BAY OF PLENTY DISTRICT HEALTH BOARD

MĀORI HEALTH PLAN

2016/17

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Contents

Overview

Abbreviations

Māori Population: Profile and Health Needs

National Indicators

Accuracy of ethnicity reporting in PHO registers

Percentage of Māori enrolled with PHOs

Ambulatory sensitive hospitalisation rate (0-4, 45-64, 0-74 years)

Full and exclusive breastfeeding rates at 6 weeks, 3 months, and 6 months

Breast screening rates (50-69 years)

Cervical screening rates (25-69 years)

Smoking cessation in pregnancy

Percentage of infants fully immunised by eight months of age

Seasonal influenza immunisation rates (65 years and over)

Reduction in rheumatic fever rates

Oral health

Mental health

Sudden Unexpected Death of an Infant (SUDI)

Local Indicators

Did-Not-Attend (DNA) rate for outpatient appointments

Appendix A – Methodology for Local Indicator Selection

References

Version 160630

This document is subject to ongoing updates. Readers are encouraged to refer to the BOPDHB website for the latest

version of the plan.

Please direct correspondence related to this plan to george.gray@bopdhb.govt.nz

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Overview This plan describes Bay of Plenty District Health Board’s (BOPDHB) priorities in Māori health for

the 2016-2017 time period. This plan aligns with the requirements of the New Zealand Public

Health and Disability Act (2000) which directs District Health Boards (DHBs) to reduce disparities

and improve health outcomes for Māori. The format of this plan and the indicators listed within it

follow the direction given in the 2016/2017 Māori Health Plan Guidance from the Ministry of

Health.

This plan aligns with the BOPDHB’s Annual Plan (AP) and the Midland DHBs’ Regional Services

Plan.

Over the coming year we will continue to take a population health approach to Māori health. We will

continue to work with other organisations to address the primordial causes of health inequality and to

address the indicators listed in this plan. As in the past, we will monitor progress through our Māori Health

Plan Steering Group (MHPSG); this quarterly forum comprises representatives from the various

organisations involved in achieving the targets listed in this plan. The group includes representatives from

primary care, secondary care, regional public health services, community providers, and the DHB.

The Māori Health Plan gives a one-year subset of actions and aspirational targets related to Māori health;

longer term activities (2-5 years) to improve health for Māori and non-Māori are described in the 2016-2017

BOPDHB Annual Plan. The methods used to determine the local indicator listed in this plan is summarised

in Appendix A.

In addition to the Māori Health Plan Steering Group, quarterly performance results for the Māori Health

Plan indicators will be disseminated to four key audiences. First, results will be submitted to the Board for

review and discussion in the same manner that Annual Plan and Health Target results are presented.

Second, quarterly performance reports will be reviewed by the DHB Runanga. Third, quarterly performance

results will be presented at the DHB’s executive management meetings. These three dissemination groups

represent both operational and governance levels of the organisation. Fourth, the DHB’s Māori Health Plan

performance will be presented in our Annual Report. We look forward to progressing the objectives

described in this plan.

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Abbreviations

ABC An approach to smoking cessation requiring health staff to ask, give brief advice, and facilitate

cessation support.

ACS Acute Coronary Syndrome

AP Annual Plan

ARF Acute rheumatic fever

ASH Ambulatory sensitive hospitalisation

BFHI Baby friendly hospital initiative

BOP Bay of Plenty

BOPDHB Bay of Plenty District Health Board

CME Continuing medical education

COPD Chronic obstructive pulmonary disease

CVD Cardiovascular disease

CVRA Cardiovascular risk assessment

DAR Diabetes annual review

DHB District Health Board

DHBSS DHB Shared Services

DMFT Diseased, Missing, or Filled Teeth

DNA Did not attend (used in the measurement of outpatient clinic attendance)

EBPHA Eastern Bay Primary Health Alliance

ENT Ear, nose and throat

GM General Manager

HbA1C Glycosylated haemoglobin

IGT Impaired glucose tolerance

IHD Ischaemic heart disease

ISP Independent service provider

ISDR Indirectly standardised discharge rate

MHPSG Māori Health Steering Group

MOH Ministry of Health

NCHOD National Centre for Health Outcomes Development

NMO Nga Mataapuna Oranga (Primary Health Organisation)

NSU National Screening Unit

NZ New Zealand

NZHS New Zealand Health Survey

PHO Primary Health Organisation

POPAG Population Health Advisory Group

RR Rate ratio

WBOPPHO Western Bay of Plenty Primary Health Organisation

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Māori Population: Profile and Health Needs

1. Geographic Distribution ● BOPDHB’s population was 215,000 at the 2013 Census. 25% of BOPDHB’s population identified as

Māori (53,700 people) at the Census, compared with 14% nationally.1

● BOPDHB comprises five territorial authorities. In 2014 the majority of the population were based in western areas,

56% lived in Tauranga City with a tapering population count towards the east; ● Absolute numbers of Māori reflect the total population’s pattern, tapering from west to east.

However Māori make up a greater proportion of each district’s population toward the east.

Table 1. Bay of Plenty (BOP) population distribution by territorial authority.2

District Western BOP Tauranga Whakatane Kawerau Opotiki Total Popn. 45,900 121,800 34,300 6,600 8,830

Māori Popn. 8,795 21,734 15,167 4,043 5,262 Māori (%) 19 18 44 61 60

2. Health Service Providers Key health service providers in BOPDHB include:

● Two public hospitals: Tauranga (349 beds) and Whakatane (110 beds). ● Three PHOs. ● Multiple local and national non-profit and private health and social providers.

3. Iwi within BOPDHB Multiple Iwi lie within or across BOPDHB’s borders including:

• Ngai Te Rangi • Ngāti Ranginui • Te Whānau ā Te Ēhutu

• Ngāti Rangitihi • Te Whānau ā Apanui • Ngāti Awa

• Tūhoe • Ngāti Mākino • Ngāti Whakaue ki Maketū

• Ngāti Manawa • Ngāti Whare • Waitahā

• Tapuika • Whakatōhea • Ngāti Pūkenga

• Ngai Tai • Ngāti Whakahemo • Tūwharetoa ki Kawerau

4. Age Distribution of the Māori Population ● In 2013, BOPDHB’s over-65 population was proportionately larger than the national average (17.5% vs. 14.3%), with

both the BOPDHB and national populations getting older; ● The BOPDHB Māori population is skewed towards younger age groups, one-third of Māori are aged under 15. In

comparison just 17% of non-Māori are aged under 15; ● Only 7% of Māori are aged over 65, whereas 22% of non-Māori are over the age of 65.

Table 2. Age distribution of the BOPDHB population.3

1 "District Health Board Māori Health Profiles 2015, Research ..." 2015. 14 Mar. 2016

<http://www.otago.ac.nz/MHP2015> 2 Statistics NZ infoshare, Population Estimates at 19/11/2014. Baseline 2013 Census

3 "District Health Board Māori Health Profiles 2015, Research ..." 2015. 14 Mar. 2016

<http://www.otago.ac.nz/MHP2015>

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5. Population Growth Projections

Māori are projected to comprise a consistent 25% of the DHB’s population to 2033. However, the median age for this

group will continue to be significantly younger than the total population of BOPDHB.

Table 3. Age distribution projections of the BOPDHB population to 2033.4

6. Deprivation Distribution Māori in BOPDHB are more likely to be in the two most deprived NZDep categories than non-Māori in the DHB or

nationally. Over 50% of BOPDHB were found in NZDep 9 and 10 in 2013; 17% of non-Māori were found in the same

deciles. 4% of Māori are within NZDep deciles 1 and 2 compared with 15% of non-Māori.

Figure 1. NZDep distribution of the BOPDHB Māori and non-Māori populations.5

4

ibid. 5

ibid.

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7. Primary Care - PHO Enrolment In Q1 2016 the highest number of Māori were enrolled with Eastern Bay Primary Health Alliance (EBPHA), followed by

Western Bay of Plenty PHO (WBOPPHO), and finally Ngā Matapuna Oranga PHO (NMO).

Table 4. Enrolled populations in BOPDHB PHOs as at Q1 2016.6

PHO EBPHA WBOPPHO NMO Total Enrollees 45,526 151,466 11,385

Māori 21,232 18,864 8,107 Māori (%) 47 12 71

6

"Enrolment in a primary health organisation | Ministry of ..." 2011. 14 Mar. 2016 <http://www.health.govt.nz/our-

work/primary-health-care/about-primary-health-organisations/enrolment-primary-health-organisation>

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National Indicators

Accuracy of ethnicity reporting in PHO registers

Outcome we seek: Greater accuracy of ethnicity data in PHO enrolment databases.

How will we know if we have been successful?

Ethnicity data accuracy will increase as measured through implementation of the Ministry of Health’s primary care ethnicity data auditing tool.

Target: n/a - a target will be determined once baseline data has been collected

Māori: Clinics and PHOs were introduced to the Ethnicity Data Audit Tool in 2015. 2016 will be used to gain baseline data, work with PHOs to set targets, and monitor performance improvement.

Non-Māori: n/a

What we are planning to do:

By 31 July 2016 Milestone 1 - Appoint an indicator champion to oversee the completion of the tasks described here for this indicator. This will help improve ethnicity data quality by ensuring that the tasks described here are implemented and monitored through the year and that a key person is accountable for activity completion.

By 30 November 2016 Milestone 2 - Assess the level of implementation of the ethnicity data auditing tool (EDAT) among BOPDHB clinics. This will help improve ethnicity data quality by determining the level of implementation across PHOs and clinics; it will also help to identify the resources, training, and support required to implement the tool in all remaining clinics.

By 31 December 2016 Milestone 3 - Collate EDAT scores and ethnicity data accuracy for 80% of clinics in BOPDHB. This will help improve ethnicity data quality by ensuring that the EDAT has been implemented in a sufficiently high number of clinics.

By 28 February 2017 Milestone 4 - Facilitate sharing of best practice processes from high scoring clinics to others with low EDAT results within the three BOPDHB PHOs. This will help improve ethnicity data quality by accelerating organisational learning among clinics; the resources and processes used in the best performing clinics will be shared with clinics performing less well on this measure.

By 28 February 2017 Milestone 5 - Complete a register of clinic EDAT scores in order to track current implementation across clinics along with a repeat audit in 1-3 years (depending on initial results). This will help improve ethnicity data quality by identifying the clinics that have implemented the EDAT and setting a reminder date for the tool to be repeated. This will ensure that ethnicity data quality is repeatedly checked and improved.

By 31 January 2017 Monitoring will be performed through the quarterly meeting of the Māori Health Plan Steering Group. This group comprises representatives from each of the PHOs in BOPDHB. This forum will be used to collaborate with the PHOs on ways to improve the baseline results. Audit results will be provided to all general practices in keeping with the current performance feedback activities already performed by PHOs.

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Percentage of Māori enrolled with PHOs

Outcome we seek: Increased access for the Māori population to primary health care services.

How will we know if we have been successful?

100% of Māori in BOPDHB will be enrolled with a PHO.

Target: 100%

Māori: 91% (Jan-Mar 2016)

Non-Māori: 99% (Jan-Mar 2016)

What we are planning to do:

By 1 July 2016 Finalise a champion for this indicator.

By 1 July 2016 Work with the Ministry of Health to incorporate additional patients into the PHO enrolment estimate who are engaged with a clinic that is not registered with a PHO (e.g. Te Kaha). This will improve access to care for Māori by giving a more accurate picture of primary care access and utilisation.

By 1 July 2016 Compare the anonymised PHO enrolment demographics (numerator) with the 2013 Census (denominator) to identify enrolment gaps stratified by geography, ethnicity, gender, and other variables. This will improve access to care for Māori because it will help to identify the demographics of the 4,413 Māori who are not enrolled (as at February 2016) in PHOs. This will help BOPDHB and the PHOs to tailor enrolment initiatives towards these groups.

By 31 August 2016 Provide PHO enrolment deficit analyses to PHOs in BOPDHB in order to help PHOs target enrolment improvement initiatives to specific populations. This will help improve access for Māori by helping PHOs to understand where enrolment gaps are in their communities.

Ongoing Track PHO enrolment on a quarterly basis.

By 31 December 2016 Complete an audit of ethnicity data accuracy in 80% of BOPDHB clinics (see previous indicator: Accuracy of ethnicity reporting in PHO registers). The audit will enable the Māori Health Planning and Funding Team to reconcile the impact of underreported or misclassified Māori ethnicity on reported PHO enrolment rates. Multiple studies have reported misclassification rates as high as 35%.

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Ongoing Monitor indicator performance on a monthly basis through the Māori Health Planning and Funding Team. Monitor indicator performance on a quarterly basis through the Māori Health Plan Steering Group.

7 Bramley, Dale, and Sandy Latimer. "The accuracy of ethnicity data in primary care." Journal of the New Zealand

Medical Association 120.1264 (2007). 8 Swan, Judith, Steven Lillis, and David Simmons. "Investigating the accuracy of ethnicity data in New Zealand

hospital records: still room for improvement." New Zealand Medical Journal (2006).

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Ambulatory sensitive hospitalisation rate (0-4, 45-64 years)

Outcome we seek: Reduced ambulatory sensitive hospitalisation (ASH) rates in the 0-4 and 45-64 age groups

How will we know if we have been successful?

Indirectly standardised ASH rates for Māori will be the same as those for the total population of New Zealand.

Targets (Māori): Māori: 0-4 years: 113 Māori: 45-64 years 144

Baseline Māori (year to 31 Mar 2016):

0-4 years: 127 45-64 years: 189

Baseline total population (year to June 2015):

0-4 years: 115 45-64 years: 102

What we are planning to do: For the 45-64 years age group:

By 30 June 2016 Develop a test of change project focussed on reducing Māori ASH 45-64 years and submit to the Alliance Leadership Team (ALT) for approval. Commence socialisation of the test of change in ED working with all stakeholders to develop a pragmatic innovative model to enable primary care or home based management of ED presenting ASH conditions. All Māori individuals presenting at ED will also be followed up by a primary care nurse to increase education and self-management skills with the aim of reducing reoccurrence. Bi weekly meetings with Primary Care ASH champion and secondary care ASH co-champion plus secondary care managers to be established. Committed support and resource of the BOPDHB Service Improvement team and GPL to support reduction in ASH rates for Māori to be confirmed. This will ensure the tests of change are well supported from within the hospital environment and from general practice. Working party to look at heart failure self-management (SM) established within the Midlands cardiac network. Performance measure: Test of change approved by ALT Working party for heart failure SM established

By 31 July 2016 Provision of CME and CNE education facilitated by DHB SMO’s to support primary care management of commonly presenting ASH conditions affecting Māori. This will include heart failure, COPD, cellulitis and DVT All commonly presenting ASH conditions to be supported by a pathway visible on Bay Navigator. Funding secured to ensure that ASH conditions and related interventions can be managed at general practice at no cost to Māori patients. Funding also secured to support nursing support and intervention if a higher level of support is required or if home based services are required. Increase ASH visibility through the development of a shared data platform identifying ASH by condition, ethnicity, hospital site and PHO. Provision of a more detailed level of data identifying ASH conditions by practice to be provided to each PHO. Data to be refreshed monthly. Performance measures:

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Bay Navigator pathways in place for all main ASH conditions Funding secured to support reduction of Māori ASH conditions Visible shared ASH data shared monthly

By August 2016 Test of change within Tauranga ED completed, this will be supported by utilisation of a primary care nurse to assist with the identification of Māori patients who may be suitable for primary care management rather than admission. Heart failure self-management program availability within primary care. The self-management program to be underpinned by the living with heart failure resource developed by the heart Foundation. Self-management may be in groups or on an individual basis and may be delivered in a home environment, Marae, Hauora or community clinic. Performance measures: Test of change implemented and completed in Tauranga. Number of Māori individuals who were referred to primary care instead of admitted to hospital for an ASH condition Number of eligible individuals accessing primary care delivered heart failure self-management programs in WBoP. Reduction in Heart failure readmission rate

By 30 Sep 2016 Employment of a full-time community advanced nurse to provide in-reach Māori advanced nursing support within specific Eastern Bay geographical locations to enable home based management of ASH presenting conditions rather than inpatient admission. Develop Baywide health promotion to manage skin infections and respiratory infections specifically targeting Māori. Usage of Tauranga Moana radio plus the free newspapers will support the promotion. The health promotion messages will be developed collaboratively with Toi Te Ora and will support

Early presentation at general practice - Promotion of diabetes self-management group attendance for Māori, this

will include continued support for provision of courses to be held on Hauora and Marae.

- Promotion of self-management groups for heart disease including heart failure

Performance measures: Advanced primary care nurse employed to support ASH reduction in EBoP Reduced ASH length of stay Full write up of the test of change in Tauranga and recommendations submitted to ALT. Decisions on next steps made.

By October 2016 Explore the possibility of primary care undertaking the interface into ED. Write a test of change and submit this to ALT for consideration. Performance measure: Test of change submitted to ALT

By January 2017 Referral to primary care of all suitable Māori ASH presentations who present at Tauranga ED. Performance measure: 15% Reduction of Tauranga ASH admissions 20% Reduction in Tauranga ASH length of stay

Ongoing Monitor the ASH indicator on a quarterly basis through the Māori Health Plan Steering Group.

What we are planning to do: For the 0-4 years age group:

By June 2016 Establish Secondary Care paediatrician ASH lead and linkage with GP liaison Implement new dASHboard for Māori children which gives clear visibility of

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opportunity areas (splitting out ED, split by geography and presentation reason, PHO) Embed focus in mainstream service improvement priorities Establish secondary care led 0-4 ASH multi-disciplinary working group Performance measure:

1. Dashboard designed and circulated widely each month 2. Framework to support a two year improvement programme in place

By 31 July 2016 All commonly presenting ASH conditions to be identified and a timetable produced for associated pathway development on Bay Navigator. ASH data refined to allow targeted action on opportunity areas – to be listed on the dashboard with a quarterly improvement plan schedule developed Develop political linkages with local councils and MPs through Toi Te Ora and Board members to contribute to growing local discussions on solution to homelessness in Tauranga Include ASH measure in hospital balanced scorecards First defined target area improvement workstream commenced Establish mechanisms to follow up frequent fliers for follow up in appropriate clinic under the coverage of Regional Māori Health Services Performance measures:

1. Visible shared ASH data shared monthly across primary and secondary care teams

2. Clinical opportunities identified and prioritised for targeted improvement plan (one opportunity per quarter)

3. Initial sessions arranged with local council and MPs to share child ASH data

4. Defined first improvement area workstream commenced, with reporting through MHPSG to BOPALT

By August 2016 For each high ASH presentation reason, determine from analysis whether this can be attributed to housing, geography, clinical decision making, GP access etc in order that each presentation type where there is a notable Māori-Non-Māori disparity has a primary reason determined. Commence a review of the ED component and establish a waiting time improvement target for 0-4 year olds which is less than three hours. Ensure that breaches are documented as relating to either clinical risk management or system capacity. Commence improvement programme on system capacity component Performance measures:

1. Reasons are specified for the most common ASH disparity presentations 2. ED presentation waiting time improvement plan developed for work over

next three months

By Sep 2016 Revision of dashboard to include information on ‘what we know’ and ‘what we need to determine’ pointers GP liaison to commence GP education programme on asthma action plans

By October 2016 Commencement of prioritised opportunity area 3 improvement workstream

By January 2017 Commencement of prioritised opportunity area 4 improvement workstream. Implement opportunistic ward immunisation protocol, INR status check on all admissions Performance measure: 15% Reduction of Tauranga ASH admissions (including ED 3+ hour waits)

Ongoing 1. Monitor the ASH indicator on a quarterly basis through the Māori Health Plan Steering Group

2. Monitor the ASH indicator monthly through hospital balanced scorecards and Board reports

3. Monitor 0-4 year old ED wait times as a new internal target

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Full and exclusive breastfeeding rates at 6 weeks, 3 months, and 6 months

Outcome we seek: Higher rates of breastfeeding for Māori infants at 6 weeks, 3 months, and 6 months.

How will we know if we have been successful?

Māori infants will have attained breastfeeding rates consistent with the age-related targets set by the Ministry of Health in the Well Child Tamariki Ora Quality Improvement Framework.

Targets: 75% at 6 weeks (full or exclusive) 60% at 3 months (full or exclusive) 65% at 6 months (full, exclusive, or partial)

Māori (Jul-Dec 2015): 59.3% at 6 weeks (full or exclusive)9

38.5% at 3 months (full or exclusive) 54.9% at 6 months (full, exclusive, or partial)

NZ European/Other (Jul-Dec 2015):

75.3% at 6 weeks (full or exclusive)10

65.3% at 3 months (full or exclusive) 70.3% at 6 months (full, exclusive, or partial)

What we are planning to do: The factors influencing breastfeeding for Māori women have been identified in past research.

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12 The barriers identified in the research include: difficulty establishing

breastfeeding within the first six weeks; poor or insufficient professional support; perception of inadequate milk supply; and returning to work. The interventions listed below are aimed at addressing some of these factors by supporting initiation and delaying cessation of breastfeeding.

13 We will continue to

achieve high initiation rates through continuation of the World Health Organization’s Baby Friendly Hospital Initiative (BFHI) in BOPDHB hospitals.

By 31 July 2016 Breastfeeding forum in the Western Bay of Plenty will be meeting regularly and have agreed on makeup of attendees and Terms of Reference. Key activities of this group to include a stocktake of breastfeeding promotion and support currently available to consumers, discuss trends where decline is evident, and strategise for improvement. This group will have representation at affiliated projects and groups in the DHB including Toi te Ora obesity steering group and Maternity Safety and Quality Governance Group. Monthly meetings will evaluate breastfeeding rates for Māori and trends occurring. This forum would also provide support for Baby Friendly Hospital Initiative (BFHI) in BOP DHB Hospitals and community events such as The Big Latch. This forum will evaluate the Baby Friendly Community Initiative for relevance to this community (BFCI) and BFHI maintenance as a universal activity.

By 31 August 2016 Breastfeeding forum will work in collaboration with Māori Health, DHB, PHO, LMC and WCTO providers to provide planning for a service suitable for Whānau Access to receive improved support and education to increase breastfeeding rates. - This is envisaged as a targeted home-visit service where Marae-based support could also be successful, as has been implemented in Lakes DHB. Current data shows inequality with the earlier cessation of breastfeeding from Māori clients at the 3-month age band as compared with other ethnicities. This has been identified as an increasing trend across the past 3 quarters. Total population has exceeded the current target of 60% at each quarter.

9 Source: Ministry of Health. Data supplied April 2016.

10 ibid

11 Manaena-Biddle, H, J Waldon, and M Glover. "Influences that affect Māori women breastfeeding." Breastfeeding

Review 15.2 (2007): 5. 12

Glover, Marewa et al. "Barriers to best outcomes in breastfeeding for Māori: mothers' perceptions, whānau

perceptions, and services." Journal of Human Lactation 25.3 (2009): 307-316. 13

Dyson, Lisa, F McCormick, and Mary J Renfrew. "Interventions for promoting the initiation of breastfeeding."

Cochrane Database Syst Rev 2 (2005).

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- Ensure pathways are developed for health professionals and clients to access timely lactation services. - Evaluate need for increased lactation service following stocktake of current level of service - If need is agreed upon, progress to business planning.

By 31 March 2017 Well child providers to build on capacity and capability of evidence based lactation support. Assess WCTO Activity to support Breastfeeding support through measuring performance through care delivery components from individual well child practitioners for their caseload. Evaluate use of Mama Aroha talk cards within WCTO environment, assess for need of refresher training and practice development.

Ongoing Monitor the breastfeeding indicator on a quarterly basis through the Māori Health Plan Steering Group.

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Breast screening rates (50-69 years)

Outcome we seek: Lower breast cancer morbidity and mortality among Māori women through better utilisation of the national breast screening programme for women aged 50-69 years.

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How will we know if we have been successful?

Screening rates for Māori women (50-69 years) in BOPDHB will have reached the national target of 70%.

Target: 70%

Māori (baseline): 59.9% (Q3 2016; Jan-Mar 2016)

Non-Māori (baseline):

73.5% (Q3 2016; Jan-Mar 2016)

By 31 July 2017 ISPs to implement recruitment strategies, 3 months prior to the scheduled breast screening

mobile unit visit, for priority women to access the breast screening mobile unit specifically in the

Katikati, Waihi, Te Puna region through a hapu approach to ensure maximum utilisation of

allocated appointments, such as promoting the mobile screening unit on the local Tauranga

Moana iwi radio station programme (Moana AM Māorivation), working with the Runanga,

adopting Mana Wahine Champions from the hapu to promote mobile unit visits, working with

local GP Practices. Performance Measure: Increase in the number of Māori women screened with the breast

screening mobile unit.

By 31 July 2016 The ISPs will implement the Waikato DHB’s Mammogram project which aims to focus on using

daughters to encourage and support their mothers to get a mammogram, and to be a conduit of

good information for their mothers. The approach also adds to the knowledge younger women

have about breast screening for when they reach the 45+ age group. Performance Measure: Increase in the response rate (increased number of enquiries for enrolment or bookings). Results (increased number of bookings converted to completed mammograms). Awareness (feedback and overall assessment of campaign, plus follow-up survey of sample if

required.

By 31 July 2016 Review the Institute of Healthcare Improvement project that was implemented in 2015/16 to

understand bottlenecks in the patient journey, and make iterative changes to the intervention

based on results from using a part-time patient navigator. Once iterative changes are identified

work with PHOs to ensure data matching with BSM and apply the strategy to another GP clinic

with low enrolments of eligible Māori women to the breast screening programme.

Performance Measure: Increase in the number of Māori women who enrol to the national

breast screening programme.

By 31 July 2017 ISPs, Planning and Funding, Primary Care and Colposcopy will participate in the regional

planning process with BSA providers.

Performance Measure: Participation in two regional coordination meetings per annum.

Ongoing Monitor performance on a monthly basis within the BOPDHB Māori Health Planning and

Funding team. Monitor screening performance on a quarterly basis through the MHSG. Performance Measure: Screening performance is monitored monthly and quarterly and key

actions to lift performance are identified.

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It is acknowledged that the national breast screening program facilitated by the NSU provides coverage for women

aged 45-69. The BOPDHB Māori Health Plan 2014/15 refers to the 50-69 year age group in keeping with existing performance reporting for this indicator.

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Cervical screening rates (25-69 years)

Outcome we seek: Lower cervical cancer morbidity and mortality among Māori women through better utilisation of the national cervical screening programme for women aged 25-69 years.

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How will we know if we have been successful?

Cervical screening rates for Māori women will have reached the national target of 80%.

Target: 80%

Māori: 65.3% (at Q2 2016, 25-69 year age group)

Non-Māori: 86.6% (at Q2 2016, 25-69 year age group)

What we are planning to do:

By 30/06/2017 The Taku Wahine Puroto programme (provision of outreach and after hours cervical

screening services for eligible Māori women) to be extended and delivered by

Western Bay of Plenty PHO, Nga Mataapuna PHO and Eastern Bay Primary Health

Alliance. Performance Measure: Number of women screened at the outreach clinics

By 31/12/2016 Toi Te Ora will assist PHO’s with the use of the National Screening Unit’s monthly

electronic data-matching reports to identify women who have slipped through the

General Practice recall systems Performance Measure: Number of practices supported to identify and recall unscreened and underscreened

Māori women

By 31/12/2016 Te Kupenga Hauora o Tauranga Moana will establish regular cervical screening

clinics at Tauranga Hospital specifically targeting Support Services where there are

high eligible Māori women employed. Eligible women will also be encouraged to enrol

and book a breast screening appointment at the time of screening Performance Measure: Number of women screened at the clinic

By 30/06/2017

Strengthen the communication skills of Primary Care Provider staff to enable

improved cervical screening health literacy and improved access to cervical

screening services particularly for Māori women Performance Measure: Number of training sessions delivered on taking a best practice health literacy

approach to cervical screening

By 31/12/2016 ISPs and Colposcopy to undertake a quality initiative to review and improve the

relevant administration processes so Māori women receive timely colposcopy

treatment Performance Measure: Māori women receive timely colposcopy treatment

Ongoing Monitor performance on a monthly basis within the BOPDHB Māori Health Planning

and Funding team. Monitor screening performance on a quarterly basis through the MHSG.

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It is acknowledged that the national cervical screening program facilitated by the NSU provides coverage for

women aged 20-69. The BOPDHB Māori Health Plan 2014/15 refers to the 25-69 year age group in keeping with the indicator guidance listed on page 154 of the 2014/15 Operational Policy Framework on the National Service Framework Library website.

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Performance Measure: Screening performance is monitored monthly and quarterly

and key actions to lift performance are identified.

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Smoking cessation in pregnancy

Outcome we seek: More Māori women who are smokefree at two weeks postnatal.

How will we know if we have been successful?

The percentage of Māori women who were pregnant and were offered smoking cessation advice and support and who are smokefree at two weeks postnatal will increase over 2016/17 as a result of our efforts.

Target: 95%

Māori: 61% (Jan-June 2014)

Non-Māori: 80% (Jan-June 2014)

What we are planning to do:

By 30 September 2016 Enhance referral pathways from LMCs, DHB midwives and ante-natal education

providers to national and local smoking cessation providers, taking into account new

providers and programmes funded by the Ministry following the Realignment of

tobacco control services RFP process.

By 31 December 2016 Provide training appropriate to providers and DHB staff on engaging with Māori

pregnant women (and their whanau) and their smoking behaviours. Training will differ

for staff depending on whether they are carrying out ABC and referring, or delivering

a regular supportive quit smoking programme for Māori smoking pregnant women.

By 1 April 2017 Increase the proportion of smoking Māori pregnant women who accept cessation

support from 15.8% (Q2 2015/16 result) to 40%.

Ongoing Work with the MoH to improve reporting on this indicator. Monitoring of the target at two weeks postnatal is not timely with a long lag period for

results. It is not useful therefore for monitoring results changes quickly following

introduction of new activities. Maternity tobacco data collected at registration with LMC is reported quarterly but

does not reflect smoking status at two weeks postnatal.

Ongoing Monitor smoking cessation advice provision performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team. Monitor smoking cessation advice provision and smokefree rates at two weeks postnatal on a quarterly basis through the Māori Health Plan Steering Group.

20

Percentage of infants fully immunised by eight months of age

Outcome we seek: Reduced immunisation-preventable morbidity and mortality.

How will we know if we have been successful?

95% of Māori infants will be fully immunised by eight months of age (by 31 December 2014).

Target: 95%

Māori (Q2 2016): 86.2%

Non-Māori (Q2 2016): 88.6%

What we are planning to do:

By 30 June 2017 We will have met with at least 50% of Lead Maternity Carers (LMCs) in the Bay of

Plenty by 30 June 2017 and agree a way forward to refer all expectant Mother’s

information to their respective GP at an earlier stage (when antenatal bloods

available) so the practice can set up immunisation notifications. We will report progress on this initiative to the Māori Health Plan Steering Group on

the following four dates: 1) 30 September 2016, 2) 31 December 2016, 3) 31 March

2017, and 4) 30 June 2017.

By 30 September 2016 We will conduct a review of the immunisation outreach services (OIS) contracts with

PHOs to ensure the different models currently used are meeting the 95% target by

31 July 2016. We will explore with PHOs the potential benefits for the co-location of immunisation

outreach staff and customise our approaches in order to reach 100% of non-

immunised babies by 30 September 2016. We will report to the Māori Health Plan Steering Group on interventions that will

increase integration between the OIS, immunisation facilitators at the DHB and

PHOs, and the NIR. We will report on the completion of these initiatives to the Māori Health Plan Steering

Group by 30 September 2016.

By 30 June 2017 We will work closely with our PHOs to ensure that immunisation information relayed

to parents, GPs, Nurses and the general public is consistent. We will work closely

with individual PHOs to implement at least 3 immunisation promotional activities

each by June 2017. We will report progress on this initiative to the Māori Health Plan Steering Group on

the following three dates: 1) 31 December 2016, 2) 31 March 2017, and 3) 30 June

2017.

Ongoing Monitor immunisation performance on a monthly basis within the BOPDHB Māori

Health Planning and Funding team and via the BOPDHB Planning and Funding

immunisation champion. Monitor immunisation performance on a quarterly basis through the Māori Health

Plan Steering Group.

21

Seasonal influenza immunisation rates (65 years and over)

Outcome we seek: Reduced influenza morbidity through increased seasonal influenza vaccination rates

in the eligible population (65 years and over).

How will we know if we have

been successful? 75% of Māori in the eligible population will have received the seasonal influenza

vaccination in the period January to July 2016.

Target: 75%

Māori (Q1 2014-15): 62.6% (High-needs population)

Non-Māori (Q1 2014-15): 69% (Total population)

What we are planning to do:

By 31 May 2017 Promotion of the seasonal influenza vaccination through PHOs, Māori Women’s

Welfare League, Koroua and Kuia health service providers, Whanau Ora providers,

and other Hauora providers, using the locally developed te reo resource. N.B. There is no national strategy for increasing uptake in Māori, nor any national

health education resources produced in te reo.

By 31 May 2017 Promotion of the seasonal influenza vaccination through Māori media such as the

Māorivation programme on Moana FM Tauranga.

By 31 May 2017 Enhanced recall processes in general practice for Māori patients aged 65+. This

would involve more proactive engagement with whanau following the standard

patient recall systems.

Ongoing Coverage rates are available by PHO by ethnicity through national data collections

for primary health. This data is available on a quarterly basis only and is derived

from practice payment claims. Data is also available from the NIR for vaccinations delivered in general practice and

probably by 2017 winter from pharmacies, DHB staff and perhaps from other

occupational health nursing services. The NIR data would be available monthly

through datamart.

Monitor immunisation performance on a monthly basis within the BOPDHB Māori

Health Planning and Funding team and via the BOPDHB Funding and Planning

immunisation champion. Monitor immunisation performance on a quarterly basis through the Māori Health

Plan Steering Group.

22

Reduction in rheumatic fever rates

Outcome we seek: Reduced rates of acute rheumatic fever.

How will we know if we have

been successful? The admission rate for an initial case of acute rheumatic fever in BOPDHB will reach

the target for BOPDHB established by the Ministry of Health, as part of the national

two thirds reduction in hospitalisations by 2017.

Target: Reduction of first episode ARF cases in total population to 3 over the 2016/17 year. Reduction of first episode ARF rate in total population to 1.3/100,000 over the

2016/17 year.

What we are planning to do: Detailed actions are documented in the Bay of Plenty Rheumatic Fever Plan 2013-

17. Key activities are described below:

By 31 December 2016 Planning and implementation of a sustainable healthy housing programme across

the BOP incorporating existing community projects in Western BOP District Council,

Murupara township and Opotiki.

By 31 December 2016 Development of a funding strategy for 2017/18 that will allow the continuation of

evidence-based sore throat management programmes in schools, community, and

general practice that reach the priority populations.

By 31 July 2016 (ongoing) Carry out systems failure analysis of all new notifications of acute rheumatic fever,

and put into place all recommendations arising from that analysis.

By 1 July 2016 and ongoing Delivery of an effective, quality Bicillin preventative programme through district

nursing primarily across the BOP district.

Ongoing Reconciliation of regulatory notifications to the Medical Officer of Health with

admission records to obtain current numbers of cases and rates. Oversight of all healthy housing activity in the BOP (and lakes) DHB districts by a

multiagency Healthy Housing Forum to be established by 30 September 2016.

Completion of 2015/16 Bicillin programme audit using the BOP rheumatic fever

register, and utilise the data to inform ongoing quality improvements. Undertake a case review of all cases of first episode acute rheumatic fever, and

complete any actions determined from those case reviews. Use information and recommendations from the national evaluation of the cost

effectiveness of all school-based sore throat management programmes to determine

the future of these programmes.

By 1 July 2017 Implementation of a sustainable programme in primary and community care for easy

access for sore throat management of priority populations outside of school-based

programmes. Priority populations are 4-19 year old Māori and Pacific living in

Quintile 5 neighbourhoods.

Ongoing Monitor performance on a monthly basis within the BOPDHB Māori Health Planning

and Funding team. Monitor screening performance on a quarterly basis through the Māori Health Plan

Steering Group.

23

Oral health

Outcome we seek: Improved oral health outcomes for Māori children.

How will we know if we have been successful?

95% of Māori preschool children will be enrolled in a dental clinic.

Target: 95% by 31 December 2016

Māori (December 2015): 67%

Non-Māori (December 2015):

88%

What we are planning to do:

By 31 December 2016 A 95% enrolment rate for preschool Māori by 31 December 2016 will be achieved by:

● Commencing a data matching project between July-September 2016 to match client data between NIR and Titanium through BOPDHB Data Intelligence Service. This will identify children not enrolled Community Dental Services (CDS).

● CDS to commence contacting these families of non-enrolled children by leveraging and utilising the existing networks of NGO providers, Wellchild and Hauora Māori in the BOPDHB region from October 2016.

● Continue to work with Māori Regional Health Services to have greater reach into communities through the CDS Oral Health Promotion Team. Target regions will be the East Coast from Opotiki – Whangaparaoa and Murupara due to rurality, isolation and deprivation. The aim will be to deliver “lift the lip training” for the under 5yr olds as an early intervention tool to Kaupapa Māori Organisations, Marae and Kohanga/Kura. The Oral Health promotion team will also deliver healthy cooking and oral health nutrition programmes within these settings. These initiates will be delivered between July 2016 and March 2017.

● Continue to track referral sources for pre-enrolment requests from July 2016 and to review this information monthly to determine where additional focus needs to occur.

By 30 September 2016 The Oral Health Promotion team is to develop the train the train programme for oral health promotion to ECC’s into a resource for Kohanga Reo that is translated into Te Reo by September 2016. This resource is to be used for:

● To train Kohanga Reo Kaiako (Teachers) to deliver this programme to increase awareness of good oral health nutrition and practices for the children and their families. Promotion and Training to commence from October 2016.

● To enable Te Kohanga Reo to adopt further good oral policies and practices based on this programme and for this to be ongoing.

● To work collaboration with Kohanga Reo to gain more participation in World Oral Health Day (March) and National Oral Health Day (November) each year.

● Oral Health Promotion Team to measure participation and effectiveness of this programme by 30

th June 2017.

Ongoing Monitor dental clinic enrolment performance on a monthly basis within the BOPDHB Māori Health Planning and Funding team and via the BOPDHB Funding and Planning oral health champion. Monitor dental clinic enrolment performance on a quarterly basis through the Māori Health Plan Steering Group.

24

Mental health

Outcome we seek: Appropriate rates of use of Section 29 of the Mental Health Act (community treatment order).

How will we know if we have been successful?

To be determined in collaboration with the MoH.

Target: No targets set for 2016/17

Māori (Q1 2016): 196 per 100,000 per year

Non-Māori (Q1 2016): 37 per 100,000 per year

What we are planning to do:

By 31 August 2016 Identify variance in use of Section 29 across BOPDHB by establishing consistent data collection processes for this indicator.

By 30 September 2016 Analyse the degree of variance in use of Section 29 within the DHB by reviewing the rationale for its use in samples of Māori patients seen by different practitioners in different parts of BOPDHB. Compare Māori and non-Māori patients.

By 30 October 2016 Report findings of analyses to practitioners and a clinically-led multidisciplinary mental health forum. Develop guidelines and regular auditing processes to support standardised application of Section 29 throughout BOPDHB.

By 1 November 2016 (Ongoing)

Monitor the impact of the implementation of guidelines and auditing processes.

Ongoing Monitor indicator performance on a quarterly basis through the Māori Health Plan Steering Group.

25

Sudden Unexpected Death of an Infant (SUDI)

Outcome we seek: Lower rates of SUDI among Māori infants.

How will we know if we have been successful?

The rate of SUDI among Māori infants will be 0.4 cases per 1,000 live births or less.

Māori (baseline): 1.93/1,000 live births, compared with 1.75/1,000 live births for all Māori in New Zealand, and 0.38/1,000 live births for non-Māori. Five year annualised rate of SUDI 2010-2014. Data supplied by the Ministry of Health. 46.7% of Māori infants had a caregiver provided with SUDI information at Core Contact 1 in 2014.

Targets: 0.4 cases per 1,000 live births or less. 70% of caregivers of Māori infants are provided with SUDI information at Well Child Tamariki Ora Core Contact 1.

What we are planning to do:

Ongoing BOPDHB to continue to fund the Pepi Pod program and wahakura wananga

By 30 June 2016 Improve the number of infants receiving all Well Child Tamariki Ora (WCTO) core contacts in their first year of life, along with SUDI provision, by ensuring the WCTO Quality Improvement Plan includes the following actions:

● Complete Core Contact one before 49 days of age ● Provide SUDI information at core contact 1

By 30 June 2016 Improve the number of infants enrolled with LMCs and WCTO providers, by ensuring the WCTO Quality Improvement Plan includes the following actions:

● a confirmed newborn enrolment process ● a triple enrolment form at birth ● having a focus on early referral to WCTO

By 30 September 2016 Ensure that safe sleep practices are implemented in healthcare settings as follows: ● Key BOPDHB staff, WCTO and Antenatal Parenting providers will receive

mandatory education and resources that promote safe infant sleeping practices and SUDI prevention, including ways of communicating risk to parents and caregivers, and families / whanau.

● Each BOPDHB service will be responsible for providing safe sleeping arrangements for infants up to one year of age who sleep within BOPDHB facilities.

● All parents/caregivers with infants up to one year of age will be informed about safe infant sleeping and SUDI prevention.

● BOPDHB staff will advise and role model only safe infant sleeping, safe night feeding and safe settling practices within BOPDHB facilities (and when relevant in community settings) and promote these as strategies to use at home.

● Infants who are exposed to any smoking, alcohol or drug use during pregnancy, who are born before 36 weeks gestation or less than 2500gm birthweight will be assessed as being vulnerable to SUDI. This assessment will be documented as part of routine health care for all infants up to one year of age that are placed to sleep within BOPDHB facilities.

● A care plan for infants vulnerable to SUDI will include smoking cessation action and discharge planning by staff to support safe infant sleeping arrangements at home, e.g. referral to the Pēpi-Pod® Programme for infants 0 – 6 weeks, SUDI risk information will be included in the discharge summary to primary health care.

● All BOPDHB facilities that provide sleeping arrangements for infants up to one year of age will be supported by ‘Safe Sleep Champions.’

26

● Monitoring of safe infant sleeping in BOPDHB facilities will be achieved by regular audit using an approved audit tool.

By 30 June 2016 Review and evaluate Antenatal and Parenting services for effectiveness, efficiency and consistency. A report on this review/evaluation will be provided to the Māori Health plan Steering Group by 31 July 2016.

By 1 July 2016 Ensure that all the Antenatal and Parenting education programs delivered from 1 July 2016 must include information about safe infant sleeping and SUDI prevention.

● Prior to 30 June 2016, the champions will meet with all Well Child Tamariki

Ora, LMC and Plunket providers to ensure they understand the

requirements of the target from 1 July 2016 to 30 July 2017.

● LMC, Well Child Tamariki Ora, and Plunket providers have an early

intervention approach to SUDI prevention and refer vulnerable infants to the

Pepi-Pod Programme.

● 70% of referrals to the Pepi-Pod Programme will be made by LMCs (currently <50%).

Ongoing Monitor indicator performance on a quarterly basis through the Māori Health Plan Steering Group.

27

Local Indicators

Did-Not-Attend (DNA) rate for outpatient appointments

Outcome we seek: Lower did-not-attend (DNA) rates by Māori in outpatient appointments clinics.

How will we know if we have been successful?

The DNA rate for outpatient appointments for Māori will reach 5%.

Target: 5%

Māori (YTD): 15.6%

Non-Māori (YTD): 4.4%

What we are planning to do:

By July 2016

Plan of specific initiatives based on stakeholder (internal and external) meetings

about current and previous work, enablers and barriers to attendance is in place. Organisational monthly reporting dashboard available to these stakeholders to

document progress. For clinics with DNA rates >12% there is specific senior management intervention.

Reporting progress through to the Hospital Advisory Committee. Dedicated resource from Māori Health management teams to work within the

Service Improvement Unit as the Māori DNA lead

By July 2016

Establish partnerships at Executive level with six Iwi across the Bay as a means to

understanding the varying local issues communities face and to better understand

how the system is not working for Māori. Ensure learnings are publicised on our

intranet for future reference

By July 2016 Provide DHB website information to support literacy, access and other information

for Māori which addresses issues that Iwi have raised as barriers to attendance

By August 2016

Implement new systems to ensure specific patient populations have systems in

place to reduce barriers to attendance e.g. patients from Matakana Island have

appointments which fit within barge transport times, potential to provide community

group hospital appointments on the same day - use IHI Methodology and small tests

of change to trial

By October 2016 Expand the Patient Information Centre to include a member of staff who speaks Te

Reo. Ensure PIC processes/practices document and meet cultural requirements to

reduce barriers to attendance.

By November 2016 Work with Ko Awatea to transition the informal DHB DNA network started by

BOPDHB to the proposed national Innovation Hub to share national successes and

learnings in Māori DNA improvements

By December 2016 Communications Plan in action to ensure organisational knowledge about initiative

achievements and focus of future improvements – shared with internal and external

stakeholders.

By February 2017 Move outpatient appointment services closer to home for renal patients living in

Whakatane.

28

Ongoing

Monitor DNA performance on a monthly basis within the BOPDHB Māori Health

Planning and Funding team and via the provider arm DNA champion. Monitor DNA performance on a quarterly basis through the Māori Health Plan

Steering Group.

29

Appendix A – Methodology for Local Indicator Selection

Local indicators were developed through a five-step process involving:

1. Identification of information sources; 2. Identification of leading health issues; 3. Ranking health issues; 4. Scoring the leading health issues; 5. Review and finalisation

1. Identification of Information Sources

External Information Sources

The most useful source of health needs information was a 2008 Health Needs Assessment completed by

the MOH. This document provided epidemiological summaries for a range of conditions stratified by age

gender, and ethnicity. Health service utilisation was also presented.

Internal Information Sources

Epidemiological and service utilisation reports were gathered from Toi Te Ora – Public Health Service,

Funding and Planning, and the DHB’s Population Health Advisory Group (PoPAG).

2. Identification of Leading Health Issues

Health conditions and service utilisation issues were collected in a spreadsheet if they met the following

criteria:

a) A statistically significant difference between Māori and non-Māori outcomes was present; b) There were high inequalities between Māori and non-Māori in BOPDHB (a rate ratio of 1.2 or

greater was used) – indicating worse health outcomes for Māori compared with non-Māori within the DHB;

c) There were high inequalities between Māori in BOPDHB and Māori nationally (a rate ratio of 1.2 or greater was used) – indicating worse health outcomes for Māori in BOPDHB than Māori in the rest of the country.

3. Ranking Health Issues

Rate ratios between Māori and non-Māori on BOPDHB were calculated. The list of health conditions and

service utilisation options were then ranked based on the size of the rate ratio – this gave a measure of

inequality within BOPDHB.

4. Scoring Health Issues

The issues with the highest rate ratios were scored against a list of indicator selection criteria developed

by the National Centre for Health Outcomes Development (NCHOD).

5. Review and Finalisation

The highest scoring options were reviewed by a public health physician from the regional public health

unit, before a set of three condition related indicators were finalised with the DHB’s PoPAG and the

General Manager Māori Health.

30

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