Rheumatology Services Model of Care_2007_Lakes DHB

RHEUMATOLOGY SERVICES MODEL OF CARE

2007

Rheumatology Model of Care Report March 2007 2

This review was completed by Andrea Jopling


TABLE OF CONTENTS EXECUTIVE SUMMARY Page 5 SECTION 1 RATIONALE Page 8 SECTION 2 SERVICE STANDARDS Page 17 SECTION 3 CURRENT SERVICE DELIVERY Page 22 SECTION 4 SYNERGIES WITH OTHER LDHB SERVICES 0 SECTION 5 SERVICES DELIVERED BY OTHER DHBS Page 31 SECTION 6 STAKEHOLDER ENGAGEMENT AND EXPERT OPINION Page 35 SECTION 7 PROPOSED MODEL OF CARE Page 38 SECTION 8 PROPOSED SERVICE REQUIREMENTS Page 41 SECTION 9 DIAGNOSTIC REQUIREMENTS Page 47 SECTION 10 PHARMACEUTICAL REQUIREMENTS Page 49 SECTION 11 FACILITY REQUIREMENTS Page 52 APPENDICES


EXECUTIVE SUMMARY The management of chronic conditions is one of the greatest challenges facing health care systems, and Lakes District Health Board (DHB) must develop solutions for managing the rising burden of the dramatic increase in chronic conditions. It is estimated that one in six New Zealanders over the age of 15 lives with at least one type of arthritis, and this number is expected to rise as the population ages. The proposed Model of Care and recommendations in this report were developed with input from local stakeholders and experts and in light of evidence based guidelines from overseas. The report makes the following recommendations:

1. That the model of care below be implemented by Lakes DHB.

Referral as agreed to

Return to GP

Referral to

Refer to

General PracticeGeneral PracticeGeneral PracticeGeneral Practice

Referral TriageReferral TriageReferral TriageReferral Triage

(Rheumatologist)

Other specialtiesOther specialtiesOther specialtiesOther specialties

Book patient

Specialist Outpatient ClinicsSpecialist Outpatient ClinicsSpecialist Outpatient ClinicsSpecialist Outpatient Clinics

(Rheumatologist) Holistic AssessmentHolistic AssessmentHolistic AssessmentHolistic Assessment

(Rheumatology Nurse)

Nurse takes recommendations to

MultiMultiMultiMulti----DisciplinaryDisciplinaryDisciplinaryDisciplinary Team meeting Team meeting Team meeting Team meeting

(Core team = rheumatologist, nurse, physio, OT, counsellor)

CarePlus CarePlus CarePlus CarePlus

Nurse led clinics & helpline

OT Comm’y-based education

MDT lead Intensive Rehab

Orthotics GP/ CarePlus

Physio Podiatry Dietetics Counsell’g

Health PromotionHealth PromotionHealth PromotionHealth Promotion

Health Promotion

Health Promotion

Health Promotion

Health Promotion


2. That Lakes DHB considers implementing a common approach to chronic care management across services to meet the needs of growing numbers of patients living with chronic conditions.

3. That should Lakes DHB decide to take advantage of the potential benefits of

overhead cost reduction, cross-specialty collegiality, facility and systems sharing by merging the AT&R and rheumatology services; that the specialised skills, knowledge and experience inherent in the rheumatology services be maintained and protected within the wider AT&R function by preserving a core multi disciplinary team dedicated to rheumatology.

4. That CarePlus services be developed for PHO enrolees living with chronic

rheumatological conditions and who meet the eligibility criteria, as part of an integrated and coordinated rheumatology service.

5. That the links between PHOs and Arthritis NZ are supported and encouraged

and the potential for the community based sector to deliver services such as the expert patient and train the trainer courses for people living with arthritis and musculoskeletal disorders is realised.

6. That Lakes DHB continues to purchase 600 First Specialist Assessments and

1200 Follow-up appointments in the short term. These services should be delivered by specialist rheumatologists and that approximately one third of the specialist appointments should be provided in Taupo.

7. That Lakes DHB purchase a total of 0.6FTE Rheumatology Nurse Specialist

to perform nurse led clinics, holistic needs assessments, MDT coordination and helpline services and that nurse led clinics and holistic needs assessments are delivered regularly in Taupo.

8. That the focus of the rheumatology service should be an outpatient multi

disciplinary team model.

9. That the number of intensive rehabilitation bed days be reduced to 177 inpatient and 157 outpatient bed days per annum and are reserved for those patients who are most severely disabled by their disease and whose needs cannot be met through the outpatient MDT services.

10. That consideration should be given to the provision of intensive rheumatology

rehabilitation in Taupo as part of the wider AT&R model of care.

11. That Lakes DHB considers convening a working party to develop formalised criteria upon which to base referrals to intensive inpatient/day patient rehabilitation programmes.

12. That Lakes DHB purchases 2730 outpatient physiotherapy contacts in the

next funding round, and increase of 30% on 2006/07 volumes.

13. That physiotherapy services for patients referred through the rheumatology MDT process are delivered by physiotherapists experienced in and dedicated to the delivery of rheumatology services.

14. That rheumatology physiotherapy services are established in Taupo to

service the Taupo/Turangi communities.


15. That Lakes DHB purchase 320 occupational therapy contacts in the next funding round, and increase of 30% on 2006/07 volumes.

16. That occupational therapy services for patients referred through the

rheumatology MDT process are delivered by occupational therapists experienced in and dedicated to the delivery of rheumatology services.

17. That rheumatology OT services are delivered in Taupo for the Taupo/Turangi

population. 18. That Lakes DHB purchase 80 counselling contacts in the next funding round,

and increase of 100% on 2006/07 volumes and that outpatient counselling services should be delivered in Taupo to the Taupo/Turangi population as a visiting service when required.

19. That counselling services for patients referred through the rheumatology MDT

process are delivered by counsellors with experience in the delivery of services to patients living with chronic diseases, particularly rheumatology.

20. That adequate support is in place to perform the administrative tasks

essential to the efficient operation of the rheumatology service.

21. That Lakes DHB monitors any developments in diagnostic investigations in order to foresee future direct and indirect costs.

22. That Lakes DHB continues to monitor developments in drug therapies as an

area likely to have significant impact against the pharmaceutical budget in the short to medium term future.

23. That key facilities for the provision of a rheumatology service include,

examination rooms and a clean area, rooms for nurse led clinics and holistic assessments, limited medical day stay facilities, OT assessment area, physiotherapy gym, hydrotherapy facilities, room for individual and group counselling and education, inpatient and day patient intensive rehabilitation beds and acute medical beds as required.


SECTION 1 RATIONALE

1.1 Purpose of Project The aim of this project was to produce a modern Model of Care from which to develop rheumatology services for the Lakes DHB using expert input, evidence based best practice guidelines and consumer engagement.

1.2 Background Rheumatology deals with the investigation, diagnosis, management and treatment of patients with arthritis and other musculoskeletal conditions. The term ‘musculoskeletal conditions’ incorporates over 200 disorders affecting joints, bones, muscles and soft tissues. These include inflammatory arthritis, soft tissue conditions, autoimmune rheumatic disorders, osteoarthritis, spinal pain and metabolic bone disease. While a large number of musculoskeletal conditions are confined to the musculoskeletal system, many also affect other organ systems, making their management complex.1 In practice, the conditions which may be referred for a rheumatological assessment can be largely grouped under the headings of Arthritis – which includes rheumatoid arthritis (the most common form of inflammatory arthritis), ankylosing spondylitis, psoriatic arthritis and juvenile idiopathic arthritis (JIA) and osteoarthritis; Soft tissue and Bone Disease including osteoporosis, fibromyalgia, tendonitis and Vasculitis and Connective tissue disease including lupus, Sjogren’s syndrome and polymyalgia. Many of these conditions are termed chronic in that they will persist and require a sustained level of management over time. Patients with chronic disabling diseases do not fit comfortably within the traditional medical model of patient care. The effects of chronic disease on the individual can result in a wide variety of psychological, social and rehabilitation needs that cannot be adequately met in a service which is focused on acute and episodic interventions. Chronic conditions place a significant burden on social, welfare and economic systems through temporary and permanent absences from work, lost productivity and increased demands on familial structures. According to a report commissioned by Arthritis NZ in 2005, almost 522,000 (16.2% or 1 in 6) New Zealanders aged 15 or over were living with at least one type of arthritis. Over half of these were of working age (15-64 years). The prevalence of arthritis is expected to grow to around 719,300 (or 19.2% of the 15 plus population group) by 2020 due to ageing. In 2005, 25,440 New Zealanders were out of work due to arthritis costing the country over $1bn in lost productivity.2 Rheumatology services have been delivered to Lakes patients for many years by QE Health (QEH), a non-DHB community trust owned private hospital in Rotorua. The rheumatology contract between Lakes DHB and QE Health amounted to approximately $1.2 million in the 2005/06 financial year. As a comparison, Lakes DHB funded the DHB hospital Assessment, Treatment and Rehabilitation (AT&R) service at a little under $2 million per year to provide rehabilitation for every other disease state including stroke, dementia and cardiovascular diseases. This apparent imbalance has lead to concerns regarding the equity of access to services for Lakes patients living with different conditions.


The relationship between QE Health and Lakes DHB has at times been an uneasy one, with questions being raised by the DHB regarding the high level of input for patients accessing inpatient and day patient rehabilitation programmes and frustration on the part of QE Health believing that the service they deliver is neither understood nor valued by the funder. Two rheumatology reviews have been conducted in recent times, by Andrew Harrison in May 2003, and Jan Barber in March 2004. Since then, Waikato and Taranaki DHBs have exited the once Midland-wide contract with QEH – for which Lakes was lead DHB - and are funding and providing rheumatology services independent of a regional contract. They are continuing to purchase limited volumes of service from QEH. As of 1 July 2006, it was agreed that the three remaining DHBs, being Lakes, Bay of Plenty and Tairawhiti would contract autonomously with QE Health whilst each worked on a business case to determine the nature of future service provision for their own populations. In mid 2004 Lakes DHB commissioned a Clinical Services Plan (CSP) to introduce modern models of care and drive the options for facility development across the continuum of clinical services funded and provided for Lakes patients. The Lakes Health Services Improvement Project (LHSIP) is now taking the principles of the CSP forward in order to develop and implement new patient centred models of care and gain approval for facility developments at the DHB hospital sites from the National Capital Allocation Committee. This project worked within the LHSIP framework to develop a model of care for Rheumatology, however, a Content User Group was not chosen as the preferred process. Given the likely warmth of feeling surrounding the issues and in order to enable a wide range of people and opinion to be heard during the process, it was decided that small group and individual meetings would be convened.

1.3 Method A large number of documents were reviewed including but not limited to:

• Lakes DHB Strategic and Annual Plans • Lakes DHB Health Needs Assessment, 2004 • Service Coverage Schedule and Service Specifications • Lakes DHB Clinical Services Plan 2005 • NSW Guide to the Role Delineation of Health Services, 2002 • NHS Scotland Guide to Service Improvement • National Referral Guidelines and National Access Criteria for First Specialist

Assessment • Local and international clinical and best practice guidelines • Elective Services Strategy, 2000

A large number of individuals and groups were interviewed in one-to-one meetings and telephone conferences. Details are provided in Section 6 of this report. Inpatient and outpatient data was collected and analysed from Lakes DHB hospitals. Data was also requested from QE Health. Some other DHBs were also contacted to provide information. It should be noted that difficulties in accessing data from QE Health due to IT system inadequacies did hamper the analysis of service user information somewhat.


1.4 Demographic Profile of Lakes DHB

Lakes District

Rotorua

Taupo

Tauranga

Whakatane

Hamilton

Taumaranui

New Plymouth

Hastings

Gisborne

Hawera

Wanganui

Thames

Te Kuiti

TokoroaMurupara

Turangi

Mangakino

The information in this section is taken largely from the Lakes DHB Health Needs Assessment 20043 and is used to provide an overview of the Lakes DHB population. In 2004 it was estimated that there were 102,225 people living in the Lakes DHB area with around two thirds of these living in the Rotorua Territorial Local Authority (TLA) and one third living in the Taupo TLA (the latter includes approximately 3500 resident in Turangi and 1,300 in Mangakino). Lakes DHB’s population is currently relatively youthful compared to the total New Zealand population. However the age structure of Lakes and New Zealand is projected to change dramatically by 2026. The Lakes population of older people is projected to increase from 10,662 (11.1% of the total population) at the 2001 census to 23,605 (21.5% of the projected total population) in 2026. As a percentage of the TLA population, the increase in older people will be more evident in Taupo although the increase in actual numbers of older people will be higher in the Rotorua TLA. The Lakes DHB Health Needs Assessment 2004 outlines that this shows the effect of ‘population ageing’ or transition from a younger to an older population structure, reflecting the combined impact of sub-replacement fertility (when live birth rates are below the level that the population needs to replace itself without migration), longevity gains (longer life expectancy) and the ageing of the large “baby-boom” cohorts of the 1950s-1970s. Since the over 65 age group has high health needs and consumes more health services than younger age groups, the increasing proportion of older people is likely to place a higher demand on health and disability services. The changing age structure of the Lakes district requires consideration when planning services such as rheumatology as an ageing population will lead to an increase in the number of patients living with arthritic conditions which will require diagnosis and management. At 35%, the proportion of Maori in the Lakes population is significantly higher than in the national population which stands at 15%. Throughout NZ, Maori and Pacific


populations have higher proportions of younger people and fewer older people than other ethnic groups due to their higher birth rates and lower life expectancy. However, the number of Maori aged over 65 in Lakes is projected to increase from approximately 500 in 2001 to around 1900 people by 2026.

1.5 Global Strategic Directions Around the world, increasing emphasis is being placed on the burden of chronic diseases as a group, and also more specifically musculoskeletal conditions. Chronic Care Management The term ‘Chronic Condition’ is used to describe health problems that persist across time and require some degree of ongoing health care management. Globally, as in New Zealand, chronic conditions are on the increase due to several factors including the ageing of populations, urbanisation and the adoption of unhealthy, sedentary lifestyles. Increasingly, people are living with one or more chronic conditions for decades placing new, long term demands on health systems. In 2002, the World Health Organisation published a report Innovative Care for Chronic Conditions: Building Blocks for Action4 alerting decision makers to the reality that the management of all chronic conditions is one of the greatest challenges facing health care systems globally, and to present health care solutions for managing the rising burden placed on systems by the dramatic increase in chronic conditions. The report predicts that as long as the acute model continues to dominate health systems, health care expenditure will continue to escalate but improvements in populations’ health status will not. The WHO report identifies the following eight essential elements for taking action to better manage chronic conditions:

I. Support a Paradigm Shift Health care services which are organised around an acute, episodic model of care no longer meet the needs of many patients, especially those with chronic conditions. Patients, healthcare workers and decision makers must recognise that effective chronic condition care requires a different kind of healthcare which is extended and regular in its nature.

II. Manage the Political Environment For change in the care of chronic conditions to be successful, it is crucial to build consensus and political commitment among stakeholders.

III. Build Integrated Health Care Care for chronic conditions needs integration to ensure shared information across settings and providers and across time (from the initial patient contact onwards).

IV. Align Sectoral Policies for Health The policies of all sectors which affect health need to be aligned to maximise health outcomes.

V. Use Health Care Personnel More Effectively Organisations require team care models and evidence-based skills for managing chronic conditions. Advanced communication skills, behaviour change techniques, patient education and counselling skills are necessary in helping patients with chronic conditions. Clearly workers do not have to be


physicians to provide such services and healthcare personnel with less formal education and trained volunteers have critical roles to play.

VI. Centre Care on the Patient and Family Emphasis must be placed on the patients’ central role and responsibility in healthcare because the management of chronic conditions requires lifestyle and daily behaviour changes. This will require a shift in the current clinical practice of many healthcare workers and systems which relegate the patient to the role of passive recipient of care.

VII. Support Patients in their Communities Healthcare has to extend beyond the clinic walls and permeate patients living and working environments. Communities can fill a crucial gap in health services that are not provided by organised healthcare.

VIII. Emphasise Prevention Strategies for reducing onset and complications of many chronic conditions include early detection, increasing physical activity, reducing tobacco use and limiting prolonged unhealthy nutrition. Prevention should be a component of every health care interaction.

The Bone and Joint Decade The Bone and Joint Decade was formally launched in January 2000 at the headquarters of the World Health Organisation in Geneva. This came on the heels of the November 1999 endorsement by the United Nations. UN Secretary General, Kofi Annan said, "There are effective ways to prevent and treat these disabling disorders, but we must act now. Joint diseases, back complaints, osteoporosis and limb trauma resulting from accidents have an enormous impact on individuals and societies, and on healthcare services and economies." The goal of the Bone and Joint Decade is to improve the health-related quality of life for people with musculoskeletal disorders throughout the world which cause severe long-term pain and physical disability and affect hundreds of millions of people across the world. The Bone and Joint Decade aims to raise awareness and promote positive actions to combat the suffering and costs to society associated with musculoskeletal disorders such as joint diseases, osteoporosis, spinal disorders, severe trauma to the extremities and crippling diseases and deformities in children. The campaign aims to: � Raise awareness of the growing burden of musculoskeletal disorders on

society � Empower patients to participate in their own care � Promote cost-effective prevention and treatment � Advance understanding of musculoskeletal disorders through research to

improve prevention and treatment

1.6 Local Strategic Directions and Accountability R equirements Decisions regarding the provision and nature of services to be provided by Lakes DHB are made within a framework of accountability requirements and strategic directions with are dictated and influenced by several sources. They include the Board of the DHB, Ministry of Health and established clinical practice as well as numerous reviews, reports and recommendations from previous projects within Lakes DHB. The project manager examined a large number of these accountability


requirements, strategic and operational plans, and their impact on the provision of rheumatology services are outlined in this section. They are in no specific order. National Health Committee The National Health Committee is an independent advisory group to the Minister of Health. It provides advice on a wide range of health and disability issues. In 2005 the NHC published a discussion document5 outlining the following information: � Most New Zealanders now die of chronic conditions. Chronic illness accounts

for over 80% of all deaths � The management of chronic conditions is the leading cause of hospitalisations � It is estimated that 70 percent of health care funding is spent on chronic

disease � The most common chronic conditions in New Zealand (by diagnosis) are:

o chronic neck or back problems (one in four adults) o mental illness (one in five adults) o asthma (one in five adults aged 15-44 yrs) o arthritis (one in six adults) o heart disease (one in ten adults)

The NHC, in its draft report to the Minister of Health comments that funding, education and delivery of health care have pursued a cure-focussed approach that focuses on turning acute episodes into survivable events. Different systems are needed to allow for a flow from episodic to continuous care and to provide for ongoing, regular contact between people with chronic conditions and health professionals. Different models are needed for the longer-term relationships with people who have chronic conditions, models that place a greater emphasis on communication and multi-disciplinary teamwork. There should be a strong focus on patient self-management and greater attention paid to the psychosocial, emotional and spiritual well-being of patients. All these changes aim to provide effective care for people with chronic conditions by providing coordinated and integrated services throughout an individual patient’s life course and across the health continuum of populations. Lakes DHB Strategic and Annual Plans Rheumatology is not specifically identified as a priority area in the Lakes DHB District Strategic Plan (DSP) or the District Annual Plan 2005/06 (DAP). However, there are some generic directions which have resonance for this project. The three main priorities of the Lakes District Health Board are: � To achieve continuing improvement in health outcomes and disability support

for Maori in the Lakes region � To achieve improvements in the quality of health services within the region � To reduce inequalities among the Lakes DHB population

The District Strategic Plan (DSP) also acknowledges that it must improve a number of areas, including: � Addressing the significant workforce issues that exist � Addressing service and facility issues � Ensure models of care and the facilities in which people are cared for support a

seamless journey to the appropriate level of acute care including secondary and tertiary care, and back to the community again.


There is a focus at both the Strategic and Annual Planning level on the management of chronic conditions, expressly with regards to cancer, diabetes and cardio-vascular disease. Overtime it will be pertinent to encompass a more generic approach to the way the Lakes health systems support people with all chronic conditions.

The DSP also states Lakes DHB’s commitment to providing timely and equitable access to services by achieving the objectives of the Government’s Elective Services Strategy, Reduced Waiting Times for Public Hospital Elective Services (2000) including: � A maximum waiting time for six months for first specialist assessment for

patients accepted onto a waiting list. Service Coverage Schedule and Operating Policy Fram ework The Service Coverage Schedule forms part of the Crown Funding Agreement and sets out national minimums in the range and nature of services for which DHBs are held accountable to provide for their populations. Under the service coverage framework, Lakes DHB is required to provide access to rheumatology services and services to support rheumatology inpatient and outpatient services. The Schedule also states:

While most of the Medical and Surgical Services Described here are available through public hospitals, some more highly specialised lower volume services are provided only at the larger centres, usually referred to as ‘tertiary’ centres. The hospitals providing regional or national services are required to have systems in place to ensure that access is available according to the criteria set out in the relevant service specification.

The Service Coverage Schedule also states that where national service specifications are nationally agreed, then DHBs must fund and deliver services according to the specifications in the nationwide service framework (NSF). Service Specifications Under the terms of the Operational Policy Framework (OPF) which forms part of the contract between the Ministry of Health and Lakes DHB it is a mandatory requirement that the DHB use the appropriate service specifications from the Nationwide Service Framework (NSF) Library. The service specifications contain varying levels of detail. In common with most other medical specialties there is no separate service specification for rheumatology. Instead, the provision of rheumatology services are described in limited detail in the Tier One – Specialist Medical and Surgical Services Specification and the Tier Two – General Medical Services Specification (Appendix 5). The Tier One specification outlines:

Specialist medical and surgical services provide services to people whose condition is of such severity or complexity that it is beyond the capacity and technical support of the referring service.

The Tier Two specification continues in more detail:

Secondary general medicine covers a wide range of acute, sub-acute and chronic illnesses and multi-system disorders. Rare, complex or severely acute illnesses and disorders requiring additional technical expertise or specialist knowledge will either require advice from, or referral to specialists at a tertiary facility.


It is difficult to lay down rigid lines of direction between General Medicine and the sub-specialities. The range of services directly provided in medicine varies according to the level of clinical support available, the presence of other speciality or tertiary services, and qualifications, training and skill of medical staff.

And: In smaller centres general physicians who may have sub-speciality skills or interests provide the service. People needing more specialised treatment are referred on to a larger centre or seen by a visiting specialist.

Therefore again there is little firm guidance in the service specifications as to the level of service that should be delivered by DHBs. There are service specifications for Specialist Community Allied Health services, Specialist Community Nursing Services and Assessment, Treatment and Rehabilitation services all of which can be appropriately applied to rheumatology medical and rehabilitation services. However, by segregating service purchasing into distinct silos, the Nationwide Service Framework creates a significant level of difficulty for DHBs seeking to be proactive and innovative in their approaches to addressing local issues. The NSF constrains the ability of funders and providers to develop multi-disciplinary approach to service delivery as several service specifications may need to be used for each purchasing agreement rendering contracts unwieldy and confusing for both funder and provider agreement managers. Taupo Health Services Review, 2003 The Final Report of the Taupo Health Services Review was delivered to the DHB by Neil Woodhams in December 2003. To review services in the Taupo TLA had been one of the recommendations of the Joint Study 2001 between Lakes DHB and the Ministry of Health. The purpose of the project was to review the health services available to the communities of Taupo, Turangi and Mangakino and identify options for the provision of health services over a twenty year timeframe. The Woodhams report was well received by the community due to the thorough community engagement that took place, and largely due to the recommendation that Taupo Hospital remain on the current site and that bed numbers be maintained. Of relevance to this project was the recommendation that the Board maintain flexibility regarding the provision of outpatient clinics in Taupo and over time increase the visiting services from Rotorua. The Woodhams report makes no specific recommendation regarding the provision of Rheumatology services in Taupo. Clinical Services Plan, 2005 In mid 2004 Lakes DHB commissioned a Clinical Services Plan (CSP) to introduce modern models of care and drive the options for facility development. The Plan recommends that the DHB moves towards ambulatory care for a larger number and range of services than is currently the case. The Lakes Health Service Improvement Plan Staff Update of July 2006 included the following description of ambulatory care:

Literally this means the practise of medicine for patients who are physically capable of walking. It includes all types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients in a hospital facility. While many inpatients may be ambulatory, the term ambulatory care usually implies that the patient must travel to a location to receive services which do not require an overnight stay.

Ambulatory care is any non-emergency medical care. Many medical / clinical conditions do not require hospital admission and can be managed


by visiting the hospital for consultations and tests. Many forms of medical investigations can be performed on an ambulatory basis, including blood tests, X-rays, endoscopy and even biopsy procedures of superficial organs. The full range of allied health can also be offered via ambulatory care – e.g. physiotherapy, speech language therapy and occupational therapy.

Other procedures able to be carried out from (or in) an ambulatory centre include chemotherapy, day surgery, blood transfusions for certain conditions, renal dialysis, wound clinics, and a range of assessment, treatment and rehabilitation modalities (AT&R). Additionally many specialty services such as cardiac, diabetes and respiratory rehabilitation may also be delivered from an ambulatory care centre.

The CSP recommended increasing the range and frequency of specialist clinics delivered at Taupo Hospital especially in those specialties for which older persons represent a significant proportion of the service users. The Plan also recommends that clinical staff have responsibilities at both Rotorua and Taupo hospitals where appropriate. It recommends that the proposed new facility at Taupo should have the capacity to manage step-down and rehabilitation beds for patients who have been assessed and/or managed elsewhere but need further rehabilitation. It is recommended that the focus of rehabilitation should be on an ambulatory or “day care” basis. However, there is little direction given specifically to the delivery of rheumatology services at Lakes, probably due to the prevailing status quo at the time of QE Health delivering rheumatology services.


SECTION 2 SERVICE STANDARDS

2.1 Evidence Based Guidelines and Standards of Care Lakes DHB has a commitment to the planning and development of services which are evidence based. Evidence based practice is defined as decision making based on a systematic review of the scientific evidence of the risks, benefits and costs of alternative forms of diagnosis or treatment.6 During the development of this Model of Care, a number of clinical guidelines were identified and reviewed from the UK, US78 and Canada9. It became apparent that more guidelines had been produced for rheumatoid arthritis and to a lesser degree osteoarthritis than were available for other conditions such as fibromyalgia, SLE and ankylosing spondylitis. However, as the development of the model of care for rheumatology is about service processes and delivery, rather than clinical algorithms, many of the recommendations for the service design found in the condition specific clinical guidelines were applicable across a multi-condition focussed rheumatology service. A number of guidelines are in the process of being developed. The National Institute of Clinical Excellence (NICE) in England is to publish guidelines for the management of rheumatoid arthritis in 2007. Its equivalent in Scotland (SIGN) is developing guidelines on the management of psoriatic arthritis for publication in 2009. The British Society for Rheumatology will release its guideline on the management of rheumatoid arthritis after the first two years post-diagnosis in 2007. The Australian Rheumatology Association (ARA) is collaborating with College of GPs to write guidelines for the diagnosis and management of osteoarthritis, rheumatoid arthritis, osteoporosis and juvenile idiopathic arthritis in primary care which are due for publication later in 2007. The New Zealand Rheumatology Association (NZRA) does not currently recommend the use of any particular clinical guidelines to their members. The Australian Rheumatology Association referred to recently published guidelines developed by the British Rheumatology Association as being relevant and instructive.10 These have been developed following an extensive review and grading of current evidence, are comprehensive and were of significant use in the development of the model of care for Lakes DHB. The Scottish Intercollegiate Guidelines Network (SIGN) – part of the NHS Quality Improvement Scotland - clinical guidelines were also used.11 The Standards of Care for Back Pain, Inflammatory Arthritis and Osteoarthritis developed by the UK’s Arthritis and Musculoskeletal Alliance (ARMA) were a useful source of information and guidance. The Musculoskeletal Services Framework (MSF) developed by the UK Department of Health12 was also referred to during the development of this model of care. The MSF encompasses the delivery of all orthopaedic surgery and is therefore significantly wider than the scope of this project; however, the model of care for rheumatology that is outlined later in this report has been developed with the MSF in mind and can be integrated into a wider musculoskeletal service at a later date.

2.2 Common Recommendations from Guidelines and Stan dards of Care There are a number of common themes and recommendations from the documents mentioned in 2.1 above. They are outlined in no specific order.


Chronic disease management methodology All of the guidelines recommend a chronic disease management model for rheumatology which takes an holistic and long term approach to patient care rather than an acute episodic care approach. Rapid access to First Specialist Assessment & DMARD s for suspected inflammatory arthritis The guidelines all emphasise the importance of every patient who has suspected inflammatory arthritis being referred as quickly as possible for specialist assessment in order to take advantage of the ‘window of opportunity’ to aggressively treat inflammatory arthritis with disease modifying anti-rheumatic drugs (DMARDs) within 3 months of the onset of symptoms thus altering the course of the disease progress, preventing loss of function, preventing loss of function and decreasing pain. The guidelines recommended timeframe for a patient receiving a specialist assessment varies between 6 and 12 weeks after referral. Multi-disciplinary team structure All of the guidelines recommend the use of a Multi-Disciplinary Team working (MDT) closely together and meeting regularly to discuss, agree and monitor the progress of patients as being necessary for effective high quality treatment for rheumatology patients. All of the guidelines recommend that the core MDT should include a Rheumatologist, Nurse Specialist/Nurse Educator, Physiotherapist and Occupational Therapist. Several of the guidelines also recommend that the General Practitioner, counsellor, dietician, podiatrist, pharmacist and social worker should be part of the core rheumatology MDT or at least be accessible to the core team upon referral. Specialist team All of the guidelines state that outcomes for people with inflammatory arthritis are improved when the core MDT members have specific skills and understanding of rheumatological disease processes and recommend that a rheumatology service employ some core MDT members (physicians, nurse specialists, physiotherapists and occupational therapists) dedicated to and skilled in rheumatology. Central role of patient and patient education All of the guidelines stress the importance of patient centred care, in which the patient is a contributing member of the MDT rather than a passive recipient of treatment as may be the case in more medicalised models of care. Several of the guidelines recommend that every interaction between health care worker and patient be used as an opportunity for education. A cognitive behavioural approach to education is recommended in several guidelines as improving outcomes and buy-in to self-management plans. Furthermore, there is an emphasis on patient self-care, educating and supporting people with long-term diseases to assess their own condition, know what is ‘normal’ for them and their condition, know when and how to get further help and advice, understand why it is so important to take their medication, enable people to recognise and monitor their symptoms, aid their own recovery and have the confidence and skills to better live with their condition and its impact on their lives. Psychosocial function The guidelines recommend that psychological and social support be considered an important aspect of assessment and management of patients facing an uncertain future with a chronic and sometimes debilitating and progressive condition.


Use of non-qualified health professionals A common theme in the guidelines is to recommend that people other than health professionals can have an active and meaningful role in the suite of services available to people with musculoskeletal disorders in both a health service environment and a volunteer capacity through community based self help, education and support groups. Nurse led-clinics and telephone help lines The best practice documents, in line with current disease state management principles, advocate for extended roles for nurses whereby specialist rheumatology nurses undertake a range of functions including but not limited to patient assessment and education, support, MDT and service coordination and clinical tasks such as drug monitoring and joint injections. The establishment of nurse telephone help-lines is also a common theme in the guidelines enabling patients who are already in the rheumatology service to contact the nurse for advice and information. The helpline can also be used by general practitioners. Extended scope practitioners Along with the extended scope for nurse described above, some of the guidelines suggest extending the scope of other practitioners to undertake some of the functions traditionally completed by rheumatologists. In the Musculoskeletal Framework and the British Society for Rheumatology’s documents it is suggested that practitioners other than physicians – such as a GP with a special interest, nurse specialist or physiotherapist - could conduct the initial assessment of referrals from GPs in order to reduce the pressure on rheumatologists and re-direct patients who have been erroneously referred to rheumatology to another specialty or back to primary care. Outpatient-based service All of the guidelines assume an outpatient based focus for rheumatology with very limited numbers of inpatient or intensive rehabilitation programmes for the most severely disabled.

2.3 Recommendations for staffing numbers Rheumatologist FTE The optimal level of Rheumatologist coverage for a population size has been estimated in several studies with differing results. Such differences can be accounted for by variations in the type of cases referred to rheumatology and the level of support available from other health professionals operating within the service. In 1999, Rajapakse, on behalf of the NZ Rheumatology Association and the Arthritis Foundation of NZ13 recommended the ratio of rheumatologists to population should be 1:100,000. In 1985, the British Society for Rheumatology (BSR) estimated that the ratio should be one whole time equivalent (WTE) consultant rheumatologist per 85,000 population.14 More recently in 2005, the Royal College of Physicians in the UK recommended one WTE consultant rheumatologist to 90,000 population. In 2003, Andrew Harrison recommended a ‘conservative ideal ratio’ of 1 full time equivalent rheumatologist to 160,000 population. This was based on an analysis of waitlists and the then FTE ratio in the Midland region of 1:200,668 population. Harrison commented that even allowing for an assumed under-referral rate from


Midland GPs, a 236% increase of consultant rheumatologists to match the British Society of Rheumatology ideal of 1:85,000 would not be necessary given the short waiting times in 2003.15 Using international studies to estimate the ideal ratio of consultant FTE per population can be problematic given New Zealand’s primary care funding environment. For example, patients with inflammatory arthritis tend to be kept under regular specialist review; this may be quarterly, six monthly or annually depending upon the individual’s disease progress. One reason for this is that patients must pay to see their GP and for repeat prescriptions and therefore prefer a specialist appointment which is free. The specialists come under pressure to see patients every 3 months, and whilst the specialists resist this pressure, they may be faced with complaints or patients ceasing their medication regimes rather than going to the GP. Nursing, Allied Health and other FTE requirement No studies could be found in NZ or internationally recommending the optimum number of nurses, physiotherapists, occupational therapists per population or per FTE rheumatologist.

2.4 Referral Guidelines In New Zealand, referral to specialist services should be made in line with the National Referral Guidelines where available. Outpatient Services The National Referral Guidelines for a Rheumatology specialist assessment are included in Appendix 1 of this report. As an overview, the guidelines state that:

Priority should be given to early referral of patients with inflammatory disease, destructive joint disease. Evidence increasingly shows that early intervention with disease modifying agents is required in order to get good outcomes. Patients with systemic inflammatory conditions and severe pain and dysfunction will also be given priority. Immediate and urgent cases must be discussed with the Specialist or Registrar in order to get appropriate prioritisation and then a referral letter sent with the patient, faxed or emailed. The times to assessment may vary depending on the size and staffing of the hospital department.

Upon receiving a referral, the secondary service should prioritise the urgency with which a first specialist assessment is booked for the patient using the National Access Criteria for First Assessment. These are included in Appendix 2. The guidelines state that patients with seropositive Rheumatoid Arthritis should be prioritised as Category 2 Urgent and be seen within 4 weeks of referral. Inpatient The National Clinical Priority Access Criteria (CPAC) for acute Rheumatology inpatient care are included in Appendix 3. Rehabilitation The National Clinical Priority Access Criteria (CPAC) for rheumatology rehabilitation is included in Appendix 4. The guidelines state:

In general suitable patients for admission to a Rehabilitation programme will be those who will benefit from a multi-disciplinary and holistic approach to education, self management techniques and physical therapy in addition to medical treatment. They will generally be those whose joints have been severely damaged by their arthritis.


The criterion for semi-urgent rehabilitation (within 12 weeks) is ‘chronic arthritis with recent exacerbations threatening independence, unresponsive to outpatient treatment. For routine (within 26 weeks) rehabilitation the criteria are musculoskeletal disability without threat of handicap, and chronic pain syndromes.


SECTION 3 CURRENT SERVICE DELIVERY

3.1 Primary Care There are over 50 General Practitioners providing services for two Primary Health Organisations (PHO) in the Lakes district. The GP base in Lakes is skilled, stable and experienced and is an asset to the region. Discussion with local GPs provided feedback that 10-15% of routine consultations are rheumatology related. The Lakes district has complete coverage by the Low Cost Access funding formula, and as a result co-payments for some patients are lower than would be the case in other parts of the country. However, with co-payments of up to $25 for adults, there are a significant number of patients for whom there is a barrier to access for primary care services. This has an impact on when and how often some patients choose to consult their GP with health concerns. Anecdotal evidence suggests that this is particularly the case with patients being reluctant to attend for regular monitoring and follow-up over long periods. This, coupled with the heavy GP workload, full clinics and 15 minute consultation slots, means that many GPs find themselves constricted to operating under a traditional medical model focussing mainly on acute or sub-acute presentations and lacking the time to work as effectively as they might like to with patients living with chronic conditions. Implementing an effective chronic care management approach in the traditional general practice environment in New Zealand is therefore challenging.

3.2 CarePlus CarePlus was launched nationally through PHOs from 1 July 2004, with PHOs being given latitude around entry date into the programme and configuration of services. It is a government initiative targeted towards people who need to visit their General Practitioner or nurse often because of significant chronic illness, acute medical or mental health needs, or terminal illness. It is intended that people using CarePlus will get effective management of chronic health conditions, better understanding of their conditions and support to make lifestyle changes. A person is eligible for CarePlus if they are enrolled in a PHO and:

• Is assessed by a doctor or nurse at their general practice as being able to benefit from “intensive clinical management in primary care” (at least two hours of care from one or more members of the primary health team) over the following six months; and either

• Has two or more chronic health conditions so long as each condition is one that: is a significant disability or has a significant burden of morbidity; and creates a significant cost to the health service; and has agreed and objective diagnostic criteria; and continuity of care and a primary care team approach has an important role in management; or

• Has a terminal illness (defined as someone who has advanced, progressive disease whose death is likely within 12 months) or;

• Has had two acute medical or mental health related admissions in the past 12 months (excluding surgical admissions); or

• Has had six first level service or similar primary care visits in the past six months (including emergency department visits); or

• Is on active review for elective services

Some PHOs have complained that the eligibility criteria for CarePlus are too restrictive and are becoming a barrier to some patients who would benefit from the


services. The Ministry of Health is currently working with DHBs and PHOs to review the criteria. It was intended that CarePlus would fund and protect practice team time and resources to enable planned time to be spent with CarePlus patients in order to achieve better health outcomes and focus attention on the long term health status of patients and their personal health related goals. Objective measurement of health status of patients, their needs and risk factors and the creation of a self-management plan and provision of education and opportunities to up-skill are important components of the service. Lake Taupo PHO has yet to launch CarePlus services in the southern end of the district, but has conducted extensive planning with its service provider Pinnacle Ltd. to rollout a comprehensive disease management programme in the near future. Discussions are underway with other non-government organisations such as Arthritis NZ and the Heart Foundation to provide coordinated and specialised chronic care management programmes that build on existing skills and knowledge. Health Rotorua PHO (HRPHO) has been engaged in CarePlus for some time, however rollout has been slower than expected due to lack of practice buy-in and perceived financial risk. HRPHO's service provider Rotorua General Practice Group has found that there are some issues with the structure of CarePlus. These issues may be alleviated by the Ministry of Health review that is underway. HRPHO has not specifically targeted patients with chronic rheumatological conditions. CarePlus services within HRPHO are evolving on a practice by practice basis, with individual primary care teams directing the development of services to their patients on a case-by-case basis.

3.3 Lakes DHB Hospitals Rheumatology Service Delive ry Patients with acute conditions are admitted to Rotorua or Taupo hospitals or occasionally to Waikato hospital if tertiary level care is required. Patients who are medically unstable, require after hours care or intervenous therapy will be admitted to a DHB hospital under General Medicine, Orthopaedics, Assessment Treatment and Rehabilitation (ATR) or Paediatrics. Whilst medical inpatient consultations are sometimes requested from and provided by the QE Health rheumatologists, they are infrequent, possibly due to the split site situation making ‘corridor conversations’ between specialties a rarity. Identifying the number and type of patients presenting each year to Lakes DHB hospitals is made difficult by coding issues. A report was requested from Lakes DHB concerning patients coded with a rheumatological condition as the primary reason for admission. There is no accepted list of International Classification of Disease (ICD-10) codes for arthritic conditions. Therefore the list used by Access Economics in consultation with three expert rheumatologists and the NZ Health Information Service was used.16 The true extent of patients with arthritic conditions being treated by LDHB hospitals is difficult to ascertain as patients may be coded with a primary diagnosis of another condition which may be attributable to their arthritis, such as bleeding peptic ulcer due to long-term use of anti-inflammatory drugs. Therefore the information in this section of the report should be read with caution. In the 2005-06 financial year there were a total of 13 presentations at Rotorua and Taupo emergency departments for whom a primary diagnosis of arthritis was recorded. 11 of those 16 presentations were for gout. These presentations accounted for an equivalent of $20,208 (GST Excl) or 6.7742 case weights.


However, as the emergency departments at Rotorua and Taupo hospitals are bulk funded rather than funded as a result of throughputs this figure is representative only. For general medicine, the following graph shows the number of acutely unwell patients who were admitted to Lakes DHB hospitals with a primary diagnosis of arthritis:

2005-06 Acute Medical Admissions LDHB hospitals wit h rheumatology ICD-10 Code

0

1

2

3

4

5

6

7

Diagnosis

Num

ber o

f Pat

ient

s

rheumatoid arthritis

Gout

Polyarthritis

coxarthrosis

Polyarteritis nodosa

Other giant cell arteritis

Polymyositis

Polymyalgia rheumatica

Unspecif ied discitis lumbar region

Other spondylosis cervical region

There were a total of 21 admissions to the medical units which accounted for a total of 19.1039 case weights or $56,988 (GST Excl) For the same period there was one patient admitted to Taupo hospital under the Assessment Treatment and Rehabilitation (AT&R) contract with a primary diagnostic code of arthritis. This admission had an associated case weight of 0.9479 or $2,828 (GST Excl) of funding. Acute admissions to orthopaedics at Rotorua hospital are charted below. There were a total of 54 acute admissions during the 2005-06 year, with a total case weight value of 62.38 or $186,081.41 (GST Excl).

2005-06 Acute Orthopaedic Admissions Rotorua Hospit al ICD-10 code athritis as primary diagnosis

Pyoge

nic ar

thrit is

Bursit

is

Gout

0

1

2

3

4

5

6

7

8

9

10

1Diagnosis

Num

ber

of P

atie

nts

Pyogenic arthritisBursitisGoutOther primary coxarthrosisSynovitis & tenosynovitisOther specif ied arthritis low er legStaph arthritis polyarthritis Oth strep arthritis polyarthr low er legUnspecif ied spondylosis lumbar regionSynovial cyst of popliteal space [Baker]Arthritis polyarthr dt oth bact low legRheumatoid arthritis NOS low er legUnspecif ied discitis lumbar regionOther juvenile arthritis low er legOther chondrocalcinosis low er legMonoarthritis NEC low er legOther primary gonarthrosisVertebral osteomyelitis thoracolumbarTrigger f ingerEnthesopathy unspecif ied


The orthopaedic unit at Rotorua hospital had a total of 218 elective admissions in 2005-06 for patients with a primary diagnostic code related to rheumatology. This accounted for a total of 696.26 case weights and $2,076,963 (GST Excl). The numbers of admissions by primary diagnoses are charted below:

2005-06 Elective admissions to Rotorua hospital ort hopaedic unit with rheumatology ICD-10 code

0

10

20

30

40

50

60

70

80

90

100

Diagnosis

Num

ber o

f pat

ient

s

coxarthrosis

Gonarthrosis

Synovitis, tenosynovitis &trigger f ingerPrimary arthrosis

Arthritis 1stcarpometacarpal jtRheumatoid arthritis

Seropositive rheum arthrNOS ankle footGout unspecif ied ankle andfootArthritis unspecif iedshoulder regionSynovial cyst of poplitealspace [Baker]Adhesive capsulitis ofshoulder

3.4 QE Health Rheumatology Service Delivery QE Health delivers a multi-faceted rheumatology service and is contracted by a number of DHBs, ACC and private patients. The information in this section is limited by the difficulties QE Health experiences in retrieving and manipulating data from its IT system.

3.4.1 QE Health Specialist Outpatient Clinics Specialist outpatient clinics are provided for Lakes patients referred by GPs and physicians from other specialties. For the 2006-07 year, Lakes DHB has contracted with QEH to provide 600 first specialist assessments (FSA) and 1,200 follow-up (FU) specialist appointments. This is broadly in line with the recommended number of new and follow-up appointments per 100,000 population outlined by the Royal College of Physicians17 of 698 FSAs to 1,247 FUs and somewhat less than those recommended by the New Zealand Rheumatology Association (NZRA) of 750 FSAs and 1800 FUs per 100,000 population per annum. However, given that there are not large numbers of patients on the waiting list, all patients with suspected inflammatory conditions are able to be seen well within the recommended timeframe of 12 weeks following referral, and the level of comfort on the part of GPs with the availability of outpatient appointments, it is fair to assume that the level of FSA and FU appointments purchased by Lakes is acceptable for the needs of the population. Diagnoses for patients attending for a first specialist assessment in the 2005-06 financial year as provided by QEH are shown below. By far the largest category of patients attending for FSAs are those with soft tissue rheumatism and chronic pain syndromes such as fibromyalgia.


The annual incidence of rheumatoid arthritis is estimated by the UK's Arthritis Research Campaign18 to be 83 new cases per 100,000 population per annum. This is in line with the 90 first specialist assessments provided by QEH for patients with RA and connective tissue disorders. The same study estimated the incidence of soft tissue rheumatism (including chronic pain and fibromyalgia) to be around 3,655 new cases per annum. Using the Royal College of Physician’s19 assumption that 7% of soft tissue rheumatism cases are referred for specialist assessment, then the expected number of new cases being referred for Lakes patients would be around 255 per annum. Again this correlates closely with the reported 241 FSAs for this type of patient delivered in the 2005-06 year by QEH. The parallels between international and local referral rates suggest that the referral practices of the GPs in Lakes are very much on a par with their UK colleagues and reflect the needs of the Lakes community appropriately. Current outpatient clinic services, whilst incorporating specialised nursing care, do not reflect a fully functional multi-disciplinary approach to chronic condition management. Instead the approach is a more traditional secondary service model with consultants managing the medical requirements of the patient and then referring either to an inpatient/day patient intensive programme, or for specific allied health outpatient care or in some cases directly back to the GP for ongoing care.

3.4.2 QE Health Outpatient Allied Health Services The following table outlines the contract for Allied Health Services between Lakes DHB and QEH and delivery against contract for the 2006-07 year. The volumes recorded here as the numbers actually delivered are taken from the monthly reports supplied to Lakes DHB by QEH.

Purchase Unit Contracted Volume

Unit Price

Total Price Excl GST

Actual delivery 1/7/06 – 31/12/06

Extrapolated to full year Variance

AH01003 – Occupational Therapy

246 $58.04 $14,277.84 54 108 -138

AH01005 – Physiotherapy

2,100 $43.06 $90,636.00 1,282 2564 464

AH01007 – Social Work 40 $66.11 $2,644.40 12* 24 -16

AH01007 – Nurse Lead Outpatient Clinics

0.2 FTE $70,000 $14,000.00 70**

Total $121,558.20

2005-06 First Specialist Assessment Diagnoses QEH

0

50

100

150

200

250

300

Diagnosis

Num

ber of patients

Soft tissue & regional (includes pain/fibromyalgia) Rheumatoid arthritis & connective tissue disorder Osteoarthritis & bone disease

Miscellaneous (includes gout, neurological etc)

Seronegative spondyloarthropathy (includes ankylosing spondylitis/psoriatic arthritis etc)


*the monthly reports supplied by QEH to Lakes DHB do not record the number of social work volumes provided. Instead, the volumes of counselling contacts are recorded. An assumption has been made that the purchase unit code AH01007 is being used to purchase counselling services rather than social work. **it is unclear as to what is being reported here. It may be the actual number of nurse to patient contacts or it could be the actual number of clinics. The contract between Lakes DHB and QEH does not include a service specification for the nurse lead clinics and therefore the service provision requirements and reporting parameters are uncertain. For the 2006-07 financial year, the contract was changed between Lakes DHB and QE Health and currently only specialists can refer to the QE Health allied health outpatient team. This change was instituted due to concerns that GPs were referring non-rheumatology patients to the QE allied health team. It may be that the overprovision of physiotherapy contacts in the early part of the 2006-07 contract can be explained by the historical referral patterns to QE with some non-rheumatology patients from the previous financial year completing physiotherapy programmes. All outpatient physiotherapy and counselling/social work appointments are delivered at QE Health. From the quarterly reporting templates provided it would appear that all of the occupational therapy appointments are provided in patients homes.

3.4.3 QEH Inpatient/day patient Rehabilitation Serv ices The rehabilitation service at QE Health provides a multi-disciplinary approach with the activities of the MDTs coordinated by Rheumatology Nurse Co-ordinators. Services are delivered according to treatment protocols which have been developed for conditions such as:

• Rheumatoid Arthritis (Newly Diagnosed and Refresher courses) • Osteoarthritis • Ankylosing Spondylitis (Newly Diagnosed and Refresher courses) • Chronic Pain • Fibromyalgia Syndrome • Post Polio • Osteoporosis (falls risk) • Chronic back pain.

Rehabilitation services are offered on either a day patient or inpatient basis. The only difference between the two being that inpatient services include meals and hotel-type services. QE Health’s rehabilitation philosophy is “to educate and provide tools for patients to self-manage and enhance their capacity to live independently within the community.”20 Rehabilitation services for the 2006-07 year have been contracted by Lakes DHB for a total of 66 inpatients with an Average Length of Stay (ALOS) of 11 days (not including weekends) and 75 day patients with an ALOS of 7 days. These volumes were based on the expected number of patients per diagnosis as follows:

Diagnosis Number of patients Rheumatoid Arthritis 53 Osteoarthritis 44 Fibromyalgia syndrome 17 Ankylosing Spondylitis 5 Chronic Pain 18 Post Polio 1 Other 3 Total 141


The following chart shows the actual number of day/inpatients by diagnosis for the first 8 months of the 2005-06 year.

Rehabilitation patients by diagnosis 1 Jul 05 - 28 Feb 06

21

19

17

12 12

9

2 2

0

5

10

15

20

25

Diagnosis

Num

ber

of p

atie

nts

Osteoarthritis

Chronic Pain

Rheumatoid Arthritis

Fibromyalgia

Gen Arthritis

Other

Ankylosing Spondylitis

Post Polio

QE Health aims to deliver a schedule of programmes throughout the year enabling patients living with like conditions to share peer support during their rehabilitation. However, the data supplied indicates that for the first 8 months of 2005-06, 80 of the 94 patients taking part in rehabilitation programmes were admitted under ‘individual protocols’ – that is they were admitted for rehabilitation based on their extant need rather than being booked on a programme with other patients of a similar diagnosis. That is a clinical decision and also likely reflects the inability of many patients to take a significant amount of time out of their daily lives to take part in an intensive programme. Further information was requested on the 22% of patients admitted under the categories of ‘Gen Arthritis’ and ‘other’ for this 8 month period and was supplied as follows:

General Arthritis - Breakdown Number of patients Gout 3

Juvenile onset RA 1

Peripheral upper limb arteritis 1

Paget's disease 4

Scleroderma 1

Charcot Marie Tooth 1

Unknown 1 Total 12 Other – Breakdown Number of Patients Chronic pain 1

Low back pain 1

Post-op rehabilitation 2

Spinal stenosis 1

Congenital foot deformity 1

Peripheral neuropathy 1

Total 7


Information was requested regarding domicile, age, sex and ethnicity of patients receiving services under the rehabilitation purchase lines and this was not provided by QEH due to systems and workload issues and therefore deeper analysis was not possible. There appears to be no formalised criteria to aid decision making regarding which patients are referred to outpatient or day patient intensive rehabilitation either within QE Health or within the other DHB services which refer to QE Health other than the very brief guidance given by the National Clinical Priority Access Criteria. The decision to refer into intensive rehabilitation one made by individual clinicians, and although this is appropriate, it would appear that patients are sometimes referred to an inpatient/day patient programme to access the aspects of the MDT model that are currently not available on an outpatient or less intensive basis.


SECTION 4 SYNERGIES WITH OTHER LDHB SERVICES There are some synergies between rheumatology services and other services delivered by the hospitals owned by Lakes DHB.

4.1 Chronic Disease Management Lakes DHB delivers medical outpatient services. Some of these services have in recent years implemented a chronic disease management type approach to varying degrees. The DHB should place an emphasis on developing cross-subspecialty systems and processes to manage the growth in chronic diseases and continue to move away from the traditional acute and episodic service delivery models which do not meet the needs of many patients. Whilst this is difficult in an environment where acute and episodic care still needs to be provided, good chronic disease services based on team care models and evidence-based skills are necessary to help patients to manage their conditions and remain productive, functioning and healthy members of society and to reduce the number of acute admissions. This shift in focus away from the acute will require an acknowledgement that advanced communication abilities, behaviour change techniques, patient education and counselling are required skills in building multi-disciplinary teams regardless of the health issues the team focuses on. With the current development of new models of care for secondary services across the Lakes district there are considerable opportunities to implement a standard model of multi-disciplinary team care, modified to meet the needs of different patient groups. The benefits of a standard model for chronic care would include clarity for referrers and MDT members, and common processes for allied health services such as podiatry and dietetics which would work across all the chronic conditions. Recommendation: That Lakes DHB considers implementing a common approach to chronic care management across relevant services in order to meet the needs of growing numbers of patients living with chronic conditions.

4.2 Assessment Treatment and Rehabilitation (AT&R) Lakes DHB purchases AT&R services through the service level agreement with its provider arm. ACC also purchases AT&R services from Rotorua hospital. There are commonalities between the rehabilitation services offered by the DHB secondary service and rheumatology services. Both should be offering comprehensive multi-disciplinary team care approach dedicated to maximising, developing or restoring a person’s physical and social functioning. Both the AT&R service and the rheumatology service employ a range of professionals including specialists, occupational therapists, physiotherapists and nurses and there is a duplication of some facilities. AT&R services are delivered by the Lakes DHB hospitals are done so according the national standard service specification for AT&R. Inclusion criteria for AT&R services as detailed in the national service specifications are as follows:


Admission to these services from the community (either own home or residential care setting) or from an acute hospital setting may occur where the person:

� Has an age related or other disability � Has been assessed by the AT&R tem and it has been determined that the

person: o Is considered likely to have their health status and degree of

independence improved by the AT&R process. o Would make demonstrable rehabilitation gains from admission to an

AT&R service by virtue of requiring; - early intervention to arrest a potentially deteriorating situation or, - intervention to maximise/maintain functional skills in the presence of

a degenerative condition or - intervention to restore or maximise functional skills following a recent

medical, social or other episode. o Is considered to be at risk without this intervention

Disability is defined as ‘a physical, intellectual or sensory impairment or disability (or a combination of these) that is likely to continue for a minimum of six months and result in a reduction of independent function to the extent that ongoing support is required.’ Patients with rheumatologic conditions which are likely to be ongoing, and reduce function meet the criteria for receiving AT&R services and there are obvious synergies between the client groups serviced under the two contracts. The parallels between the rheumatology rehabilitation service and the AT&R service would indicate that there are some potential gains to be made by amalgamating the two. There may be the potential for economies of scale and reduce the overheads which are inherent in having two similar functions located in the same town. It would likely be possible to reduce costs if the management and administration functions were combined as would be the case if only one facility needed to be maintained and equipped. There would likely not be cost saving to the DHB Funder Arm if the services were combined, given that the Funder Arm would continue to pay national price per unit of service delivered (be that bed day price or price per contact). However, combining the services would result in a contribution towards DHB hospital fixed overhead costs for each rheumatology patient receiving services. Both medical and allied health staff may benefit from the collegiality of working more closely with their peers from other specialties enabling cross-fertilisation of skills and knowledge. There would likely be a benefit to patients - especially those with co-morbidities under the care of different teams – with communication and consultation between health professionals becoming easier and more frequent. A common information system would also be beneficial to patient care; allowing clinicians access to records of patients receiving services from other departments, retrieve data easily and be assisted by support functions that would facilitate analysis of patient management information. There may also be some risks in amalgamating the services, especially if that results in the degradation of the level of skill and expertise in rheumatology. Best practice guidelines for rheumatology are clear that patients receive the best outcomes when cared for by an MDT of specialist rheumatologists, specialist nurses, dedicated rheumatology physiotherapists and dedicated occupational therapists with a high level of training and expertise in rheumatologic conditions. Rheumatology services in Lakes would suffer if the skills and experience of the people currently employed by QE Health were lost or replaced with more generalist medical and allied health staff as part of an amalgamated AT&R service.


Recommendation: That should Lakes DHB decide to take advantage of the potential benefits of overhead cost reduction, cross-specialty collegiality, facility and systems sharing by merging the AT&R and rheumatology services; that the specialised skills, knowledge and experience inherent in the rheumatology services be maintained and protected within the wider AT&R function by preserving a core multi disciplinary dedicated to rheumatology.

4.3 Radiology In 2005/06 the following radiological investigations were ordered by rheumatologists:

� X-Rays � CT Scans � MRI � Bone Density � Ultrasound

Currently QE Health refers only infrequently to the radiology service at Lakes DHB hospitals, using a combination of private providers and Waikato DHB instead. Lakes DHB currently also provides x-rays, CT scans, MRIs and ultrasounds. There are plans to upgrade the CT equipment in 2007/08 to a multi-slice scanner which will enable faster processing. Lakes DHB does not have a DEXA scanner for bone densitometry.


SECTION 5 SERVICES DELIVERED BY OTHER DHBs Rheumatology services differ widely within the Midland DHBs and around the country. Benchmarking services between different areas is only really constructive if the quality and outcomes of the services in place can also be compared, and this was not possible. Staff from some other DHBs were not confident that the levels of service they provided fully met the needs of their communities and there was some concern that comparing Lakes good service coverage with the service volumes in other areas may be detrimental to Lakes patients. Therefore whilst data comparing the purchasing within the Midland DHBs was collected, it should be used with caution.

5.1 Outpatient Services A comparison of the total number of Specialist Assessment and Follow-up volumes purchased per head of population for each Midland DHB in the 2006/07 year is tabulated below.

DHB Population FSA FUP Ratio FSA:FUP

FSA per 100,000 pop

FUP per 100,000 pop

Bay of Plenty 190,000 570 1140 1:2 300 600 Waikato 320,000 800 2500 1:3.1 250 781 Tairawhiti 44,000 85 190 1:2.2 193 432 Taranaki 103,000 150 400 1:2.7 146 388 Lakes 102,000 600 1,200 1:2 588 1176 Lakes DHB is currently purchasing significantly more FSAs and FUPs than other Midland DHBs. Waikato has the next highest service provision to Lakes and clinical staff at Waikato DHB commented that they feel that they are delivering a service under significant restraints, and that this is modifying GP referral behaviour as the service can only deliver to a very small number of patients with acute and sub-acute inflammatory disorders, some connective tissue disorders and a very limited number of bone issues. Waikato DHB staff felt that this is far from ideal, and were concerned that the level of FSAs and FUPs delivered by Waikato DHB might be used as a benchmark for planning services in Lakes given what they feel is a significant under-servicing of the Waikato DHB population. So whilst it might appear that DHBs are meeting their requirements under the elective services guidelines, that may be because GPs are aware of the service constraints and therefore not referring all patients who would benefit from a specialist assessment. Of the Midland DHBs, only Waikato DHB has implemented a multi disciplinary team model for the rheumatology services it delivers in house. Waikato has employed 1.5FTE nurse specialists to work as independent practitioners with close links to the rheumatologists to conduct a significant amount of the general follow-up and monitoring of patients. The nurses conduct assessments of new patients to gauge requirements for occupational therapy, physiotherapy, dietetics and orthotics. The nurses also monitor the monthly blood test results of patients on Disease Modifying Anti-Rheumatic drugs (DMARDs) and manage the labour intensive paperwork associated with biologic therapies register as well as running a telephone helpline which they find to be especially useful for patients who require advice and information but who may find it difficult to access the clinics due to young family commitments or immobility. The telephone helpline is also considered important for patient education given that patients may not remember all of the information given to them in clinics, or may not be ready to come to terms with a diagnosis at the time of the specialist assessment or nurse clinics. Waikato DHB employs dedicated occupational (1.5 FTE) and physio (0.5 FTE) therapists specialising in the care of


rheumatology patients. However, the physiotherapist is on occasion pulled away from rheumatology to work in other areas of the hospital and therefore the volume of service delivered to rheumatology patients is lower than required. None of the other Midland DHBs employ allied health staff who are dedicated to rheumatology service provision.

5.2 Inpatient/day patient rehabilitation programmes All of the Midland DHBs have continued to purchase some rehabilitation services from QE Health since the unbundling of the Midland-wide contract for which Lakes was once lead DHB. The details of those purchases are shown below:

DHB Population Inpatient Bed Days

Outpatient Bed Days

Total Bed Days

purchased

Bed Days per 100k pop

Bay of Plenty 190,000 1128 80 1208 636

Waikato 320,000 1021 26 1047 327

Tairawhiti 44,000 44* 0 44 98

Taranaki 103,000 Ad Hoc Ad Hoc Not available Not available

Lakes 102,000 740 500 1240 1216

*Tairawhiti DHB have advised that they expect 4 patients to be admitted for rehabilitation in 06/07 and an average length of stay of 11 days has been used to calculation the inpatient bed day numbers for this DHB Again Lakes DHB is the extreme outlier in the purchase of bed days purchased for rehabilitation from QE Health. No other DHB is delivering specialised rheumatology inpatient rehabilitation services, although there may be some patients being serviced under more general Assessment Treatment and Rehabilitation (AT&R) contracts. Both funders and clinicians from other DHBs expressed opinions that the QE Health inpatient rehabilitation services were not cost effective, and that it was better practice to keep patients at home and work with them to self-manage their conditions within their own environment rather than send them away for inpatient care.


SECTION 6 STAKEHOLDER ENGAGEMENT AND EXPERT OPINION The following groups and individuals generously gave their time to provide valuable insight into rheumatology services during the course of this project. They are listed in no specific order:

• Ben Smit, CEO QE Health • Deanna Hape, Rheumatology and Rehabilitation Manager, QE Health • Dr John Petrie and Dr Peter Jones, Rheumatologists, QE Health • Dr Kieran Faull, Research, QE Health • The Professional Advisory Committee, QE Health • QE Patients and Rehabilitees Association • Dr Peter Fleischl, GP Taupo Health Centre • Dr Liz Fitzmaurice, GP Lake Surgery Taupo • Dr Mike Tombleson, GP Lake Surgery Taupo • Dr Judi Donnell, Hinemoa House Practice, GP Rotorua • Dr Johan Morreau, Medical Director, Lakes DHB • Dr Nic Crook, Head of Department, Medical Lakes DHB • Dr Stephan Neff & Celia Royayne, Pain Service, Lakes DHB • Dr Alan Doube, Rheumatologist, Waikato DHB • Trish Holmes, Rheumatology Nurse, Waikato DHB • Dr Dan Tartaglia, Geriatrician, Lakes DHB • Dr Steven Sawyers, Rheumatologist Lakes DHB & QE Health • Toni Griffiths, Arthritis NZ • Leonie Pritchard, Portfolio Manager Lakes DHB

Individuals and groups offered their opinions as to the future shape of rheumatology service delivery through meetings, teleconferences and in the case of 3 GPs, written questionnaires. A range of views and opinions were expressed. On the whole, the sentiments expressed towards QE Health and its services were very positive. It is the feeling both within and outside of the Lakes area and across clinicians and patients alike that QE Health is a centre of excellence for rheumatology and that New Zealand as a whole benefits from the level of specialist knowledge and experience which is held within the QE team. All of the General Practitioners were very happy with the service delivered by QE Health and the availability of specialist opinions through the outpatient clinics. Stakeholders and experts were asked to comment on areas for development in the rheumatology services. Common responses included:

� Development of a true MDT model for rheumatology outpatients

� Development of group education programmes for outpatients, including ones

for newly diagnosed rheumatoid arthritis and newly diagnosed ankylosing spondylitis

� Reduction in the number of osteoarthritis patients receiving intensive

rehabilitation services

� Development of better criteria and tighter guidelines to inform decision making around access to rehabilitation services


� Better communication and collegiality between QE staff and other specialties to manage patients with co-morbidities or who are admitted to Lakes DHB hospitals

� Integrated patient information system between the DHB hospitals and QE

Health

� More emphasis on prevention of musculoskeletal disorders through health promotion of risk factors including smoking and obesity

� Better clarity and service provision regarding outpatient Allied Health services

for the Taupo/Turangi region

� Better understanding in the wider community of the impact of rheumatological disorders on the lives of those living with the diseases

Amongst the GPs who gave input to the process, there was a general sense that QE Health offered a high quality, accessible service and a “if it isn’t broken, don’t fix it”. The Taupo GPs however, did feedback that they would like outpatient allied health services to be more readily accessible in the southern part of the Lakes region. Other points worthy of note from the GP engagement included that most but not all GPs stated that they automatically referred patients with suspected inflammatory arthritis for a specialist assessment; that not all GPs routinely screened RA patients for cardio vascular risk as recommended in best practice guidelines; and that none of the GPs who responded routinely use either the national referral guidelines or those developed by their Independent Practitioners Associations (where available) when making decisions about referring for a specialist opinion.

When asked whether an extended scope practitioner such as a physiotherapist, nurse specialist or GP with Special Interest should be responsible for a first level screening of referrals as outlined in the UK’s Musculoskeletal Framework document, the response from the GPs was without exception negative. The rheumatologists and allied health staff were more amenable to the idea in principle, however, it was commented that this model would be better suited to a locality where the number of consultant rheumatologists was low for the population size and a ‘gatekeeping’ approach to accessing a specialist opinion was necessary. This not being the case in the Lakes area, the idea of a non-rheumatologist assessing and triaging patients was therefore not deemed necessary. The GPs commonly asserted that they would not be able to be present at multi-disciplinary team meetings given their full practice registers and requirement to hire locum cover if they take time away from the practice. It was expressed that whilst GPs in countries where primary care is fully government funded may be able to take time out to join MDT meetings, this was not practical in the NZ environment where there are commercial considerations.

All of the clinical professionals were in agreement that rheumatologists provided better care than general internalists with an interest in rheumatology and there was concern from number of parties both within and outside of QE Health that this Model of Care project might recommend that Lakes replaces the existing service with one that relies on a physician with special interest. The clinicians expressed anxiety that service standards in rheumatology should be maintained and that this would only be possible with properly trained rheumatologists. Opinion was also expressed that Lakes DHB should be seeking to improve and increase rehabilitation services for people with conditions other than rheumatologic, and not ‘drag down rheumatology services in order to prop up sub-standard ones’. This opinion was not unique to clinicians employed by QE Health.


There were differing opinions from clinical staff about the appropriateness of the number of patients accessing intensive rehabilitation programmes and the parameters under which those decisions were made. Those opinions were not unique to respondents working outside of QE Health. There were several individuals who believed that a well-coordinated outpatient based MDT could deliver good results to many patients who would, under the current service model, require admission to an intensive rehabilitation programme in order to access all of the streams available in the MDT model. There was also an acknowledgement that primary care teams could take a greater role in the ongoing monitoring and management of some patients, particularly those living with osteoarthritis and pain syndromes. However, the issue of patients having to part-pay for primary care services has to date meant that many patients are not willing or able to present for routine visits at primary care. However, with the rollout of CarePlus, routine contacts with the general practice team should become more affordable for those patients who qualify.

Clinicians interviewed also commented on the management of the many patients who present with co-morbidities. This patient group requires a good level of communication between the specialities (including General Practitioners) in order for drug interactions and self-management programmes or care plans to be effective and realistic for the patients. It was felt that this process was not being comprehensively addressed at the current time and could be done better.

The patient group had a high level of concern regarding the future of the QE Health service. They were vocal regarding the high level of specialty care available under the current service and anxious that this may not be valued by the funder. They spoke at length of the difference in their experiences of the QE Health and public hospital and more specifically surgical, system. The patient group felt that their unique requirements for care were ‘lost’ amongst the many different conditions being treated at Rotorua hospital, especially with reference to manual handling and joint protection issues. The benefit of emphasis placed by QE Health on the wider social and psychological impact of rheumatological conditions and the importance of self-management was also very clearly articulated by the patient group.

The Allied Health professionals involved in the inpatient/day patient rehabilitation programmes appreciated the opportunity for intensive goal setting and education with patients and the availability of all of the professionals to work with patients in a co-ordinated manner. Value was also placed on the ability to establish new routines for patients, especially with regards to exercise. The wish to make the MDT model accessible for more patients in the community was voiced, as was the desire for a telephone helpline to be established for patients to access advice and information. The possibilities to better utilise community based support and programmes outside of the current QE Health services were also explored. Clinicians, patients and other stakeholders were of the opinion that using group sessions where possible for education and therapy was of significant benefit to patients, reducing isolation, elevating mood and wellbeing and enabling shared learning through hearing of other patient’s experiences and challenges.


SECTION 7 PROPOSED MODEL OF CARE

7.1 Overview The proposed Model of Care is a hybrid of recommendations from the clinical guidelines, standards of care, World Health Organisation and other international documents in addition to input from stakeholders and experts locally. Health promotion and education overarches the entire model. Raising awareness of the impact of lifestyle choices on musculoskeletal health should form a part of the health promotion and education activities from all health service providers across the public, population and personal health spectra. Every contact between a health service provider and patient should be seen as an opportunity to provide education and information. The model places emphasis on outpatient multi disciplinary team care as the major mode of service delivery, with each core member of the MDT contributing to decision making around patient care in accordance with their individual professional skill set. This will require a significant change in practice to the current services available, but will extend the best practice MDT model currently available only for intensive inpatient and day patient rehabilitation to an outpatient setting to benefit more service users. It is proposed that the shaded boxes in the diagram represent functions that are rheumatology focussed – the non-shaded boxes represent functions that may deliver services to patients with a range of conditions or disease states. It would not be necessary for all of the functions in the continuum to be delivered by the same organisation; however, for the model to function effectively there is a requirement for members of the MDT and the other functions providing services to the patient group to have excellent channels of communication and ideally have access to a common clinical information system. Recommendation: That the model of care below be implemented by Lakes DHB.


7.2 Patient Pathway Diagram

7.3 Explanatory Notes

1. A patient with a rheumatologic condition presents to their GP. If the patient does not require secondary care, the GP will manage symptoms as appropriate and may choose to refer them to the CarePlus programme for ongoing chronic condition management. This may be the case for many osteoarthritis patients. Every patient with suspected inflammatory arthritis is referred for a specialist assessment in accordance with the national referral and best practice guidelines and should be booked for a First Specialist Assessment within 6 weeks of referral.

2. The referral letter is received and triaged by a rheumatologist, who will either

arrange for the patient to be booked into an appropriate outpatient

Referral as agreed to (6)

Return to GP

Referral to

Refer to

GeGeGeGeneral Practiceneral Practiceneral Practiceneral Practice (1) (1) (1) (1)

Referral TriageReferral TriageReferral TriageReferral Triage (2) (2) (2) (2)

(Rheumatologist)

Other specialtiesOther specialtiesOther specialtiesOther specialties

Book patient

Specialist Outpatient ClinicsSpecialist Outpatient ClinicsSpecialist Outpatient ClinicsSpecialist Outpatient Clinics (3) (3) (3) (3)

(Rheumatologist) Holistic AssessmentHolistic AssessmentHolistic AssessmentHolistic Assessment (4) (4) (4) (4)

(Rheumatology Nurse)

Nurse takes recommendations to

MultiMultiMultiMulti----Disciplinary Team meetingDisciplinary Team meetingDisciplinary Team meetingDisciplinary Team meeting (5) (5) (5) (5)

(Core team = rheumatologist, nurse, physio, OT, counsellor)

CarePlus CarePlus CarePlus CarePlus

Nurse led clinics & helpline (7)

OT (7) Comm’y-based

education (7)

MDT lead Intensive Rehab (7)

Orthotics (7)

GP/ CarePlus (7)

Physio (7) Podiatry (7)

Dietetics (7)

Counsell’g (7)

Health PromotionHealth PromotionHealth PromotionHealth Promotion

Health Promotion

Health Promotion

Health Promotion

Health Promotion


appointment, refer directly to another speciality or direct back to GP if the referral is felt to be inappropriate.

3. Patient attends specialist assessment. Along with performing the clinical

function, the specialist will agree with the patient timescales for follow-up appointments. The patient may be referred back to GP if they do not require further secondary input or to another specialty as appropriate.

4. A clinic run by a rheumatology nurse specialist will run concurrent to the

specialist clinics. The specialist may refer patients to meet with the nurse on the same day for a needs assessment to assess the holistic needs of the patient for information, education, self-management, physical or occupational therapy, counselling, orthotics etc. If it is more appropriate the assessment might occur at a later date, or in the patient’s home depending on the individual’s circumstances. Some patients may be ready to meet with the nurse straight away to begin learning about their condition and how to manage it; other patients will take time to come to terms with their diagnosis and in these cases a later appointment at the Nurse-led clinic will be necessary. Some patients will not need or not wish to take part in a needs assessment. A patient under periodic specialist review can be referred directly by their GP for an holistic assessment by the nurse should their level of need for allied health input change between specialist appointments.

5. Following the needs assessment, the nurse takes recommendations to an

MDT meeting. The core members of the MDT are a rheumatologist, nurse, physiotherapist, occupational therapist and counsellor. The nurse specialist will be responsible for coordinating the MDT and the services received by the patient, with the rheumatologist maintaining overall clinical responsibility.

6. The MDT agree the care plan and decide whether to refer the patient further

service delivery modalities, including follow-up specialist appointments, monitoring through nurse-led clinics, helpline support, OT, Physio, community based education programmes, admittance to intensive rehabilitation etc., as dictated by the needs of the individual.

7. The individual service area will conduct professional assessments of the

patients’ specific requirements and identify the expected number and frequency of contacts. All services will provide feedback to the MDT to keep the team informed of the progress of patients.


SECTION 8 PROPOSED SERVICE REQUIREMENTS

8.1 Primary Care In Section 3, primary care and specifically the CarePlus programme is discussed. CarePlus is still in its infancy in the Lakes District, and there is an opportunity for the DHB to work with the PHOs to tailor services to meet the needs of the growing number of people living with musculoskeletal conditions as the population ages. There is significant potential for CarePlus services to be offered to people living with rheumatological conditions. PHOs and their providers have the ability to tailor CarePlus services to meet the needs of their patient groups and could offer a range of interventions including patient monitoring and follow-up, care plan review and assistance, functional assessment, education and coaching. It is also possible that PHOs could choose to purchase allied health services such as podiatry or dietetics for the benefit of its patients. CarePlus could be utilised to provide ongoing care for patients with conditions such as inflammatory disease between their regular review appointments with secondary service clinicians. It could also provide services to patients with arthritic conditions and pain syndromes who may not require ongoing secondary input but who could benefit from regular monitoring and primary care contact. These services need to be developed as an integrated and coordinated approach drawing on the existing expertise and knowledge of those already active in rheumatology service provision such as Arthritis NZ educators and the secondary rheumatology services and formal referral procedures should be established. The rheumatology nurse specialist should co-ordinate the referrals to and feedback from the general practice/CarePlus team and the MDT. Recommendation: That CarePlus services are developed for PHO enrolees living with chronic rheumatological conditions who meet the eligibility criteria as part of an integrated and coordinated rheumatology service. Recommendation: That the links between PHOs and Arthritis NZ are supported and encouraged by Lakes DHB and the potential for the community based sector to deliver services such as the expert patient and train the trainer courses for people living with arthritis and musculoskeletal disorders.

8.2 Rheumatology Services Volumes In this section the expected volumes for each component of the rheumatology service is discussed. With little guidance available from other DHBs or from literature, it has been necessary to use a significant degree of estimation when recommending volumes, particularly for outpatient allied health services. Any change to an existing service will result in changes to referral practices, and potentially unforeseen service demand. Therefore it is recommended that the volumes for each component of the service be reviewed in year one of the new model of care in order to test that the assumption made in this section are still valid. Group education and therapy sessions should be used where appropriate in order to maximise the impact of the service, reduce patient isolation and enable the specialised services to benefit the greatest number of patients possible. Recommendation: That the service volumes proposed are reviewed in year one in order to inform out year purchasing. Recommendation: That group rheumatology education and therapy sessions are utilised wherever possible.


8.2.1 Outpatient Clinic Volumes – Specialist It is recommended that the number of first specialist assessments and follow-up appointments be maintained at the current level in the short term. The analysis of the findings of the Royal College of Physicians against the FSAs conducted by QE Health showed that the referral practices amongst Lakes GPs are very similar to their overseas counterparts and in line with the expected number of referrals for the population size; that is around 600 First Specialist Assessments and 1200 Follow-ups. With FSAs and FUPs scheduled for 45 and 20 minutes respectively, this requires around 4 outpatient clinics per week for the Lakes population based on a 48 week year. Remote clinics should be provided in Taupo for the benefit of the Taupo and Turangi communities. As the proposed nurse led clinics, helpline and CarePlus services become established the number of specialist appointments, particularly for follow-up visits, may be reduced somewhat over time, with the specialist nurses and general practice teams taking over more routine follow-up care. However, in the short term there would be risk in reducing the number of FSAs and FUPs until the stakeholders, particularly the referrers and secondary clinical staff are confident in the new MDT services. Reducing the numbers of FSAs and FUPs immediately would potentially lead to growing waiting lists, with referrers and specialists not being fully confident that the new services were ready to take on their extended roles and continuing to refer to the reduced outpatient clinics at the same level. In line with recommendations from clinical guidelines, stakeholders and experts these services should be delivered by a specialist rheumatologist. Recommendation: That Lakes DHB continues to purchase 600 First Specialist Assessments and 1200 Follow-up appointments in the short term. These services should be delivered by specialist rheumatologists. Recommendation: Approximately one third of the specialist appointments should be provided in Taupo.

8.2.2 Rheumatology Nurse Clinics and Helpline Again there is little guidance to be found in literature regarding the optimum level of nurse led services for a population size. Waikato DHB purchase 1.5 FTE for their population which equates to 0.47 FTE per 102k population. It is recommended that the 0.2 FTE nurse led clinics volume purchased in 2006-07 be maintained for patients to be followed-up by a specialist rheumatology nurse. These clinics will provide a good setting for the delivery of information and education specific to the patients’ circumstances and condition as well as clinical functions such as joint injections and drug monitoring. It is proposed that a further 0.2 FTE be purchased to conduct the new holistic assessment of patients needs in a clinic which runs alongside the specialist clinic as outlined in the model of care. With assessments taking 45-60 minutes, it is expected that the nurse would conduct 8-10 assessments per week. This should be reviewed six months after the introduction of the new model of care to ensure that the number of assessment appointments available is appropriate. A further 0.2 FTE nurse specialist should be purchased to perform the nurse helpline and MDT coordination functions to give a total of 0.6 FTE Rheumatology Nurse


Specialists for the Lakes region. Again this should be reviewed six months after the introduction of the model of care. Regular nurse-led clinics and holistic assessments should be delivered from Taupo in order to assist accessibility to the Taupo and Turangi communities. Recommendation: That Lakes DHB purchase a total of 0.6FTE Rheumatology Nurse Specialist to perform Nurse Led Clinics, holistic needs assessments, MDT coordination and helpline services. Recommendation: That nurse led clinics and needs assessments are delivered regularly in Taupo.

8.3 Inpatient/Day Patient Intensive Rehabilitation Section 4 of this report provided a comparison of service volumes purchased from QE Health by the five Midland DHBs for the 2006/07 year. Lakes DHB was the clear outlier, purchasing almost twice as many bed days as Bay of Plenty DHB and nearly 12 times as many bed days as Tairawhiti DHB per 100,000 population.

DHB Population Inpatient Bed Days

Outpatient Bed Days

Total Bed Days

purchased

Bed Days per 100k pop

Bay of Plenty 190,000 1128 80 1208 636

Waikato 320,000 1021 26 1047 327

Tairawhiti 44,000 44* 0 44 98

Taranaki 103,000 Ad Hoc Ad Hoc Not available Not available

Lakes 102,000 740 500 1240 1216

There is some older research to support the efficacy of inpatient rehabilitation for patients with active rheumatoid arthritis. Vliet Vlieland et al in 1997 found that an 11 day programme of inpatient multidisciplinary team care had a beneficial effect on

disease activity over a period of 2 years in comparison with routine outpatient care21. However, no research comparing multi disciplinary intensive inpatient rehabilitation with multidisciplinary outpatient care was available. None of the recent clinical guidelines recommend intensive rehabilitation is made available to patients as a matter of course, and therefore no guidance regarding the optimum number of bed days per head of population was available to inform this project. No other organisation in New Zealand provides the type or level of service delivered by QE Health for rheumatology patients and there is a wide variance amongst the Midland DHBs’ – with whom Lakes strives to maintain regional equity – purchase of rehabilitation bed days. All of these factors make identifying an appropriate number of rehabilitation bed days for the Lakes population problematic. Of the DHBs who have withdrawn from the Midland-wide contract with QE Health, Waikato is the only DHB to have implemented an outpatient multi-disciplinary team approach to date and has employed allied health staff dedicated to rheumatology. As mentioned above, the clinicians at Waikato DHB stated that their outpatient service is over-stretched and is only able to provide care to a very limited number of the most needy patients. However, the model under which the Waikato team operates is nonetheless closer to those recommended in evidence based guidelines than the services delivered elsewhere in Midland. The 2004 Clinical Services Plan, which formed the basis for Lakes service continuum redevelopment, recommended that in line with international trends, Lakes DHB


moves towards ambulatory care for a larger number and range of services than is currently the case. This coupled with the lack of support for inpatient intensive rehabilitation amongst the clinical guidelines and standards of care and the wide discrepancy between volumes purchased by Lakes and other Midland DHBs has resulted in the recommendation that the number of bed days be considerably reduced from the current number purchased. As outlined in the proposed model of care, it is recommended that the focus of rheumatology services be altered, with greater emphasis being placed on an outpatient focussed MDT service. Under this model, intensive rehabilitation on an inpatient/day patient basis becomes one referral option for the MDT meeting, reserved for those who are most severely disabled by their disease as outlined in the national clinical priority access criteria (CPAC). It is recommended that Lakes DHB considers purchasing 177 intensive rehabilitation inpatient bed days and 157 outpatient intensive rehabilitation bed days. These volumes have been based on the total number of bed days purchased per 100,000 population by Waikato DHB (327 bed days). Waikato DHB has been chosen as the benchmark because it has established a MDT care service that is similar in nature to the Model of Care recommended for Lakes DHB. The recommended volume split between inpatient (53%) and outpatient (47%) bed days has been based on the spilt that was negotiated between Lakes DHB and QE Health as part of the 2006-07 contracting round. Consideration should be given to the provision of intensive rehabilitation in Taupo. The feasibility of this, given the small volumes involved will be dependent on the outcome of the wider Assessment, Treatment and Rehabilitation model of care. Until that time, intensive rehabilitation for the Taupo/Turangi population should continue to be delivered from Rotorua. It is recommended that Lakes DHB should consider convening a working party with input from the specialised rheumatology team and other DHBs to develop more thorough and formalised referral criteria than are currently available for inpatient intensive rehabilitation services. This would mitigate the longstanding concerns of DHB staff that patients are referred to inpatient programmes based on a capacity to benefit basis rather than patients with the highest level of need being prioritised. Recommendation: That the focus of rheumatology services be altered and greater emphasis be placed on an outpatient multi disciplinary team model. Recommendation: That the number of intensive rehabilitation bed days be reduced to 177 inpatient and 157 outpatient bed days per annum and are reserved for those patients who are most severely disabled by their disease and whose needs cannot be met through the outpatient MDT services. Recommendation: That consideration should be given to the provision of intensive rehabilitation in Taupo as part of the wider AT&R model of care. Recommendation: That Lakes DHB considers convening a working party to develop formalised criteria upon which to base referrals to intensive inpatient/day patient rehabilitation programmes.

8.4 Outpatient Allied Health With the recommended reduction in intensive rehabilitation programmes it will be necessary to increase the volume of allied health services available to rheumatology patients who might previously been admitted in order to receive MDT care. Patients with functional, social or psychological impairment will be able to receive services on


a less intensive basis aimed at maintaining and improving function without removing the patient from their everyday environment. It is not expected that the implementation of a process of holistic assessments will in itself materially affect the number of patients requiring most allied health services given that the needs of the patients who would not have been admitted for intensive rehabilitation under the previous service model will not have changed.

8.4.1 Outpatient Physiotherapy services The new Model of Care will result in an increase in demand for the outpatient physiotherapy team to deliver services to those patients who would have been admitted under intensive rehabilitation programmes under the previous service configuration. Once again, it was not possible to accurately determine the optimum number of physiotherapy contacts required for a population from literature and given that with the exception of Waikato, the other DHBs do not provide rheumatology specific physiotherapy services, benchmarking against Lakes’ neighbours was not possible. Therefore the service projections for the short term have been based on the 2006/07 contract with a 30% increase in volumes. This has, by necessity, been estimated and should be reviewed during the first year of service in order to inform purchasing in out years. Rheumatology physiotherapy services should be established in Taupo, probably as a visiting service until such time as a wider AT&R service is made available. A hydrotherapy pool should be available either as part of the rheumatology service where possible, or using community facilities. The efficacy of hydrotherapy has been questioned due to a lack of well conducted trials to support the widely held opinions of many clinicians and patients that hydrotherapy is an effective treatment. However, both the British Society of Rheumatologists and the Scottish Intercollegiate Guidelines Network clinical guidelines conclude that whilst the available research included flawed methodology, there is enough evidence to suggest that hydrotherapy does provide physiological, clinical and psychological benefits to patients. Recommendation : That Lakes DHB purchases 2730 outpatient physiotherapy contacts in the next funding round, and increase of 30% on 2006/07 volumes. Recommendation: That physiotherapy services for patients referred through the rheumatology MDT process are delivered by physiotherapists experienced in and dedicated to the delivery of rheumatology services. Recommendation: That rheumatology physiotherapy services are established in Taupo to service the Taupo/Turangi communities.

8.4.2 Outpatient Occupational Therapy services The new Model of Care will result in an increase in the demand for outpatient occupational therapy services. As with the physiotherapy volumes, the recommendation has been based on the 2006/07 volumes plus 30% increase. Again it is recommended that these are reviewed during year one. Rheumatology OT services should be delivered in Taupo for the Taupo/Turangi populations, probably as a visiting service initially and then reviewed if the provision of a wider AT&R service is recommended through the AT&R model of care project. Recommendation: That Lakes DHB purchase 320 occupational therapy contacts in the next funding round, and increase of 30% on 2006/07 volumes.


Recommendation: That occupational therapy services for patients referred through the rheumatology MDT process are delivered by occupational therapists experienced in and dedicated to the delivery of rheumatology services. Recommendation: That rheumatology OT services are delivered in Taupo for the Taupo/Turangi population.

8.4.3 Outpatient counselling services To date the volume of counselling contacts for outpatients has been small. However, the reduction of inpatient rehabilitation services, which have been heavily patronised by fibromyalgia and other chronic pain syndrome patients who utilise a significant amount of counselling services, will result in an increase in the demand for outpatient counselling services under the new model of care. It is recommended that the volume of contacts purchased are doubled under the new service configuration and are reviewed in year one. Outpatient counselling services should be delivered in Taupo to the Taupo/Turangi population as a visiting service. Recommendation: That Lakes DHB purchase 80 counselling contacts in the next funding round, and increase of 100% on 2006/07 volumes. Recommendation: That counselling services for patients referred through the rheumatology MDT process are delivered by counsellors with experience in the delivery of services to patients living with chronic diseases, particularly rheumatology. Recommendation: That outpatient counselling services should be delivered in Taupo to the Taupo/Turangi population as a visiting service.

8.4.5 Administration Support Adequate provision of medical typing, booking and administration staffing should be available to ensure that clinical staff are not burdened with administrative tasks beyond those which are part of their core duties. The provision of adequate administration staff is essential to the booking, record keeping and referral processes between service providers and patients operating effectively. Recommendation: That adequate support is in place to perform the administrative tasks essential to the efficient operation of the rheumatology service.


SECTION 9 DIAGNOSTIC REQUIREMENTS There are around 200 different types of arthritis, many of which display similar symptoms, especially in the early stages. Correct diagnosis is central to effective treatment and management, and whilst the cornerstones of diagnosis are clinical history taking and physical examination, investigations are use for several reasons, including ruling out other reasons for the symptoms, assessment of disease activity, prediction of potential destructiveness of the disease over time, and to monitor drug and other therapy. The rheumatologists prefer that GPs do not order large numbers of tests as they can be unnecessary, very costly and open to misinterpretation which may result in needless anxiety for patients. Whilst no new diagnostic tests appear to be on the horizon in the near future, developments in other areas may impact on the volume of tests requested. For example, biological therapies were recently added to the PHARMAC schedule. This will impact on the number of blood tests which Lakes DHB will have to fund as patients receiving these medications require regular blood tests to monitor toxicity and efficacy. As reactivation of latent tuberculosis can be seen with the prescription of biological therapy, screening for tuberculosis with a Mantoux test and chest x-ray is essential and as the number of patients considered for these new drugs increases, so will the DHBs bill for those investigations.

9.1 Blood Tests The following tests are commonly used:

� Full blood count (FBC) � Erythrocyte sedimentation rate (ESR) � Biochemical profile � Rheumatoid factor (RF) � Antinuclear antibodies (ANA) � Urate

Other tests are sometimes used to measure levels of:

� complement (which indicates disease activity in lupus) � immunoglobulins � specific antibodies to various infections which can trigger arthritis.

Occasionally genetic studies are done to help make the diagnosis. For example, the presence of inherited antigen HLA-B27 can be tested for, which can be associated with ankylosing spondylitis. Genetic studies are not useful in most cases.

9.2 Diagnostic Imaging In 2005/06 the rheumatologists at QE Health requested the following volumes of images for Lakes domiciled patients:

Investigation Volume X-Rays 269 CT Scans 15 MRI 22 Bone Density 90 Ultrasound 44

Most imaging is provided to QE Health by Lakes Radiology. Lakes DHB has recently installed an MRI on the Rotorua hospital site, however patients requiring MRIs are


sent to Waikato DHB rather than Lakes as the waiting times are shorter. DEXA Bone density scanning is performed on site at QE Health. Diagnostic imaging is funded in the price paid to QE Health for specialist appointments. It should be noted that GPs cannot directly refer patients for bone density scanning through the primary referred radiology contract, and this may generate referrals of patients with osteoporosis for a specialist assessment in order to receive a publicly funded bone density scan.

9.3 Other Tests Other tests that may be ordered include synovial fluid analysis, tissue biopsy, and urine analysis. Recommendation: That Lakes DHB monitors any developments in diagnostic investigations in order to foresee future direct and indirect costs.


SECTION 10 PHARMACEUTICAL REQUIREMENTS

10.1 Common Medications The main types of medication used in the treatment of rheumatic conditions include:

• Analgesics (e.g. paracetamol, aspirin)

• Non-Steroidal Anti-Inflammatory Drugs (e.g. diclofenac, ibuprofen)

• Cox-2 Inhibitors (e.g. celecoxib, valdecoxib)

• Corticosteroids (e.g. prednisone)

• Disease -Modifying Anti-Rheumatic Drugs (e.g. methotrexate, suphasalazine)

• TNF inhibitors (e.g. etanercept, adalimumab)

Analgesics relieve pain but do not have anti-inflammatory properties. Many are available over-the-counter (such as codeine, paracetamol) and may be prescribed for non-inflammatory forms of arthritis such as osteoarthritis.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are used to help relieve the inflammation, swelling, stiffness and joint pain associated with arthritis and form the largest and most widely used category of medications for arthritis. They are effective in relieving these symptoms, but do not alter the course of arthritis nor do they stop the progression of joint damage. Many drugs of this group including aspirin and ibuprofen are available for purchase over-the-counter. The major side effects of these drugs are gastrointestinal including irritation and ulcers.

Cox-2 inhibitors are a relatively new type of anti-inflammatory medicine used to relieve pain, swelling and inflammation. There is good evidence of efficacy of their use in the management of inflammatory arthritis and there is a pattern of reduced gastrointestinal symptoms and adverse events over other NSAIDs. However, no Cox-2 inhibitors are currently subsidised in New Zealand and there have been studies showing an increased risk of heart attacks and strokes in people taking some Cox-2 inhibitors.

Corticosteroids are effective in reducing pain and inflammation in joints. Whilst low-dose, well spaced corticosteroids injected into joints are thought to produce few side effects, long term use of oral, intra-muscular and intra-venous corticosteroids – even at low doses – carries increased risk of significant side effects including weakening of the skin, osteoporosis, fracture and cataracts. High doses of corticosteroids do have a role in establishing control of synovitis or bridging disease control when starting or increasing DMARD therapies due to the speed with which they take effect. However, long-term use of corticosteroids is not recommended.

Disease Modifying Anti Rheumatic Drug (DMARD) therapy has become the mainstay of early intervention in rheumatoid and some other inflammatory arthritis. Whereas once DMARDs were considered to be ‘second line’ drugs, increasing evidence supporting early diagnosis and intervention and aggressive packages of care having significant impact on disease progression has resulted in DMARDs being recommended as first agents. DMARDs are delivered either orally or by injection and often in combination and do not reduce symptoms. It can take several months before any improvement can be observed.


For patients with severe treatment-resistant rheumatoid arthritis, biologic therapy with TNF inhibitors is the last resort. Etanercept (Enbrel) has been funded since 2004 for juvenile chronic arthritis under Special Authority. The PHARMAC Board decided in October 2005 to list the TNF inhibitor adalimumab on the Pharmaceutical Schedule under Special Authority for adult patients with severe treatment-resistant rheumatoid arthritis (RA). Adalimumab (Humira) was made available from 1 January 2006.

10.2 Cost Estimates

Access Economics conservatively estimated the cost of prescription pharmaceuticals for arthritic conditions as being $21,493,748 for New Zealand as a whole in the year to March 2005. This included medications that do not appear on the Pharmac schedule and are therefore not funded by the DHBs (such as Celebrex and Arcoxia). This figure also included Vioxx which was withdrawn by the manufacturer in October 2004. The non-funded medications amounted to $11.5m of the total estimated cost of prescription pharmaceuticals, so the adjusted cost of DHB funded medications for arthritic conditions in NZ is around $10m. The Lakes population accounts for approximately 2.4% of the total NZ population, and therefore it would be expected that the cost of arthritis medications to Lakes DHB would be in the region of $240,000 per annum.

This estimate should be treated with extreme caution. The estimate only includes drugs classified in the M1 market data, which includes NSAIDs, DMARDs and TNF inhibitors. The estimate therefore does not include medications outside of the musculoskeletal classification which may be prescribed to rheumatology patients including the anti-rheumatics Methotrexate (classified as a chemotherapeutic agent) and sulphasalazine (an anti-diarrhoeal), paracetamol and corticosteroids such as prednisone. Notably the Access Economics report was published prior to the addition of the costly adalimumab (Humira) to the Pharmac schedule in December 2005. The authors also cautioned that the estimated cost of funding etanercept, which was added to the schedule in 2004, was also considered to be low and likely to rise in the near future.

10.3 Future Developments When Pharmac added adalimumab to the schedule of subsidised medicines in 2006, it was estimated that 300-400 patients nationwide would meet the stringent criteria for being funded. Lakes currently has around 10 patients receiving biologic therapies, a number which is appropriate given the size of the districts population relative to the national population. The rheumatologists predict that if the indications are broadened (for example to also include patients with ankylosing spondylitis and severe psoriatic arthritis) then the number of patients meeting the criteria could potentially double over the next few years. At around $25,000 per patient per year, a doubling of eligible patients could see Lakes DHB facing an annual cost of $500,000 in the medium term. This will have a significant impact on the DHBs pharmaceutical budget. Rituximab is part of the modern family of targeted drugs which includes the breast cancer drug Herceptin. Rituximab (brand name MabThera) is available in NZ under Special Authority to treat non-Hodgkins lymphoma and has been found to be effective in the treatment of rheumatoid arthritis in patients overseas who have been unable to tolerate or have not responded to TNF blocking drugs. The National Clinical Institute of Clinical Excellence (NICE) for Scotland announced in late 2006 that the use of Rituximab for limited use within the NHS Scotland had been accepted. A decision by the NICE for England is expected in 2007. It is possible that in time Rituximab will be licensed for use in the treatment of RA in New Zealand, and although it might be less expensive than TNF Inhibitors, the cost of this treatment cannot be estimated at this time.


Recommendation: That Lakes DHB continues to monitor developments in drug therapies as an area likely to have significant impact against the pharmaceutical budget in the short to medium term future.


SECTION 11 FACILITY REQUIREMENTS Key facilities required for the new rheumatology model of care include:

� Adequate examination rooms for specialist clinics (4 clinics per week), including clean area for joint and soft tissue injections.

� Adequate rooms for nurse-led clinics and holistic assessments (total 4 clinics

per week) plus room for group education sessions and office space from which to conduct helpline service.

� Limited day-stay facilities for drug infusions, possibly as part of a wider

medical day-stay or ambulatory centre for an estimated 20 patients per year. Around half of these patients would receive a one-off infusion, other patients may require multiple infusions but the numbers remain small. Resuscitation facilities and pharmacy support are therefore required.

� An OT assessment area is required.

� A physiotherapy gym is required.

� Hydrotherapy facilities should be available.

� Adequate rooms should be available for individual and group counselling and

education sessions.

� Inpatient and day patient rehabilitation beds should be available. The number of beds is difficult to assess until the recommended working party has been convened to establish criteria for referral to intensive rehabilitation and a course programme has been developed.

� Access to acute medical beds.

Recommendation: Key facilities for the provision of a rheumatology service include, examination rooms and a clean area, rooms for nurse led clinics and holistic assessments, limited medical day stay facilities, OT assessment area, physiotherapy gym, hydrotherapy facilities, room for individual and group counselling and education, inpatient and day patient intensive rehabilitation beds and acute medical beds as required.


APPENDIX 1


APPENDIX 2


APPENDIX 3


APPENDIX 4


1 1 ‘Consultant Physicians working with Patients’ 3rd edition 2005; Royal College of Physicians UK. 2 ‘Economic Cost of Arthritis in New Zealand’ 2005, Access Economics 3 ‘An Assessment of Health Needs in Lakes DHB Region’ 2004, Lakes DHB 4 ‘Innovative Care for Chronic Conditions’ 2002, World Health Organisation 5 ‘People with Chronic Conditions – A discussion document’ 2005, National Health Committee 6 ‘District Strategic Plan 2002-2012’ 2002, Lakes District Health Board 7 ‘Guidelines for the management of early rheumatoid arthritis’ 2002 update, American College of Rheumatologists 8 ‘Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee’ 2000, American College of Rheumatology 9 ‘Rheumatoid Arthritis: Diagnosis and Management’ 2006, British Columbia Medical Association and British Columbia Ministry of Health 10 ‘Guideline for the management of Rheumatoid Arthritis (The first 2 years)’ 2006, British Society for Rheumatology 11 ‘Management of Early Rheumatoid Arthritis’ 2000, Scottish Intercollegiate Guidelines Network 12 ‘The Musculoskeletal Service Framework, A Joint Responsibility: Doing it Differently’, July 2006, Department of Health 13 ‘Provision of health services for patients with rheumatic diseases in New Zealand’ 1999, NZRA and Arthritis Foundation of NZ. 14 ‘Musculoskeletal disorders: providing for the patients needs. A basis for planning a rheumatology service.’ 1995, British Society of Rheumatology. 15 ‘Midland Rheumatology Review’ 2003, Andrew Harrison MB ChB FRACP PhD on behalf of the Midland District Health Boards. 16 ‘The Economic Cost of Arthritis in NZ’ 2005, Access Economics on behalf of Arthritis NZ 17 ‘Consultant Physicians Working With Patients 3rd edition’ 2005, Royal College of Physicians, UK 18 ‘Healthcare Needs Assessment for Musculoskeletal Diseases’ 2002, Arthritis Research Campaign, UK 19 Ibid, p.316 20 ‘Programme Protocols for Lakes DHB 2006/2007”, 2006 contract negotiation proposal by QE Health. 21 ‘The two year follow-up of a randomised comparison of in-patient multidisciplinary tea care and routine out-patient care for rheumatoid arthritis’, Vliet Vlieland TPM, Breedveld FC, Hazes JMW. British Journal of Rheumatology 1997

Rheumatology Services Model of Care_2007_Lakes DHB

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