /15 Year /16 Year /17 Stakeholders Measured by DNS to implement methods to reduce pain associated with Bi-cillin (e.g. through the use of Buzzy Bee device) Ongoing education of both patients and health professionals re the importance of timely Bicillin injections Effective clinical follow up of patients Clinical management as per Heart Foundation /Cardiac Society standard (including echocardiographs) Ensure all patients are under the care of a specialist for provision of Bi-cillin script and clinical review Work to embed clinical follow up and outpatient appointments into IT systems (e.g. register, WebPas, Isoft) Ongoing Ongoing Ongoing Paediatricians, Cardiologists, Qualitative information in quarterly reporting 37

38 6.2 Notification of ARF cases to the Medical Officer of Health (MOH) Key objective Intervention Actions Year /14 Year /15 Ensure that all cases of acute rheumatic fever are notified to the Medical Officer of Health (MOH) within seven days of hospital admission Monitor length of time between hospital admission and notification to MOH Any exceptions are followed up with notifying doctor Toi Te Ora analyst to compare hospitalisation figures with notifications Year /16 Year /17 Stakeholders Ongoing Ongoing Ongoing Toi Te Ora, BOP and Lakes paediatricians, physicians, cardiologists, DNS Measured by Percentage of cases notified within 7 days 6.3. Review of cases to identify known risk factors and system failure points Key objective Intervention Actions Year /14 Year /15 Identify activities that will ensure known risk factors and system failure points in cases where rheumatic fever is identified Notifications are reviewed by the MOH and the notifying clinician Processes implemented that will ensure action is taken if system failures are identified Develop a clear review process (for both school based swabbing programme areas and non-programme areas) Feedback of information on a case by case basis and/or when patterns emerge. Where any cases were potentially preventable, recommendations are made for system improvements. Year /16 Year /17 Stakeholders Ongoing Ongoing Toi Te Ora, BOP and Lakes paediatricians, physicians, cardiologists, RF clinical lead in school-based programme areas Measured by Annual reporting 38

39 6.4 Other actions to facilitate the effective follow-up of identified RF cases Key objective Intervention Actions Year /14 Year /15 Effective follow-up of identified rheumatic fever cases during hospital stay Finalise RF pathway of care to ensure seamless transition from admission to discharge. Promote clinical integration between public, primary, secondary and tertiary health services for on-going management of ARF and RHD cases. Pathway of care finalised and implemented by 15 January 2014 Review and improvements to pathway Year /16 Review and improvements to pathway Year /17 Review and improvements to pathway Stakeholders Toi Te Ora, BOPDHB paediatricians, cardiologists, physicians, patients, whānau Measured by Focus on transition from paediatric to adult services ensure clients are appropriately prepared for and referred to adult clinics Effective oral health care post - discharge Establish oral health pathways and dental referrals for newly diagnosed and existing RF patients Work with Community dental services and district nurses to deliver a practical dental pack and promote the importance of dental care for all RF patients currently on the Bi-cillin list Review effectiveness and continue annually if effective Ongoing Ongoing Toi Te Ora, DNS, Community Dental Services Number of packs delivered Supporting information developed Promote the importance of good oral hygiene to prevent the risk of infection leading to carditis 39

40 Section 7: Actions to facilitate the effective follow-up of patients with rheumatic heart disease 7.0 Introduction Whilst this plan is aimed at preventing new cases of ARF, section 7 acknowledges the need to ensure appropriate clinical follow up of patients with an existing diagnosis of RF and RHD. This is a local priority and will not be reported on to the Ministry. This section will consider interventions for two patient categories: a. those who do not have established (or documented) RHD b. those who do have established RHD 7.1 Interventions for patients who do not have established RHD With regard to historically diagnosed patients (when there was no easy availability of echocardiogram), many are likely to have had undiagnosed valvular disease. Key objective Intervention Actions Year /14 Year /15 Effective treatment of patients who do not have established (or documented) RHD Develop and implement a considered programme of recall, for clinical assessment echocardiography and clinical planning to occur. Those that have had comprehensive assessment, and do not have rheumatic valve disease, can then just receive the relevant prophylactic Benzathine Penicillin care and follow up as per Heart Foundation Guidelines Develop plan and project approach In the EBOP patients on Bicillin list have their case notes reviewed at time of script GP consideration of known patients beyond prophylaxis age groups (as per Heart Foundation Guidelines) Implementation and review Year /16 Year /17 Stakeholders Ongoing Ongoing BOPDHB paediatricians, cardiologists, physicians, patient, whānau, GPs DNS, Measured by Percentage of patients with written care plan / follow up 40

41 7.2 Interventions for patients who do have established RHD Those with established rheumatic valve disease warrant ongoing follow up and supervision of their valve status to be confident that all are receiving the health care they need. The required level of care needs are determined and then provided by the paediatricians, physicians, cardiologists and general practitioners (GPs) delivering their care, (this already happens to a variable degree of adherence except for those who have been for a number of reasons lost to the system ). Key objective Intervention Actions Year /14 Year /15 Year /16 Year /17 Stakeholders Measured by Effective treatment of patients with established RHD These patients need at least initial review, so that health professionals can be confident that the patients understand what has occurred to them, and what is likely to occur. Develop plan and project approach. In the EBOP, patients on Bi-cillin list have their case notes reviewed at time of script GP consideration of known patients beyond prophylaxis age groups (as per Heart Foundation Guidelines). Ongoing Ongoing Ongoing GPs, paediatricians, cardiologists, physicians Provide information and education to empower the patients to care for themselves. This includes understanding on the need for prophylaxis re subacute bacterial endocarditis Hand-outs on future clinical issues. Discussed predischarge for DNS, cardiology and paediatric review Interval follow up as per Heart Foundation Guidelines 41

42 Section 8: Summary of the Rheumatic Fever Prevention Plan Table 5: Summary of Rheumatic Fever Prevention Plan 2013/ / / /17 BOPDHB target (provided by the Ministry of Health) Rheumatic Fever champion BOPDHB champions appointed and will act as the main point of contact for rheumatic fever issues in each DHB BOP DHB Rheumatic Fever Champions will work within the DHB and with champions across Midland DHBs, to drive and co-ordinate actions in the DHB plan and Midland Regional Services Plan to achieve DHB and Midland targets Ongoing Ongoing Key stakeholders and providers involved in implementation of the plan Key stakeholders consulted Ongoing, active feedback will be sought as the plan is implemented Ongoing, active feedback will be sought as the plan is implemented Ongoing, active feedback will be sought as the plan is implemented BOPDHB financial investment 689, , , ,599 Ministry of Health financial investment 262, ,750 65,000 0 Total financial investment (DHB and Ministry of Health) 951, , , ,599 42

43 Actions to prevent the transmission of Group A streptococcal throat infections Develop referral pathways from health services to local housing and/or social services for follow up and intervention. Referral pathways implemented and monitored to ensure both process and interventions are effective Ongoing review and monitoring Ongoing Warm Up NZ: Healthy Homes. BOPDHB is actively looking for funding partners (on top of funding from the DHB itself) to insulate up to 1,000 homes in the BOP each year for the next 3 years. Ongoing funding / insulation of houses under Warm up NZ Ongoing funding / insulation of houses under Warm up NZ Ongoing Develop effective messages and utilise health literacy methods through a community engagement / response model. Promote messages as part of awareness raising campaigns Ongoing Ongoing Key hand hygiene messages will be promoted to schools and ECE settings. Schools assessed and identified with substandard hand washing facilities Improvements made in schools with substandard hand washing facilities Improvements made in schools with substandard hand washing facilities Promote the Bay Navigator skin infection pathway to health professionals Repeat the 2010/11 analysis of admissions to BOPDHB hospitals for skin infections using ICD coding to inform PoPAG plan. Annual trend monitoring of skin infections Annual trend monitoring of skin infections Establish annual trend monitoring 43

44 Actions to treat Group A streptococcal throat infections quickly and effectively Ongoing funding of BOPDHB programmes to identify and treat GAS infections in high risk areas Ongoing funding of BOPDHB programmes Ongoing funding of BOPDHB and MoH programmes Ongoing funding of BOPDHB and MoH programmes Ensure teams are following quality manual and working effectively and mechanisms are in place to train staff Ongoing Ongoing Ongoing Ongoing education of children, parents and whānau re the importance of completing antibiotics utilising appropriate health literacy approaches. Explore expanding awareness raising and service provision to colleges e.g. by utilising existing college nurses Work with BOPDHB GP Liaison to develop pathway. Ongoing update pathway as required Ongoing update pathway as required Ongoing Promote awareness of and adherence to the sore throat management guidelines Work towards making RF education a sustainable part of CME/CNE RF education integrated in CME/CNE RF education integrated in CME/CNE RF education integrated in CME/CNE Build guidelines into existing technology (e.g. Medtech at a primary care level). 44

45 Explore options to make primary care more accessible and affordable e.g. drop in clinics attached to EDs Pilot of new access approaches Review of pilot Develop and implement communications plan Work in with national awareness campaigns, messages and resources provided by the Health Promotion Agency (HPA) and MoH Review of the campaign and its effectiveness 45

46 Actions to facilitate the effective followup of identified rheumatic fever cases Establish a register working group to address/resolve the contractual and IT barriers that prevented the roll out of the register across the BOP Register established and fully functioning across BOP and Lakes Ongoing Fund the register and work with PHOs / providers to develop a contracting and clinical quality assurance framework BOPDHB champion to address performance against this standard for the MHP targets. BOPDHB champion to address performance against this standard for the MHP targets. BOPDHB champion to address performance against this standard for the MHP targets. Annual audit of Bi-cillin delivery by 30 June 2014 DNS to implement methods to reduce pain associated with Bi-cillin (e.g. through the use of Buzzy Bee device) More frequent auditing undertaken when register is fully functional Work to embed clinical follow up and outpatient appointments into IT systems (e.g. register, WebPas, Isoft) More frequent auditing undertaken when register is fully functional Ongoing More frequent auditing undertaken when register is fully functional Monitor length of time between hospital admission and notification to MOH. Any exceptions are followed up with notifying doctor. Toi Te Ora analyst to compare hospitalisation figures with notifications. Notifications are reviewed by the MOH and the notifying clinician. Processes implemented that will ensure action is taken if system failures are identified. Feedback of information on a case by case basis and/ or when patterns emerge Ongoing 46

47 Develop a clear review process Pathway of care finalised and implemented by 15 January 2014 Where any cases were potentially preventable, recommendations are made for system improvements. Work with Community dental services and district nurses to deliver a practical dental pack and promote the importance of dental care for all RF patients currently on the Bicillin list. The Ministry of Health template for the reporting framework is attached as Appendix 7. 47

48 Appendix 1- Rheumatic Fever Hospitalisation Rates Bay of Plenty and Lakes District Health Boards, Data showing admissions to hospital for rheumatic fever in the period from were used to calculate rheumatic fever hospitalisation rates for Bay of Plenty and Lakes DHBs. This information was extracted from the National Minimum Data Set (NMDS) before any detailed information was received from the Ministry of Health and it was used as the basis for these rate calculations. The calculated rates will be reviewed when sufficiently detailed rheumatic fever information has been received from the Ministry of Health and 2013 Census data are available to ensure more accurate denominators can be used in rate calculations. If a person was admitted to hospital more than once for rheumatic fever during the time period analysed ( ), only the first admission was included. It is possible that some of these people may have also been admitted to hospital for rheumatic fever prior to 2007 so this is not identical to the Ministry of Health definition which is based on first admission for rheumatic fever in 20 years. A comparison of this data with Ministry of Health data shows that the number of cases with this definition is very similar to the Ministry of Health totals for both DHBs. (This data shows an average of 9.4 first admissions per year for BOPDHB compared with MOH data which shows 8.6 per year and an average of 6.4 first admissions per year for Lakes DHB compared with MOH data which shows 7.0) Census data and medium population projections for 2011 were used to estimate denominators for the rate calculations. Rates were not calculated for non-maori because the number of events was too small for this group to enable meaningful analysis. Only seven non-maori from each DHB had first hospitalisations for rheumatic fever in the five year period. 95% Confidence Intervals are shown in the tables provided to give an idea of the precision of the calculated rates and to indicate whether or not observed differences are statistically significant. Normal distribution confidence intervals were used for data at DHB level because at this level numerators for the five years were greater than 20. Poisson distribution confidence intervals were used for data at local authority level because numerators for the five years at this level were less than 20. Where there are a small number of events, confidence intervals can be quite wide. For example, for Maori living in the BOPDHB area, the calculated rate was 15.5 per 100,000 but 48

49 the confidence interval ranges from 10.7 to This means we can be 95% sure that the true rate is between 10.7 and When comparing groups, if confidence interval ranges overlap, then observed differences are not statistically significant. Rates were calculated for all age groups combined and for children aged 5-14 years for both Maori and Total (the overall population of all ethnic groups). Rates for the Overall Population This analysis showed that: For both DHBs the Maori rate was significantly greater than the rate for the overall population Although the rate for Lakes DHB was higher than the rate for BOPDHB this difference was not statistically significant. First Hospital Admission for Rheumatic Fever Rate/100,000 and 95% Confidence Interval BOPDHB and Lakes DHB, DHB Maori Total BOPDHB 15.5 ( ) 4.6 ( ) Lakes DHB 18.3 ( ) 7.7 ( ) Rheumatic fever rates were also calculated at local authority level to analyse patterns across the Toi Te Ora area. In many cases the number of events was too small at this level of analysis to detect statistically significant differences, even with five years of data aggregated. This data shows that: 49

50 In all areas Maori have a higher rheumatic fever rate than the overall population but this difference was only statistically significant for Rotorua District. For areas where a very high proportion of the population are Maori (e.g. Kawerau) the difference between the Maori rate and the overall population rate is less. Rates are higher in Eastern BOP areas (Whakatane, Kawerau and Opotiki) and Rotorua compared with Western BOP areas (Tauranga City and Western BOP District) and Taupo. Most of these differences are statistically significant for the overall population. First Hospital Admission for Rheumatic Fever Rate/100,000 and 95% Confidence Interval By Local Authority, Local Authority Maori Total Western BOP 7.5 ( ) 1.4 ( ) Tauranga 8.4 ( ) 2.3 ( ) Whakatane 24.6 ( ) 11.2 ( ) Kawerau 23.3 ( ) 17.3 ( ) Opotiki 22.6 ( ) 13.4 ( ) Taupo 8.3 ( ) 3.0 ( ) Rotorua 22.2 ( ) 10.0 ( ) 50

51 Graph Showing Overall Rheumatic Fever Rate By Local Authority Area Graph Showing Overall Rheumatic Fever Rate By Local Authority Area with 95 % Confidence Intervals 51

52 Graph Showing Maori Rheumatic Fever Rate By Local Authority Area Graph Showing Maori Rheumatic Fever Rate By Local Authority Area with 95% Confidence Interval 52

53 Rates for Children aged 5-14 years For both DHBs the rate for Maori children aged 5-14 years was greater than the rate for all children but this difference was only statistically significant for BOPDHB. For children aged 5-14 years the rate for Lakes DHB was higher than the rate for BOPDHB but this difference was not statistically significant. The rheumatic fever rate for Maori children aged 5-14 years is quite similar for the two DHBs. First Hospital Admission for Rheumatic Fever Rate/100,000 and 95% Confidence Interval Age 5-14 Years, BOPDHB and Lakes DHB, DHB Maori Total BOPDHB 55.5 ( ) 23.7 ( ) Lakes DHB 58.2 ( ) 32.5 ( ) Rheumatic fever rates were calculated at local authority level to analyse patterns across the Bay of Plenty and Lakes Districts. The number of events was generally too small at this level of analysis to detect statistically significant differences even with five years of data aggregated. It is possible however to make some general observations from this data. In all areas except Kawerau, Maori children aged 5-14 have a higher rheumatic fever rate than the rate for all children aged For areas where a very high proportion of the population are Maori (e.g. Kawerau) the difference between the rate for Maori children and the rate for all children is less. Rates are generally higher in Eastern BOP areas (Whakatane, Kawerau and Opotiki) and Rotorua compared with Western BOP areas (Tauranga City and Western BOP District) and Taupo. This was true for both Maori and overall. Some of the differences between districts were statistically significant. (e.g. The overall rate for Kawerau children was significantly higher than the overall rate for Western BOP children). 53

54 First Hospital Admission for Rheumatic Fever Rate/100,000 and 95% Confidence Interval Age 5-14 Years, By Local Authority, Local Authority Maori Total Western BOP 31.9 ( ) 9.2 ( ) Tauranga 29.5 ( ) 11.8 ( ) Whakatane 70.2 ( ) 45.7 ( ) Kawerau 97.4 ( ) 98.6 ( ) Opotiki 81.1 ( ) 61.6 ( ) Taupo 28.3 ( ) 12.4 ( ) Rotorua 63.5 ( ) 41.2 ( ) 54

55 Graph Showing Rheumatic Fever Rate for Children By Local Authority Area Graph Showing Rheumatic Fever Rate for Children By Local Authority Area with Confidence Intervals 55

56 Graph Showing Rheumatic Fever Rate for Maori Children By Local Authority Area Graph Showing Rheumatic Fever Rate for Maori Children By Local Authority Area with 95% Confidence Intervals 56

57 Data Used for Calculation of Rheumatic Fever Rates Total Population (All Ethnic Groups) First Hospitalisation for Rheumatic Fever and Estimated Average Annual Population , All Ages Local Authority First Hospitalisation for RF Combined Average Population Annual Western BOP Tauranga Whakatane Kawerau Opotiki BOPDHB Taupo Rotorua Lakes DHB

58 First Hospitalisation for Rheumatic Fever and Estimated Average Annual Population , Children Aged 5-14 Years Local Authority First Hospitalisation for RF Combined Average Population Annual Western BOP Tauranga Whakatane Kawerau Opotiki BOPDHB Taupo Rotorua Lakes DHB

59 Data Used for Calculation of Rheumatic Fever Rates: Maori First Hospitalisation for Rheumatic Fever and Estimated Average Annual Population , Maori, All Ages Local Authority First Hospitalisation for RF Combined Average Population Annual Western BOP Tauranga Whakatane Kawerau Opotiki BOPDHB Taupo Rotorua Lakes DHB

60 First Hospitalisation for Rheumatic Fever and Estimated Average Annual Population , Maori Children Aged 5-14 Years Local Authority First Hospitalisation for RF Combined Average Population Annual Western BOP Tauranga Whakatane Kawerau Opotiki BOPDHB * Taupo Rotorua Lakes DHB * * Note: Added child populations for local authorities do not equal totals for DHBs because population projection data available for Maori at each of these geographical levels were from two different sources with different totals resulting at DHB level. It appears that denominators for Maori children at local authority level may be slightly too high leading to a small underestimate of rates at this level. These denominators are being checked. 60

61 Appendix 2 - Stakeholders Stakeholders BOP/ Lakes Rheumatic Fever Steering Group BOPDHB Planning and Funding and paediatrics teams Lakes DHB Māori Health team BOPDHB Māori Health Planning and Funding team Eastern Bay Primary Health Alliance Korowai Aroha Rotorua Lakes DHB Planning and Funding and paediatrics teams Ngati Awa Social and Health Services Rotorua Area Primary Health Services (RAPHS), Te Ika Whenua Hauora Te Kaokao o Takapau Te Manu Toroa (Nga Mataapuna Oranga PHO) Toi Te Ora - Public Health Service Whakatohea Iwi Social and Health Services BOP/ Lakes Rheumatic Fever Sector Group Eastern Bay PHA Korowai Aroha Rotorua Ngati Awa Social and Health Services Te Ika Whenua Hauora Te Kaokao o Takapau Te Manu Toroa (Nga Mataapuna Oranga PHO) Toi Te Ora - Public Health Service 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. Housing Sector Smart Energy Solutions Eastern Bay Energy Trust Tauranga Electricity Community Trust Population Health Professional Advisory Group (PoPAG) BOP Child and Youth Strategic Action Steering Group 61

62 Appendix 3 Logic model for Toi Te Ora Goal 1: Reduce childhood admissions from ARF, respiratory and skin infections, each by 2/3rdc in 5 years 62